Monthly Archives: March 2016

Re-establishing trust must precede primary care reform in Ontario

Last week was yet another banner week in the relationship between the Ontario government and Ontario’s doctors. Health Minister Eric Hoskins announced to every media outlet that “Unpredictable and frankly out of control billing by some doctors is a problem”. Predictably, physicians responded angrily, frustrated by the latest dishonest PR attack by the government on the profession.

Most concerning in all of this is the progressing erosion of trust that physicians have in the provincial government. Every sound bite of intentional misinformation over the past year has chipped away another piece of that relationship. Rather than view the government as a partner in building up our health system in an evidence-based manner, most Ontario physicians now view every new policy or statement from the Ministry of Health with overwhelming cynicism.

Why is this important? Why should the government care what physicians think or how they feel?

First, this should be a concern for humane reasons. A workforce that feels lied to, underappreciated, and ignored, will be a workforce that is very prone to burnout. Read this recent article from ethicist Art Caplan about physician burnout being a public health crisis, and see if you can see any parallels to the current situation with Ontario physicians. It may surprise the government, but to most physicians, their frustration with the government ceased to be solely about compensation a long time ago.

The second reason that the government needs to re-establish trust with physicians is a practical one.

Progressive Conservative health critic Jeff Yurek stated last week “The government is set to redesign the health care system, the biggest redesign in over 50 years, and they don’t have the doctors on side.”

Truer words have never been spoken. The magnitude of what is being planned is enormous. Completely transforming the way primary care is delivered in the province. Downloading responsibility to LHINs, and asking them to work with local health care providers to optimize access, establish local accountability measures, and provide local solutions.

With one major problem. It is difficult to move forward with any meaningful changes without overwhelming physician buy-in. Physicians, the one group in health care that has a birds-eye view of the entire system, with a strong connection to both stewardship and patient care, and with the potential to successfully steer these projects in the right direction, feel alienated by the governing powers.

To the LHINs’ credit (and mine in particular, the South West LHIN), they have made attempts to engage with physicians, but without a strong message and feeling of trust from the upper echelons of the Ministry of Health, rank-and-file physicians will not be willing adopters of any new system.

As an example, I wrote an article last week that called for a program that mandates that any billing specialist must register with the LHIN or LHINs in which they see their patients. Simple enough, I thought, and some LHINs already had similar plans in the works. But the most common feedback I received from physicians was “Great idea, but we don’t trust the LHINs to do this.”

Let that sink in. Physicians trust the Ministry and the LHINs so little that they don’t even feel comfortable with them maintaining a simple list, one that would likely help them in practice. And somehow this relationship will magically improve enough for physicians to become eager partners in this transformation?

The Ministry needs to begin the healing process, if for no other reason than to make it easier for the LHINs to do their job of engaging physicians. This likely involves coming to a amicable solution on compensation (I still have faith this is possible), and more importantly, stopping the anti-physician rhetoric coming out of Queen’s Park. Physicians feel defeated as it is, and don’t need a monthly reminder of the disdain that the government seems to have for them.

I truly hope that the government takes some of this to heart, as I don’t see a smooth path forward for primary care reform given the current distrustful climate. Something needs to change in this relationship, and it needs to change soon.


Who are the doctors in your neighbourhood?

Patient X comes in with Issue Y, and requires a referral to a specialist. But who to refer to?

I think most Canadian patients would be surprised to learn that there are no standardized databases/lists/processes for accessing specialists in a most regions. Our referral patterns are essentially dependent on a combination of specialists we know personally, specialists who have seen our other patients, or specialists we have heard of through word of mouth. I have been working in my community for a decade, and I still come across specialist names that have been apparently working in our community for many years, and I wasn’t aware of them. It’s an insanely inefficient process, and has a negative impact on patient care as their care is entirely dependent on how familiar their physician is with local human resources. I know that there are exceptions to this, as some local specialty groups do provide physician listings, but these are very infrequent, and often only include hospital-based physicians.

