Monthly Archives: January 2015

#BellLetsTalk? Ok, let’s talk.

It’s the annual Bell Let’s Talk day, which is “designed to break the silence around mental illness and support mental health all across Canada”. I applaud the program for bringing mental illness to the forefront of discussion, and for re-enforcing the efforts to de-stigmatize psychiatric illnesses. Raising funds to support programs, celebrities coming out in support of these efforts….these are all very good things.

But let’s be honest about what the main issues are. Stigma is certainly an issue for some seeking care, but as a physician, I would argue that stigma alone is playing less and less of a role. It is one thing to encourage people to come forward with concerns, but we need to be confident that we can then provide resources to help them. There is nothing more deflating for someone with the courage to come forward than to tell them that our hands are tied with what we can offer them. These are often individuals experiencing hopelessness and despair to begin with, and we need to provide them a stable therapeutic infrastructure. Which doesn’t exist right now in this country.

So shall we talk?

Let’s talk about the fact that our most ill psychiatric patients spend days in ERs across the country waiting to be placed in an inpatient bed. These are patients who often have very little insight into their illness, and leaving them in a foreign, non-therapeutic environment for days is probably one of the worst things we can do to establish their trust in the system. When they are back in the community and have a relapse of symptoms, most are reluctant to seek attention early because of their arduous hospital admission experiences.

Let’s talk about how many inpatients are being discharged before achieving any true improvement in symptoms. Most psychiatrists would tell you that these patients should be in hospital longer, but they have to be cognizant about the constant pressure to admit new, emergent patients to their service. The revolving door swings too fast for these patients, and they return to hospital before long.

Let’s talk about the impossibility of finding community psychiatrists for most patients. Family physicians have filled many of the gaps out of necessity by treating patients who would have normally been followed by psychiatrists. Better access to community psychiatrists will allow them to support family physicians in complex cases with diagnosis and management, with the family physician then taking over care again. (Side note: the recent cuts to physician compensation in Ontario will make attracting new psychiatrists nearly impossible).

Let’s talk about our two-tiered system for psychology services. Those who have benefits through work or whose physicians are in a family health team, and those who are left to pay out of pocket. This disparity is shameful and our provinces should stop playing favourites with these services. Short-term therapy for all who need it, then subsequent discharge from care. Make things equitable.

Let’s talk about the complete void in our system for child and adolescent mental health. Every day in my office I see at least one child or adolescent with a new mental health issue. Generalized anxiety, OCD, suicidality, depression, the list goes on. Older physicians are astonished at the number of individuals presenting with these conditions. As a physician I am legitimately frightened at what the future holds for us given the increased prevalence of these conditions in our youth, and the fact we have no plan to help these children. Not enough child psychiatrists, not enough counsellors in schools, not enough group programs, not enough education, not enough self-management programs, and a lack of coordinated intake for where parents and health care professionals can turn for entry into treatment. Interestingly the Ontario government recently announced a funding infusion into post-secondary mental health care. I would argue that the quality of mental health in colleges and universities is already head and shoulders above the rest of the system in terms of accessibility. Provinces need to recognize the gaps in child and adolescent care, and soon.

Let’s talk about the absurd waiting lists for residential care for children and adolescents with behavioural and substance use disorders. These are young people who, without early and thorough intervention, will be condemned to a life of dysfunction, crime, and substance abuse. Their parents are crying out to us to offer something to help their children, and we are helpless to provide any further options while they toil on these waiting lists. This is one area where government investment would pay off in spades down the road with decreased utilization.

Let’s talk about the potential negative consequences of social media on mental health. It is no secret that the neurobiology of our youth is being significantly altered by their environment, and they are essentially lab rats in an ongoing sociological experiment. This is perhaps an overly simplistic view of a complex topic, but it provides some important basic tenets of the effects social media has on the brain. Most paediatric organizations recommend limiting screen time for reasons linked to obesity, but very rarely do we hear that we should be limiting screen time for mental health reasons. This should be a priority.

Let’s talk about how difficult our mental health system is to navigate for a health professional, let alone for a suffering patient. There are many quality organizations doing good work in our communities, but without a centralized point of reference or entry for programs, most patients will remain unaware of most programs. Even health care professionals who spend significant periods of time to learn about local resources will often be quickly overwhelmed by the disorganization of system resources and contacts.

Let’s have frank discussions with adolescents with the effects of substance use on their developing brains, but doing so without being overly paternalistic or complex. They are often quite engaged when I give them a quick science talk about these substances. They know how the substance makes them feel, and explaining the temporary relief of symptoms with potential long-term consequences does resonant with some of them. We need to reassure adolescents who are experiencing mood disorders that they can experience improvement in their symptoms without resorting to illicit substances.

