A Bad Day

One day this week, I had a bad day. Much of what happened can really not be spoken about at all. Actually because of psychiatric terminology, some of it would be incomprehensible to anyone but other psychiatrists. That was one worry. The other worry was more ethical and moral. Because of that, it may only have been a worry to me, because we all have different morals and ethics.

Every doctor does have bad days with just such dilemmas. In fact, every professional group has these same dilemmas, dilemmas that cannot be discussed easily with our usual confidantes because of technical complexity or confidentiality.

The issue of physician assisted dying is the kind of dilemma that can cause bad days, exactly because it poses questions that have different correct answers depending on your perspective. So many people are wrestling with the consideration of physician assisted dying at present – patients and their advocates, doctors, nurses, politicians, journalists, faith groups – both for and against, jurists – the interest is great.

When all is said and done, however, the final decisions and actions regarding physician assisted dying are going to be down to the patient and the doctor.

A number of physicians are going to be morally and ethically opposed to assisting in a patient’s death. They will have to face the dilemma that the law will require them to refer that patient to a physician with very different values than their own – not better, not worse, just different. A number of them will break the law. Another group will not, again for reasons that are too difficult to dissect.

Other physicians’ values will put patients’ needs at all times above their own concerns. They will fully support their patient in seeking physician-assisted death, although they may not ever consider performing that act themselves.

Some patients, in great pain, with a terminal illness will never consider physician assisted death, even though they might wish to die, because their values prohibit such action. Others might, but know their families could not bear this decision. Other patients with a terminal condition, realizing that their families are under undue financial stress because of their illness, might seek physician-assisted death as a solution to that dilemma. These are personal choices. None of them is necessarily wrong to the person making the decision.

The variations of this dilemma that I have described are not the only variations that are going to arise. I raise these to demonstrate the complexity of the issue and the variety of issues that patients and their doctors will have to face. They will have a hard enough time working together without the commentary and judgment of all the other interests around them.

Medicine today espouses a team-based model but there are many situations just like physician assisted death in which the team fades into the background. The decisions are now left to two principals: patient and doctor. Google “Medical Team Assisted Death” or “Nurse assisted death”. When you google the latter, you get to “The Nurse’s Role in Physician Assisted Death”. That seems to be as close as the team gets, and, of course, the nurse is the only other health professional to enter the scenario, in a supporting role. Who else comes to a patient’s or a doctor’s aid other than a nurse?

My goal in writing this has been to show that, as much as families, politicians, journalists and faith groups may have opinions about these medical decisions, in the end, the final decisions will be left to patients and their doctors, with nurses providing support. Society has decided on physician assisted death. This will mean that some days, a doctor will be making a choice that someone will disagree with. They may even disagree with the decision themselves to provide their patient with the care they require. These choices cause bad days.

“Who has choices need not choose, we must who have none…” Peter S. Beagle

Loss Leader

IMG_0499flu2 IMG_0498fluThe two pictures attached to this article were provided to my husband when he picked up a prescription this week. They are the Pharmacy’s questionnaire for people wishing to get a flu shot and the “informed consent” that they must sign in order to be inoculated. Now my husband wasn’t there for a flu shot so it is interesting that they just happen to be giving out this paperwork. Do you think this is a public service? I took it as more of a flyer, letting people know who’ve been advised to get the flu shot that they can get it “free” at the pharmacy, a little chore they can get done while they’re getting their prescription or picking up shampoo. In fact, having heard how convenient it is to do this at the pharmacy, many people may actually decide to get their flu shot there. I am pretty cynical about the motivation of pharmacists to provide this service and so I see these documents as “flyers” advertising a “loss leader”.

Contrast this with the experience should the patient happen to have visited their family doctor for the flu shot, which I did. My family doctor asked me many of the questions on the “Flu Vaccine Questionnaire” and outlined some of the new aspects of this year’s vaccine, but he took the fact that I was there seeking this service as my informed consent and certainly didn’t ask me to sign a waiver. I don’t think it’s an error on his part. I believe that this reflects that he provides and coordinates all of my health care. When I signed up for his practice, that was our agreement that he would direct my primary care and I would get my care from him.