Let’s talk about how the solution to all of these ills will not simply be through funding. The primary goal has to be better organization within the system, then the funding can follow. Otherwise we’re going to throw our money haphazardly at programs left and right.

So we want to change our mental health care system for the better? Sure, let’s talk. But it has to be more than 140 characters at a time.

ER wait times: A few remedies for this lingering headache

I think it’s safe to say that more ink has been spilled on wait times in emergency departments than on any other health-related issue. Regardless of what Canadian jurisdiction you live in, chances are you’ll find an article or editorial every few weeks detailing a local crisis. And we aren’t alone in this. A quick glance across the pond shows that a similar story plays out regularly with the National Health Service in the UK, with backlogs part of expected daily life.

In my local paper (London Free Press), here’s a brief sampling of headlines over the past few months:

Emergency room wait times worsening in London – Sept 25/14

Bottleneck reaches record levels, with Victoria Hospital 125% full on Sunday and Monday -Dec 29/14

Hospital looks to biz to cut waits – Apr 3/14

UH ranks worst – July 1/14

“We need to do better” about wait times – Dec 15/14

Inspiring, no? Inevitably the crisis du jour is followed by buzz on talk radio, and the peanut gallery in coffee shops and Internet comment sections offer up their scapegoats, usually including a combination of CEO salaries, nursing cuts, bed-blockers, teaching hospitals, tertiary centres, ER frequent fliers, influenza, etc. (Andre Picard does a good job here countering the message that influenza is to solely blame for holiday backlog). So everyone is fired up, but nothing changes, and we wait for the next article decrying wait times. Wash. Rinse. Repeat.

I’ll start off by stating that more funding alone is not the solution to all of our ills. More funding will be a necessity for a few of the issues I will discuss, but throwing money alone at this problem won’t solve anything. The proposal by the Ontario NDP party during the last election to reduce ER wait times by 50% by adding nurse practitioners made for a great election sound bite, but would do nothing to change the fundamental flaws in the system.

There is a tremendous urgency to improve the ER system now. We are incredibly fortunate that our news isn’t littered with stories of patients suffering complications as a result of wait times. I have sent patients from my clinic to the ER on many occasions with urgent conditions, to be shocked when they had not been assessed hours later. And this is no fault of the ER physicians, who do their best to essentially survive one shift at a time. They were trained to treat emergencies, yet as a result of angry waiting patients, non-emergent presentations, and bed backlog with admitted patients, many are on the verge of burnout. Talk to an emergency physician and ask them whether they are satisfied with their jobs, and most will tell you the same story. Their dissatisfaction affects how they interact with nurses, staff, and admitting services, then those individuals become inevitably irritable, and the spiral of morale continues to descend.

So let’s start to fix it. I see our ER congestion as being a consequences of two main system flaws: a problem with access and a problem with flow.

Access is getting appropriate care to patients when medically necessary and when they feel they need assistance. As much as we criticize patients for visiting the ER for non-emergent issues, for whatever reason, they felt that their visit was appropriate. I will explore various strategies for ensuring that patients receive timely care, and increase satisfaction, without simply increasing ER resources.

Flow describes how patients move through the hospital system, and having patients in the most appropriate location at all times. Flow solutions are largely hospital-dependent, but there are a few principles that can be administered system-wide. It is no secret that the biggest barrier to flow is patients awaiting long-term care and patients who are ALC (alternate level of care). Funding is the issue. All levels of government know that funding new nursing homes is costly, and they want to put off the issue as long as possible. So either they’re waiting for the apocalypse or a repeat of the 1918 influenza epidemic, because I’m not sure how much more dire situations need to become in some jurisdictions before they act. Families and home care are looking after these patients at home as long as possible, until they inevitably decline, at which point they are admitted to hospital in crisis while they await a long-term care bed. It’s a situation that plays out across the country every day, and is a huge drain on our system.

Access

1) Linking patients with a family doctor/primary care team

Yes, you’re probably thinking, “His first big idea for ER improvement is more family doctors? Thanks for stating the obvious, genius.” Of course it’s obvious. Which makes it even more frustrating that we still have so many patients without family physicians after years of this being an issue. The proposed cuts from the Ontario Ministry of Health to bonuses for physicians who take on new patients certainly won’t help things.

1a) Have retiring physicians provide mentoring to family medicine residents to take over practice

Every community has had retiring physicians close up shop and leave patients orphaned. These patients will inevitably seek fragmented care through walk-ins and emergency departments until they can find a new physician. I can speak personally of the advantages of this form of succession, as I have taken over from my own family physician. Family medicine residents I speak to are quite interested in this type of arrangement, as it helps to allay much of their anxieties about entering the real world. The retiring physicians would love to provide their patients with continuity. Health Force Ontario, the OMA and individual residency programs can work together to provide the initial contact between residents and physicians, elective opportunities as a sort of “trial period”, and a standard protocol for the business transition.

2) Some family doctors/primary care teams need to improve accessibility to patients

When new patient enrolment models in primary care were introduced in Ontario, they made some intuitive sense to the MOHLTC. Rather than be paid per patient visit, physicians in these funding models would receive the bulk of their funding based on the number of patients on their roster. The physicians within each respective group would be responsible for providing after-hours care to any patient of any physician within the group. From the ministry’s standpoint, they would be able to better predict their costs from year to year regardless of whether the number of patient visits increased. From the physician’s standpoint, they would be paid more than they received in a fee-for-service model. And while many physicians who currently work in these models work hard and still provide great access to their patients, some physicians have taken capitation payments as an invitation to cut back on hours and number of patient visits. The only instrument of accountability is that they have payments deducted if their patients attend walk-in clinics rather than seeing a physician within the group. While it may seem Draconian, I don’t think it would be unreasonable for the MOHLTC to work towards a strategy where physicians are expected to provide same-day appointments as part of their contract terms. I know that many family physicians have moved to a “Same-Day/Advanced Access Scheduling System” where most appointments are booked the day for the same day. Whatever means they use to ensure same-day appointments, there needs to be some teeth to the MOHLTC policy to ensure compliance, which may include a patient ombudsman. Patients then need to be clearly informed of these same-day policies, because right now the majority of patients assume they can’t get in the same day, and resort to the ER or walk-in clinics. If physicians find that because of patient volume they are not able to meet those targets, the MOHLTC ideally would be a resource to allow the physician to transition to a more reasonable roster size (moving patients to a new grad taking patients, etc.). There also needs to be procedures in place that guarantee that vacationing family doctors have physicians covering their patients for them (and that patients are aware of these procedures). Too many patients are bouncing back to the ER for non-urgent follow-up while their doctor is still on holiday.

3) Hours of operation for primary care clinics and walk-in clinics need to be easily accessible online.

This may be another point that seems obvious, but is often overlooked. All physicians who see any patients in primary care should be required to post updated hours and days of operation on an easily accessible public website. They should also include hours during which phones will be answered, and locations of after-hours clinics. This is easily achievable, as the CMA provides easy-to-create websites for physicians. I realize that physicians reliably state their office hours on answering machines, but having them available online would be much more easily accessible to patients. (Clearly posting updated holiday hours is another absolute must.) Providing easily accessible interactive maps of local walk-in clinics would also help to redirect patients. This walk-in list is available for London, but a map would be much easier to navigate for patients. This map could also be prominently displayed in ER waiting room entrances.

4) Complete visit records must be sent from the ER or the walk-in clinic to the family physician or primary care team within 24 hours

This serves two major purposes. One is to inform the family physician that the patient has sought care elsewhere. There is often an issue that needs follow-up, and if the family physician doesn’t even know the visit took place, follow-up can be difficult. The second purpose is to provide complete records to guide any further evaluation. This is pretty self-explanatory. The more information the family physician has, the fewer tests are duplicated, the fewer errors are made. Here in London we have a system called the LENS, whereby the physician is sent an email every morning detailing every patient of theirs who was in any local ER or admitted/discharged from hospital. If they ever discontinued this service, I would picket my local MPP’s office personally.

5) ERs and walk-in clinics should be required to report to MOHLTC names of patients who state they don’t have a family physician or primary care team

Some ERs have programs in place where frequent users are identified and underlying socioeconomic issues are addressed. My proposal would help the MOHLTC to identify patients who are attending any acute care centre frequently, and to match them to a family physician. Of course this proposal is contingent on point #1, whereby we have enough family physicians or primary care teams to make this happen.

6) Have accessible “Urgent” clinics across many specialties, and very clear hours and days that they run, and posted preferred contact information

Every primary care physician runs into this situation. The patient comes in with an urgent issue, we know which type of specialist we want them to see urgently, but navigating the system to get to that specialist is a maze. Finally we give up, and knowing that the patient can’t wait days to see the specialist, they are sent to the ER. Every community has success stories of urgent clinics that provide tremendous service to the community. The local LHIN should provide every primary care physician with the following (created in consultation with the head of each speciality): a list of urgent clinics in every discipline, the preferred means of contact (to call the specialist directly, the resident, secretary, etc), and the hours and days of operation.

7) Community radiology facilities should be required to have same-day appointments and reporting available for x-ray and ultrasound

Primary care physicians are happy to manage urgent conditions as an outpatient, provided that we have access to the necessary testing. This is especially true for physicians working in nursing homes. Quick guaranteed access to radiology and laboratory services could prevent numerous admissions to hospital for a “diagnostic workup”. Along similar lines, the government needs to continue to work urgently towards having all lab and imaging reports (from both community and hospital) available for access to any practitioner. ER docs should have access to view (not add to) the GP’s files, and vice versa. The amount of duplication and ER visits because of this lack of access would truly disgust the public. I know that the MOHLTC have information sharing on their radar, but this has to become reality ASAP.