I believe that what my family doctor does is very similar to what every family doctor does. The pharmacist is clearly required to complete – or have you complete – a number of documents. Pharmacists don’t keep a detailed medical record such as your family doctor is required to keep that already outlines all of the medical history contained in the questionnaire. Your family doctor will also have details of any past blood work, your most recent physical and likely more medical information about you than you ever dreamed there could be. More importantly, your family doctor will understand what all of this information means to a degree that your pharmacist does not. That is the benefit of a medical education, an understanding of health and disease in all its complexities. That is why whenever a pharmacist (or any allied health professional) wants to begin to perform “simple” medical acts to save the system money and resources, I become suspicious.

A pharmacy is a big business. I do not believe that there are very many, if any, pharmacies left in my community that are not franchised. I felt more comfortable when the pharmacist was the owner and “operator” of a pharmacy. I have no difficulty with businesses working to make a profit – I think they ought to make a profit – but I don’t like false advertising. I don’t think that the main reason pharmacies provide vaccinations is to provide a service. I think the convenience is a “loss leader” for more profitable enterprises. I’d prefer that the focus of the person providing my flu shot was my health care. That’s what patient-centred means to me.

Saving Family Medicine

Last week, someone who has just started reading these articles told me, “You sure write a lot about family doctors.” I don’t disagree, because I believe that family doctors are the most important doctors in health care and that, if family medicine is strong, then the rest of health care can be built around that base.

With this in mind, I would like to consider one of the flaws in our current system of supporting family doctors, family medicine and the system of primary care that we have in Ontario and in Canada.

The government’s own definition of a Family Health Team describes “a team of family physicians, nurse practitioners, registered nurses, social workers, dietitians and other professionals who work together to provide primary health care for their community.” There are 184 Family Health Teams in Ontario and each was established according to the needs of the population they serve. The importance of this system was understood by economist Don Drummond in his 2012 report which recommended the multidisciplinary team model for all primary care.

Whenever I have considered this definition, which is taken from the Government of Ontario website, I could not believe that it did not include patients as members of the team. Perhaps it is of little consequence since the health professionals on the teams certainly see patients and their families as being at the centre of their organizations. Having said this, I think we should ask patients to participate more in many aspects of their care, from prevention right through to developing plans for their treatment. Consider that management for most medical conditions includes not just lab tests, or X-rays, or taking medication or but also lifestyle changes. Doctors and governments alike talk about patient-centred care, but is that the same as care in which the patient is actively involved?

In fact, the multidisciplinary nature of many group primary care practices means that patients can access not just medical care but also other services, such as consultations with a nutritionist and even psychotherapy. Such complete care from birth right through to the end of one’s life not only addresses any acute illnesses or medical conditions a person might have but also clearly assists in preventing illness over the lifespan. Considering that this is the ideal situation, why not include patients in the team? What might this mean for primary care practices if patients were integrated into care as team members?

Right now, patients in groups are expected to sign up for a certain family doctor’s “roster” and they commit to getting their care with that family doctor. The commitment is not too onerous and, for the most part, the obligations are all on the side of the physician, at least as far as penalty goes, although, again, one might argue that keeping your contract with your family doctor’s practice and getting your primary care in one “medical home” gives you a better chance of good health outcomes. That’s what the research shows, at any rate.

Let’s take this thought of the patient as a member of the team a bit further. Typically, changes in the health care system are communicated by the government to all stakeholders both individually and through professional organizations. The patient is the last person to find out when changes are anticipated and, unless they seek it, any analysis of what changes will mean for them is likely obfuscated by political messaging. For example, several of my patients were to have been picked up by a certain Family Health Team but they recently learned that the new family doctor expected in July is no longer starting a practice in Ottawa. This means that they will have care in a different practice from the rest of their family. They were all told that this is because of government cutbacks to family medicine. One of my patient’s mothers is expecting a baby and she now realizes that she will need care for the baby as well. “I’ll be running all over just for doctors’ appointments,” she told me. Clearly the system is changing into something neither patients nor doctors would want.