8) National, provincial and local bodies need to design better patient education tools for self-management

Part of making our health care system manageable is to decrease unnecessary utilization. But what may seem like unnecessary utilization to a health care professional may seem like an unsolvable ailment to a patient. This education can take the form of waiting room resources, online tools or online evidence-based guidance. More often than not, patients are simply looking for either reassurance or very simple advice, which should be very simple to provide them for viral illnesses, MSK pain, non-urgent issues, etc. Scrap Telehealth (and other similar provincial programs), put their algorithms online for patients to interpret themselves, and put some of the money saved into online patient education (I’m a unabashed fan of the work being done at the Evans Health Lab by Dr. Michael Evans and his team).  An easily accessible resource through the CMA, for instance, could be a patient’s go to resource for all acute illnesses. It won’t be an inexpensive project to complete, but the savings would be nationwide.

9) Continue to address the social determinants of health

This could be a 3,000 word essay onto itself, but we need to continue to provide funding to address poverty, homelessness and drug use, in order to curb emergency department use. The complexity of that solution is well beyond my expertise, but it needs to continue to be a top priority at all levels of government.

10) Continue to provide accessible home care

I know that the CCAC here in Ontario has come under fire at times for being top-heavy in terms of management, but over the past couple of months I have noticed the CCAC case managers doing great work in trimming unnecessary services to patients. Keep in mind that private companies are employed to administer the services, so without a case manager to oversee utilization, there would be very little accountability remaining. Physicians and other health professionals need to know that if they see a patient and make any home care recommendations, to call the case manager directly. Don’t just send a fax to CCAC and hope for the best. They’ll end up in crisis in the ER.

 

So there it is, my entire manifesto. I’d love to hear your feedback and suggestions, because I really do hope that we can moved forward in communities with some of these changes. The sooner we begin to work on local and provincial solutions, the sooner we can avoid any of the likely consequences of ER overcrowding in the future.

Food trucks in London: The need for menu nutrition labelling

The food truck debate has re-ignited In London this past week, after last May the previous council narrowly voted down the proposal 8-6. Political momentum for the food trucks certainly seems stronger than it has been previously, and public support generally appears to be favourable. As far as the economic implications go, I will leave that debate to those with far more experience than I.

What about the health implications? The projected small scale of this project (eight food trucks were proposed at the previous vote) provides a tremendous opportunity for the City of London to be a trailblazer in the area of menu nutrition labelling.

The epidemic of obesity in our society, and the wide-ranging health consequences of obesity should not be news to any citizen. Obesity increases the risk of cancer and cardiovascular disease, and is now challenging smoking as the number one cause of premature preventable death. This is established fact. Dining out has been well-identified as a major contributor to obesity, both from higher-calorie meals at restaurants compared with homemade meals, as well as from a consistent underestimation of calories consumed when dining out. Over 60% of Canadians eat out at least once a week, and 7% eat out daily (1). It has been well established in the literature that providing diners easy access to nutritional information will lead them to make better choices. The World Health Organization (WHO) declared over ten years ago that better nutrition labelling could have a major impact on the burden of global obesity (2).

But does the public want this? And will it help? A study from 2013 in the Canadian Journal of Public Health showed that in a mock restaurant simulation where detailed nutritional information was provided, individuals who changed their order after seeing labels decreased their caloric intake by 200-500 calories. A menu labelling pilot project in Tacoma, Washington, found that 71% of customers had the seen the nutrition information, and 59% acted on it in some way (3). The largest study on this issue was done in New York, Boston and Philadelphia, using Starbucks locations. Among individuals who ordered more than 250 calories per transaction, there was a 26% reduction in calories ordered in the NYC labelling group compared to the Boston/Philly non-labelling group (4). Two recent Canadian surveys found that over 90% of Canadians support menu labelling in fast food restaurants, and that 86% of Canadians want nutrition information visible at the point of purchase (5,6). The two most common nutritional values that customers would request are calorie and sodium information (79% and 74%, respectively) (7).

There doesn’t seem to be much controversy as to whether menu labelling would improve health outcomes, so why don’t we see prominent menu labelling at every restaurant? Currently menu labelling is voluntarily across Canada, and done sparingly. The majority of large chains provide nutritional information hidden from view, which is known to be a barrier to customers incorporating it into their decision-making. Numerous private members’  bills have come forward both at the federal and provincial level advocating for mandatory menu labelling, but unfortunately there has been more debate than action. Bill 45 was introduced in November 2014 which would include mandatory menu labelling for chain restaurants with 20 or more locations (it is important to note that initiatives like Bill 45 have the full support of our local Health Unit). Like anything at the federal and provincial level, things are moving at a snail’s pace.  Lobbyists with the Canadian Restaurant and Foodservices Association (CRFA) and the Ontario Restaurant Hotel and Motel Association (ORHMA) are not in favour of mandatory menu labelling, arguing they are providing the information through other means. The evidence in favour of mandatory menu labelling is very much in contrast to their opinions.

From a municipal level, I have been quite impressed with the work Toronto Public Health has done in this area. They created a comprehensive technical report in April 2013 that addresses all of the relevant issues to consider when implementing mandatory menu labelling within a municipality. They are quite clear that the jurisdiction for menu labelling can fall within any of the three levels of government. Implementing this magnitude of program in a city the size of Toronto is no small feat, and I understand that they continue to work towards their goal of mandatory labelling.

London is in a unique situation. Our size allows us to implement innovative programs on a smaller scale, and this food truck situation specifically will be on a very manageable scale.

My proposal would be this: Each food truck would be required as part of their city permit to post calorie and sodium content clearly on the menu for each item, on the front of the truck. They must also have pamphlets or brochures available with comprehensive nutritional information (calories plus 13 core nutrients).  The owner/operator will not be required to have nutritional analysis done by an outside laboratory, but can simply calculate the nutritional content using an easy-to-use program (e.g. MasterCook, etc.) to analyze the recipe. The truck will be required to have printed complete nutritional analysis available for inspection by the DineSafe program run by the Health Unit. The issue of penalties for non-compliance would be analogous to penalties for current inspection failures under the DineSafe program.

It’s as simple as that. The typical barriers that are argued by opponents of mandatory labelling are cost to the restauranteur for the new menus and the nutritional analysis. As new startups with the self-report analysis I have proposed, these barriers would not exist. What has been shown in a few studies is that mandatory labelling actually leads to the business improving their nutritional offerings as a means of attracting more customers.

This is by no means a comprehensive program, and some would argue a needless drop in the bucket of obesity management. But I think its primary value lies not solely in the nutritional value to the specific customers of the food trucks, but also by increasing the awareness of the need of this type of nutrition knowledge among our population. Our local Health Unit has come out in favour of measures like Bill 45, and this type of small project will make the path to passing that legislation smoother. Once successful, the next logical steps for the program could include mandatory labelling at all city-run food services including City Hall and Budweiser Gardens.

As the first municipality in Canada to implement a mandatory menu labelling program, London would be seen as an innovative pioneer in the area of public health, and I look forward to seeing this type of program take shape.

 

 

1. CBC News, July 10, 2012. Visa Canada Report. Retrieved November 1, 2012 from http://www.cbc.ca/news/health/story/2012/07/10/lunch-eat-out-survey.html?cmp=rss

2. World Health Organization. (2003). Diet, Nutrition and the Prevention of Chronic Diseases: Report of a Joint WHO/FAO Expert Consultation. Joint WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of Chronic Diseases. Geneva: World Health Organization

3. Pulos, E. & Leng, K. (2010). Evaluation of a voluntary menu-labeling program in full-service restaurants. American Journal of Public Health, 100(6), 1035-9

4. Bollinger, B., Leslie, P. & Sorensen, A. (2010). Calorie posting in chain restaurants. National Bureau of Economic Research, Working Paper 15648. Retrieved February 7, 2013, from http://www.nber.org/papers/w15648

5. Ipsos Reid, for Public Health Agency of Canada. (2011). Canadians’ Perceptions of, and Support for, Potential Measures to Prevent and Reduce Childhood Obesity, Final Report. Retrieved on February 7, 2013, from http://www.sportmatters.ca/files/Reports/Ipsos%20Obesity%202011.pdf

6. Canadian Obesity Network/Ipsos-Reid. (2012). What Do Canadians Know and Think About Calories?A National Survey, October 2011. Presented at Calories Count Symposium, October 25, 2012.

7. Scourboutakos, M. & L’Abbé, M. (2013). Restaurant Menu-Labelling Survey Results. Prepared for Toronto Public Health.

Ontario MDs vs. the Ontario government: We need better

Like most Ontario physicians, I’ve spent the past 24 hours trying to digest our failed negotiations with the Ministry of Health and Long-Term Care (MOHLTC).

I don’t typically consider myself to be someone who is particularly passionate about matters of remuneration. I generally feel I’m paid adequately for the services I provide, and I think most physicians would agree with that sentiment. When the negotiations fell apart in 2012 and a 0.5% clawback on our services was unilaterally imposed by the government, I didn’t feel too aggrieved. I understood that our economy and the provincial coffers were in tatters, and that some degree of austerity would be expected from public sector workers. Perhaps naively I assumed that as a result of the 2012 negotiations that the province would feel the urgency to craft a sustainable strategy that ensured no further cuts to physician compensation and adequate patient access to care. Then yesterday happened.