I like the idea of patients being involved in planning and having responsibility for their role in health. The youth in my largest clinic sit down with the team to plan activities and decide what psychoeducation or treatment they would like. We’re developing the tracking sheet for monitoring their illness together. These plans increase my patients’ commitment to the program. That increased commitment means that they will work with us to keep well.

Governments seem reluctant to have patients make firm commitments when they roster to a practice, but doesn’t that seem a bit paternalistic? The Government of Ontario website advertised where to get a flu shot in the fall saying it was “free” when everyone knows that we all pay for health care through taxes and a specific annual payment at tax time. It is as if the government is saying, “We are looking after you.” This is also paternalistic.

The people who need family medicine the most – patients – can save it, if they are a part of the team that is organizing their care, if they are asked to be accountable. They won’t mind. Mostly, they don’t want to have to worry about where or when they will get care. Accountability is a small price to pay for peace of mind. However, this will also increase their awareness of how well the Government is managing the health care system. If both physicians and patients are accountable for their roles, will the government be able to stand the scrutiny?

Finally, what do you think? Would you be accountable for your own healthcare and the team that provides it?

Physician Activism: Dr. Marilyn Crabtree and a letter

In late November, Dr. Marilyn Crabtree wrote a letter to Ontario Minister of Health Dr. Eric Hoskins on behalf of the Medical Staff Association of Winchester and District Memorial Hospital. Dr. Crabtree is the Secretary Treasurer of the hospital Medical Staff Organization. The letter was to outline the doctors’ concerns about a program designed by the government to allow new family medicine graduates to practice in groups with other family doctors. The program is the New Graduate Entry Program (NGEP) and the details are outlined here: http://www.health.gov.on.ca/en/pro/programs/ohip/bulletins/11000/bul11138.pdf

This is the text of Dr. Crabtree’s letter:

“Dear Minister Hoskins,

I am writing on behalf of the Medical Staff Organization of Winchester and District Memorial Hospital to advise you of the serious concerns this Hospital and its Medical Staff have regarding your Ministry’s “New Graduate Entry Program”. In its current form, this policy will devastate and possibly close the Winchester and District Memorial Hospital within the 3 year time frame of the current proposal.

Our Hospital is a vibrant and active facility. We have won provincial awards for our Maternity Care, for our eConsult program development and our small rural community raised millions of dollars just 10 years ago to fund the construction of our new facility. Our community is committed to its hospital and the services it provides to the entire Stormont, Dundas and Glengarry region. We also provide care to many patients from South Ottawa and to those from the severely underserviced areas around Cornwall as well. Unfortunately, we cannot function without full scope family practice physicians as over 65% of the physicians with admitting privileges are just that – Family Physicians.

In order to continue to provide the high quality care to patients that our communities have come to expect, we need to continue to recruit new Family Physicians who will do Emergency Room shifts, care for inpatients and provide OR assists and Obstetrical services. We have an aging physician demographic with 3 retirements in the last year and an expected 3 – 5 more in the coming 3 years. We must be able to recruit new physicians to take over the care of patients when our colleagues retire. These physicians may choose not to practice in a designated “underserviced area” and therefore would not be able to provide care in our hospital while working for 3 years in their community of choice.

To add to this issue, the number of patients each of our Family Physicians cares for is very large (1800-2400 patients per physician for those in practice for 5 years or more). We provide full scope office care in addition to our hospital work. Most of the physicians who do not plan to retire in the coming 3 years would like to be able to transfer part of their patient load to a new physician but again, without new graduates being able to take some of the load, our patients will continue to suffer from inadequate access due to supply-demand imbalances that can never be rectified.