As frustrating as the proposed cuts were, I am infinitely more irritated at the spin that Health Minister Dr. Eric Hoskins has been weaving both in interviews and on social media. I understand that in any labour negotiation, his job is to craft a message to the public to put the government in a good light. He has inherited an absolute mess from his predecessors, and I don’t envy him in the least. But I expect honesty from him. He has repeated his mantra of the “average physician making $360,000”, knowing full well that the public will interpret this as a net pay and not understand the weighty overhead expenses and other fees that physicians pay. And that physicians receive no pension or benefits. He has asserted that overall compensation to physicians will be unchanged, again glossing over the fact that the users within the system will continue to increase. He is intentionally confusing the public by conflating overall physician compensation with individual compensation.

“The OMA wants you to believe that doctors in this province can’t provide the same level of care as last year unless they receive a pay raise and we simply don’t agree,” Hoskins said.

Except they aren’t asking physicians to provide the same level of care. They will be asking physicians to provide more care as the system grows, without any funding to account for growth, and without any plan for managing the growth.

One of his other favourite criticisms is that physician compensation has increased 60% since 2003. Again the obvious deceit in this is that he is describing overall compensation (which accounts for more users) while knowing the public will interpret this as individual compensation. I would actually prefer that he come right out and say who he blames for the increases. Is it physicians in FHOs? (Disclosure: I am a fee-for-service physician). Is it ophthalmologists? Other specialists? Lumping all physicians into one group of fat cats muddies an already messy situation. He mentioned in a Tweet that in the negotiations, “We wanted to focus more on high earners. OMA did not accept.”. This seems to be directed at high-income specialists, but he didn’t provide any further clarification. The OMA is in a tricky position representing many group of physicians with varying financial interests, and understandably will not criticize any specific group of members, while trying to appease everyone. It is then incumbent on the Ministry to be crystal clear in communicating to the public and to physicians where they identify the remuneration problems to be. For instance, even as a family physician, I have no idea how the Ministry views the sustainability of FHOs/FHTs. Their sound bites frequently describe their commitment to these groups, but they then complain about exponential growth in physician income. Clarity is much needed.

A quick overview of Hoskins’ comments on Twitter over the past 24 hours demonstrates that he is of the opinion that physicians in Ontario are overpaid. Which is an argument that he is entitled to defend. But in addition to his above mischaracterizations to the public, he has also brought up physicians’ ability to incorporate and income split as justifications for fee cuts. An issue that was negotiated years ago in a different era, now being used to justify a fee decrease seems a bit questionable. He also notes that physicians are allowed to charge yearly block-fees for uninsured services, but he fails to mention that only a small minority of physicians actually charge that fee. I personally do not charge block-fees to patients, so to see Hoskins use that as some sort of justification for fee cuts makes me scratch my head.

Can you imagine any other public sector employees facing a long-term freeze, let alone the cuts that are being proposed to physicians? There would be mass hysteria. The Ministry started off in the negotiations looking for $740 million in savings. That’s one heck of a jumping off point. I won’t veer off track by criticizing other provincial scandals in other sectors, but trying to recoup that magnitude of funds in one fell swoop sure as hell better be supported by a great plan moving forward.

Here’s my question to the ministry. Let’s assume that the OMA accepts the proposal from the MOHLTC including all cuts, with a total savings of $650 million. What happens in 2017? Inevitably utilization of health care will increase, and the deficit will still be a major issue for the government. So more cuts to fees? What is the end game? That’s the part I struggle with the most. There has been no strategy communicated from the Ministry for how they plan on funding health care moving forward. They will likely point to the proposed “Task Force on the Future of Physician Services in Ontario” and the “Minister’s Roundtable on Health System Transformation” from Judge Winkler as the solution to our system’s ills. And while both of those initiatives are badly needed, the Ministry is asking physicians to sacrifice financially in the short-term, and asking us to trust that they will be able to solve things by 2017. Colour me skeptical. Judge Winkler articulated the problems we face in his report from Dec 14, 2014:

It is apparent that these positions are irreconcilable in the longer term. Absent some rationalization, the system may not be sustainable. Thus, the consensus emerged that without systemic changes to the health care system, the Parties seemed to be on a collision course so that a PSA (Physician Services Agreement), at some point in the future, may not be achievable.

Having reviewed the proposal from the Ministry, I don’t necessarily disagree with all of their proposals. Their argument that they shouldn’t be funding Continuing Medical Education for only certain groups of physicians is a logical one, and if they were to provide a framework for more evidence-based CME (similar to their Low Back Pain Strategy), that would be a positive development. Their proposal to eliminate patient enrollment bonuses has been criticized as being unfair to new grads, but I think at the very least physicians should be obligated to be responsible to those patients for a minimum period (5-10 years) to retain those bonuses.

One issue that is rarely addressed by the Ministry is how they plan on dealing with impending tsunami of health care utilization. Their strategy appears limited to putting our small fires with grand funding announcements, but an embarrassingly small amount of effort seems to be put towards patient health education and self-management promotion. Teach patients these principles, and they will require less costly care. If this doesn’t become a priority, we will continue to aimlessly throw money at political hotspots and fail to make any real progress.

Physicians are desperate to be part of the solution in our health care system. We see how poorly it functions, and we are in the best position to aid in the recovery. It’s part of our nature as healers to want to help. That’s why a major component of the negotiations included suggestions from the OMA on how to find efficiencies in the system. And I fear that the stance taken from the MOHLTC will embolden some physicians to withdraw from roles where they can help our system. I sincerely hope that this controversy prompts physicians to become more engaged in local system improvements, as clearly our government is sorely missing any top-down solution in the near future.

Here are a few interesting infographics from the OMA about patient education, increasing demand, and understanding overhead. They are a tad politicized of course, but provide some important numbers to the public.

Links for a lazy Sunday – New Years 2015 Edition

It’s the first week of January, so it’s a given that the majority of the online health buzz has been about nutrition, exercise, resolutions, etc. That doesn’t mean the content has been dull however, so without any further ado…

1) This hilarious video poking fun at bad nutrition advice has been making the rounds from British comedians David Mitchell and Robert Webb from their hit show That Mitchell and Webb Look. The video is from 2009, but it’s still well worth the watch. Funny enough, it’s the hardest I’ve laughed at a medical parody since the last video I watched from Mitchell and Webb.

2) Julia Belluz (@Juliaoftoronto) from Vox gives us two great pieces focusing on lifestyle changes in the new year. This one gives a good look at integrating exercise into daily life, and the other gives a 7-day nutrition start for the New Year with help from expert Dr. Yoni Freedhoff (@YoniFreedhoff).

3) I’m an unabashed fan of the work done by the people at Science-Based Medicine and Neurologica. Pharmacist and skeptic Scott Gavura (@PharmacistScott) provides us this piece from early December following up on the CBC marketplace investigation into homeopathic “vaccines” and anti-vaccine rhetoric from those providers. He also wrote this evisceration of “detox programs”, to serve as a future reference whenever we are confronted with anyone pushing detoxifying pseudoscience. Steven Novella (@SkepticsGuide) chimed in with this entertaining piece on “How to Create a Fad Diet”.

4) Many emergency departments have been dealing with longer than usual wait times over the holidays, and this video provides a light reminder to patients on what constitutes an appropriate visit.

5) For anyone who has any interest in the art of debate and logical thinking, the website “Your Logical Fallacy Is” is an absolute gem. They offer both printable posters and posters for order through the website, making for easy access to call someone out on a logical fallacy quickly.

6) Here’s a useful article for patients from the NHS in the UK on how to critically look at health-related articles in the newspaper and online.

7) More patient resources, here’s an entertaining cartoon that explains in simple terms why vaccines work.

8) Big news here in Ontario this week as the smoking laws have changed as of January 1st. A much needed step forward in curbing tobacco use.

Hope everyone has a great week!

Resolve to be a rationally prescribing and rationally ordering physician

We’ve all come across a year’s worth of diet and exercise articles online, and it’s only January 2nd. Resolutions are good, resolutions are bad, resolutions can cure hepatitis, our social media feeds are busting at the seams. So I’ll spare you yet another lifestyle-related post. You’re welcome. But seriously, find a combination of exercise and nutrition that you enjoy and do an accurate daily food diary. I’ll leave it at that.

Let me use this demarcation in the Gregorian calendar to speak to those of you who play a role in decision-making in our health care system. Not only physicians and nurse practitioners who order the therapeutics and tests, but also the other allied health professionals who advocate for certain tests.

Let’s all be rational this year. Now I know for some of you irrationality is part of your life blood, but I think we can all afford to be a bit more rational when it comes to what we order.

Looking back at training in medical school and residency, cost is almost never discussed. I don’t think it is omitted out of any malice, but I think the main reason it isn’t discussed is that most staff physicians themselves have no idea what dollar amount to put on therapeutics and tests. I’m sure a handful of them truly don’t care, but I think in our health care system that is over-burdened, we all share a duty to make cost-effective decisions in our practices. Most physicians would rather make a fiscally prudent decision if it resulted in equivalent patient outcomes.

So let’s start with therapeutics. Can you honestly say you know the cost of every prescription you wrote this week? If you can’t, you’re far from alone, as most physicians don’t have a clue. But I think we all realize how absurd this is. Big decisions with big money involved, and ignorance is frankly not justifiable. Patients and the public expect that our therapeutic decisions are evidence-based and cost-effective.