We are writing to you and forwarding a copy of this letter of concern to our local media to raise awareness about the impact the “New Graduate Entry Program” will have on rural hospitals like Winchester and District Memorial Hospital and communities like those in Eastern Ontario. We hope to see this program eliminated as we see it as a poorly thought out plan to restrict practice and payments for new physicians who only want to contribute to the care and treatment of the ill and infirm of Ontario.

Sincerely,

Marilyn Crabtree, MD, CCFP”

Dr. Crabtree’s letter caused quite a stir in her corner of Eastern Ontario because it foretold a loss of medical services. There was a view by some that she was fearmongering but, in fact, every word she wrote is true and thank goodness the Medical Staff of the Winchester and District Memorial Hospital was concerned enough to call out the Minister on a plan that was clearly not designed with smaller hospitals in mind. (The NGEP has many other flaws but, in this case, I wanted to focus on one particular problem.)

When I spoke with Dr. Crabtree, she did not seem entirely comfortable that she had upset people. It is only natural that a good doctor, used to helping people stay calm, balks at upsetting the community. It takes a lot of courage for her, and the Medical Staff she represents, to say very publicly, “This is wrong and we don’t support it.” The task of a good Medical Staff Organization is to raise awareness when the health of patients or a community might be affected. This is exactly what happened and the Winchester community now understands the impact some of the Liberal government’s plan for health care might have in their hospital and for their primary care.

Let’s hope the other community leaders are doing as good a job as the doctors to preserve the community health system they have all worked hard to build.

New Grad Entry Program: Design Failure for Both Patients and Doctors

Late last week the Ontario Medical Association learned about another of the Liberal Government’s unilaterally developed programs for Ontario doctors. The details of this New Graduate Entry Program can be found here: http://www.health.gov.on.ca/en/pro/programs/ohip/bulletins/11000/bul11138.pdf

Normally, I would not wade into discussing new Primary Care initiatives leaving such matters to such bloggers as Dr. Scott Wooder (https://drscottwooder.wordpress.com/) who has been a comprehensive family physician for many years. This time, however, I am struck by the impact that this action will inevitably have on the patients that I see, many of whom are actively seeking a family physician.

Why are so many of my patients looking for a family doctor? As a psychiatrist who sees 16 – 18 year olds, many of patients are making a transition from a pediatrician to a family physician and right now in my community, this is very difficult. Ottawa and its immediate environs are not seen as a “high needs” community by the Ministry of Health and Long Term Care, which means no new family physicians will be opening practices here in Family Health Organizations, Family Health Teams or Family Health Networks. In addition, patients with mental health problems are among the least likely to have access to primary care. This is borne out in many studies and is true in my community.

So as I consider the merits of this New Graduates Entry Program, which might address my patients’ needs, I am most struck by the preventative care requirement the Ministry dictates in order for the physician to progress through the arbitrary levels of this new program. The program description outlines that the physician will be assessed on performance metrics that consider the “percentage of target patient populations compliant with preventative care requirements”. I would not want to be assessed with respect to this metric and I have been practicing psychiatry with adolescents for the past 25 years.

Many psychiatric illnesses are episodic. When you are feeling depressed, you can barely get out of bed. It doesn’t matter if your doctor has performance targets to meet. When your anxiety is out of control, you often can’t leave your house. Many of my patients have concurrent substance abuse, which interferes with the efficacy of their medication. My program has specially developed programing to help us monitor these complications but not new physical complaints.

If I see a young man with Bipolar Disorder who has come in with symptoms of a sexually transmitted disease, I can’t be sure that he will make it to his family doctor. I often call to find out how to confirm the management that the family doctor prefers just because follow-up with his family doctor cannot be guaranteed. This patient only got to the appointment with my team because we know how to find him. His family doctor helps us and we get advice on physical conditions because this youth may never get to his office. This kind of collaborative care cannot be measured by crude metrics. It certainly won’t help “compliance” statistics.