“But the medications are covered under their plan”. The health care economy (including private insurance coverage) is a zero-sum game. That wasted money is coming out of somewhere else. So please never use that excuse. It’s lazy.

I often hear from physicians that finding out these exact costs is difficult, Which in some cases is very true, as the prices are not easily searchable online. But rather than simply resign yourself to not knowing the exact price, take a bit of time to educate yourself on the approximate costs. Here is a fantastic resource from the Alberta College of Family Physicians with the costs of commonly-prescribed medications. Take 5 minutes and read this document. You will be surprised by the costs within many of the medication classes. Ezetrol is 4-5 times more expensive than a generic statin. Adalat is almost double the cost of amlodipine. Coversyl is 5 times more expensive than generic ramipril. Brillinta (ticagrelor) is 4 times more expensive than Plavix. Glumetza is 8 times more expensive than generic metformin. Zyban is 4 times more expensive than using wellbutrin SR. Brand Nexium dwarfs the cost of other proton pump inhibitors. Look at the costs of Cipralex, Pristiq and Cymbalta. Check out Avodart vs. Proscar. (Bear in mind that these are prices from Alberta, but the general trends will hold from province to province). The Ontario Drug Benefit Formulary is also useful for comparing prices of medications.

Now you may have a justifiable clinical indication for using the more expensive option, which is why they are included in the formularies to begin with. But you need to know the magnitude of the cost differential before you make that decision.

What about ordering tests? I won’t spend any time discussing imaging, because that seems to be one area where physicians are already slowly becoming more rational. We know imaging is expensive, and we generally always think twice before ordering it.

So I’ll focus my energies on lab testing. As a medical student, I remember working with a surly emergency physician who was borderline militant with forcing me to justify every blood test I wanted to order. While my less mature self was frustrated with this tedious process, I have come to appreciate this approach. He’s still a jerk, but he’s a rationally ordering jerk.

The checklist forms provided here in the community in Ontario lend themselves quite easily to over-testing. Want a test? Just check a box. You don’t even have to consciously think about the clinical problem, just peruse the form for your selections. The form has been revised for the better in recent years, with the TSH, B12, ferritin and AST removed from the checkbox area. But it’s still too easy, so you have to actively think about whether the tests you are ordering are imperative.

Finding the costs of OHIP-covered tests in the community is actually quite challenging. None of the community labs I contacted would agree to provide me a complete list of the reimbursement prices for lab tests. They would however give me the price of specific tests I asked for, so I was able to make some rough estimates. To determine an approximate cost, visit the OHIP Schedule of Benefits for Laboratory Testing. Take the “LMS Units” on the right side of each test, and the cost in dollars is roughly 35-50% of that number. Ferritin is 28 LMS Units, and costs $10.34. CBC is 16 LMS Units and costs $6.72. On top of the costs of individual tests, the lab will then charge OHIP an additional $7.76 for a “Patient Documentation and Specimen Collection Fee”. Take 5 minutes to peruse the list and you’ll find at least a few surprises.

(Here is a list of non-OHIP covered tests. The price lists are available to providers upon request to the lab, but I am not allowed to post it publicly. It is a useful resource to have in the office.)

The dollar amounts for tests ordered in hospital doesn’t follow this formula, as the testing typically comes out of a global budget . But the theory still stands, that fewer tests ordered results in cost savings and more money for other valuable patient care. Again you may have a justifiable clinical indication for that expensive test, so do what you think is in your patient’s best interests. But know the approximate cost of that decision.

Why did you just order that chloride level in a stable outpatient? Why have you ordered their magnesium level as an inpatient every day for the past week? It was normal on days 1-6, I think you were ok to skip day 7. Ordering a patient’s lipids to check compliance? Ordering serial vitamin D levels in a patient with uncomplicated osteoporosis? (The elephant in the room here are “naturopathic MDs” who are burdening the system with piles of unnecessary tests covered under OHIP, but for now we can only control our own behaviours and order with our own conscience.)

(Hat tip to Dr. Zain Chagla, Infectious Diseases expert, in the comments section for mentioning the likely direct patient harms with over-testing. We’ve all seen that incidental elevated lab value lead down a rabbit hole of further testing, costing the system boatloads of money and the patient a lifetime’s worth of anxiety, all to discover there was no pathology.)

To implement rational decision-making in primary care is fairly simple. Our days consist of a marathon of small decisions where cost-savings can be found. If you look for them, you’ll find them. Finding these same opportunities in sub-specialty care can be a bit more tricky, but still possible. Spend the next two weeks asking mentors and colleagues what your commonly-used therapeutics and tests cost. If they don’t know, try and find the answer. Are there safe lower-cost alternatives?

So let’s spend 2015 being rational. And try to stay rational for longer than you stick to your other resolutions.