My patients may smoke, use drugs, stop taking their medications, never get a flu shot and are often street-involved. Their health outcomes are improved with a family physician who can assist in their care, but their illnesses can interfere with “compliance”, a word I hate at the best of times since it suggests that someone must be doing something wrong.

“Excellent Care for All” is guaranteed by trust: a patient’s trust that a doctor will look after them, despite the fact that they cannot always get to their appointments, or stop smoking, or eat better. The group models of primary care that the government is dismantling ensure that my patient has a medical home, where they are always welcome even when they are not “compliant”. They need doctors in groups who are also not “compliant” with metrics that cannot be achieved when you are seeing real patients.

One way the Government of Ontario’s New Grad Entry Program will prevent new family doctors from seriously consider working in groups is by setting up unachievable barriers. They will have 3 years of evaluation and scrutiny. This scrutiny will add to a doctor’s stress and drive them away from the very models of care my patients need.

As I said at the outset, this program was developed unilaterally by the Ministry of Health and Long Term Care. Having outlined all the reasons that I collaborate with my patient’s family doctor, I also want the Ministry to collaborate with the OMA. The bilateral OMA-MOH primary care committees have developed programs that work because they consider both Ministry guidelines and the wisdom of family doctors experienced in comprehensive care. It is only in that circumstance that real patients get the primary care they need.

A Good Time to be a Doctor?

Physicians in Ontario have had a difficult week – more cuts from the government they’d like to be able to work with, and division among themselves. A number of doctors have been through difficult times before and know that, in the end, this will pass. The government will realize that it cannot run a health system with dissatisfied doctors any more than it can run a healthcare system without doctors. They will begin to speak with the Ontario Medical Association again, looking for help with their situation. This will happen either because they are forced to by public opinion or by measures taken by the Ontario Medical Association.

As much as I am personally involved in working to get the government back to the negotiating table by any means possible, I am also still personally involved in getting children and youth back to school. These are not my children, in the strictest sense of the word, but their success is still very important to me for it is a measure of my success as a clinician.

The hardest thing about being a physician for adolescents and young adults is that you must let them find their own best way to do things. You must let them do this even when you know it is not going well. At the same time, you must be absolutely, completely ready for when they need you. This past few weeks at work, I have been in the happy position of knowing that twenty-one of the young people I have cared for are ready to begin university. Some are going to be away from home. They have been thrilled about this all summer. They are now terrified. They are worried they will fail.

I say: Fail? What was your average last year?

They say: Dr. Beck, that’s not fair. You know how hard that was.

I say: I do, but still, that’s not likely.

They say: The other students will be smarter than me.

I say: Not many of them. You remember, you did those tests…

They say: I’ll miss my family.

I say: Of course you will, but you can call, skype visit and, if those don’t work, you can visit. There will be       nothing like 4 days at home to remind you of why you felt it was best to go away to school. Oh, since we’re talking about probabilities, you could do amazingly well and have the best time of your life.

This time of the year is one of the busiest and best times of my practice. After a week of this kind of work I am always optimistic about the world with these young people heading off, ready to build a future that my grandchildren will live in.

Three of my patients are going to medical school. They will all be good doctors. They have all had a serious illness that could have derailed their lives. They will always understand what it feels like to be so sick that you can’t be sure you’ll get better. One of them asks this question.

They ask: Dr. Beck, it doesn’t seem like a good time to be a doctor.

I say: It’s always a good time to be a doctor.

Then I tell them about my August and September with my patients. I tell them about my conversations with their family doctor or their pediatrician, who have known them since they were babies and who are so excited that they are doing well. I tell them that my conversations with them, and with their doctors, make all the difference to my job as a doctor. My life is affected by cuts but it is not driven by them or the disrespect they symbolize. The opinions that matter are not those from Queen’s Park or a Minister’s office. For every doctor, the opinions about their work that matter are those of patients and the colleagues they work with to keep patients well.

Perhaps that’s why Dr. Hoskins can work to undermine the work of a healthcare system that doctors in Ontario build every day in their offices. He doesn’t do that work, doesn’t have to look patients and their families in the eye every day or talk to other doctors about his consultations. The community that doctors and patients build every day was here long before Dr. Hoskins started and will continue to be here long after he’s finished.

Medical Uncertainty: Is there a Doctor in the Clinic?

IMG_0464IMG_0466

This is a flyer included with Wednesday’s newspaper. Bright yellow, black lettering – great visibility in the pile of flyers and junk – telling the reader, “A BODY SCAN Can Save Your Life!” The small print also tells you that “Medicare will not cover preventative scans at this time.” I have not seen such a flyer before, although I am aware that many people have availed themselves of the MRI and CT-Scan services available in Gatineau, just across the river from Ottawa: http://www.stjosephmri.com/ You will notice that a doctor’s referral is required in order to obtain the services in Quebec, but no referral is needed for the clinic in Ogdensburg. After all, “certified technologists” and “medical doctors (M.D.)” administer and evaluate the tests. Who needs a referral?

What is deceptive about this flyer is that it makes it sound as though you will get better, quicker access to a scan when, in fact, you’re getting access whether it’s necessary or not with no guarantee of any treatment should this untargeted care reveal any finding outside normal range on the scan you undertake. More importantly, even with these results in hand, your own family physician, and the specialist to whom you might be referred, will likely have to redo these tests. The reason is that most scans are undertaken with some direction as to the clinical presentation (what your symptoms are) and possible diagnoses.

Also, while a medical doctor may “evaluate” your scan, there is no assurance that a specialist cardiologist or radiologist will supervise either the completion of the test or even provide the interpretation. The best care in Canada – and even in the United States – would require that a physician specifically trained to manage and interpret these tests would provide this service. In other words, this is not the standard of care that a Canadian patient usually has.

There are many aspects of this kind of medicine that can be discussed but I want to speculate on why, for the first time in 25 years living at my current address, I have received this kind of flyer advertising “preventative scans” available for anyone. To me, this must be related to the decreased access to care that we are experiencing in Ontario.

I am sure many will question my leap to this conclusion but the current difficulties regarding access to care are not just studied in Canada but also around the world. This Commonwealth Fund study showed that 41% of Canadians wait more than 2 months to see a specialist, one of the worst results among OECD countries: http://www.commonwealthfund.org/ In fact, this problem with access is one of the reasons often cited in the United States as a reason not to adopt the Canadian Model for healthcare.

When people are worried about their health, they want answers NOW, definitive answers. Definitive answers are not at all the norm in medicine. The best diagnoses follow from a thorough history, careful physical examination and diagnostic tests. Any doctor reading this will remember being taught that blindly ordering tests will not yield a better diagnosis. Anyone who completed clerkship with me at St. Mary’s Hospital may remember being “scored” on the “right” tests – one point added for each correct test, one point deducted for each unnecessary test. As clerks, we felt relieved to have a positive score. Is there any doctor who does not remember returning to a patient’s bedside to listen to his lungs one more time?

These skills are not part of the services being offered by the Ultra Life Clinic in Ogdensburg. It worries me that we have come to this, but I am not surprised. Granted that my work as an Ontario Medical Association Board Director means that many doctors tell me about the difficulty that their patients have accessing specialty diagnostic assessment. Granted that both patients and doctors are seeking better access. It’s unfortunate that these problems are now causing such worry that patients will seek out unnecessary tests because they are available when necessary care is not.

Good medical care is not definitive, even in the 21st century. Preventative full body scans do not add information – they make diagnosis more difficult. In Ontario, I am worried that politicians believe that the answers are so simple that they can figure them out without doctors. The impact seems to be that I now receive flyers advertising full body scans 45 minutes away in New York State. I’d like to be wrong but nothing convinces me that politics is any more definitive than medicine. Doctors are trained rigourously in uncertainties, learning to seek consultation. Are politicians?

“Medicine is a science of uncertainty and an art of probability.” William Osler