Simple solution here in Ontario? Create a program that mandates that any billing specialist (including FP focused practice physicians) must register with the LHIN or LHINs in which they see their patients (MDs who see patients via telemedicine or EConsult can be a distinct list). Regardless of whether they are accepting referrals or not, they should at the very least be part of a directory that is easily accessible to referring physicians. Referring physicians will quickly adapt if the specialist is not accepting referrals, or wait times are long, etc. It would be the responsibility of the physician to ensure that their status and contact information with the LHIN is up to date, as part of the terms in maintaining their billing number. Some of this information is obviously already collected by the CPSO, which should cut down on the work required by the LHIN.

I’m not asking for wait time data from specialists, as I know that will open a controversial and complicated puzzle that will not be easily negotiated. Along the same lines, I don’t think we should create a list of common referral problems that each physician will see, as I think this will be a potentially impossibly complex task to undertake.

But at the very least, we need to know who works in our community. No more hiding in the shadows. Referring physicians are struggling to access timely specialist care for our patients, and one of the first steps to fixing this includes adding some transparency to this process.

What anti-vaxxers and Trump supporters have in common

For a Canadian physician with ostensibly more productive ways to spend my time, I have spent far too many hours following the circus known as the Republican presidential primaries, headlined by the dreadful Donald Trump. Like the majority of Canadians, I have been disgusted by his racism, his bigotry, his arrogance, his disagreeability, his demagoguery, his inability to answer questions with a  grain of truth, his hyperbole…etc, etc.

Most of us cannot fathom how Trump can hold any appeal to an electorate. During any of his speeches or press conferences, I will scream at my television, “C’mon Trump supporters! That has to be the last straw! You can’t support him after he says something like that!”

Yet they stand by him. As Trump famously attested, he could stand on 5th Avenue and shoot somebody, and many of his supporters would still vote for him. And he likely isn’t wrong.

This phenomenon was described last week by pundits as Trump’s support having “calcified”. When I heard this term, a light bulb went off for me, and I realized that we have been dealing with this exact phenomenon in medicine for years.

The “calcification” of the anti-vaccine movement.

Many Trump supporters often begin their Trumpism innocently enough. They are frustrated with government, and gravitate to an anti-establishment candidate. But then they are shown evidence that their candidate has serious flaws. And rather than evaluate evidence both for and against their candidate, they view all criticism through the lens that it must be biased against Trump. With more criticism, more delusions of persecution follow. And after a few weeks or months, they are too invested in the idea of Trump to possibly evaluate him objectively.

And then we have anti-vaxxers. Again, many may have developed their anti-vaccine views innocently enough. Parents of children with autism who were desperate for answers. Parents who are wary of pharmaceutical company influence. Parents who are being influenced by noted pseudoscientists who are peddling books, supplements, programs, etc. It is far from shocking that so many people may begin as “vaccine-hesitant”. But at some point, they transition from being “vaccine-hesitant” to being ignorantly against all vaccines. A famous study from 2014 in the Journal of Pediatrics looked at the effect of various educational interventions on parents’ beliefs and attitudes about vaccines. Shockingly, all of the interventions (providing them evidence that MMR doesn’t cause autism, images of children with measles, text information about the dangers of disease, narratives about children with disease) failed to increase the likelihood of vaccine uptake, and some actually DECREASED the parents’ willingness to have their children vaccinated.

For anti-vaxxers, it’s always about the vaccine. “The vaccine causes autism”. Well no, it’s doesn’t. “The vaccine has mercury”. Nope, not any more. “It’s a pharmaceutical conspiracy”. It’s a game of Whack-a-Mole. Make one argument, and another one pops up. It’s not about the evidence, the science, or health. It’s about the vaccine to them, and nothing else.

To Trump supporters, it’s not about the truth, or about policy, or about foreign affairs, or about anything relevant to being president. It’s only about Trump.

(As an aside, “Making America Great Again” is essentially the Trump version of anti-vaxxers “doing things naturally”. It’s a catchy slogan, and elicits a certain positive emotion, but it completely lacks any meaningful substance.)

There’s a reason why Trump has espoused anti-vaccine views throughout this campaign. During a debate in September on national television, he told this story: “People that work for me, just the other day, two years old, beautiful child went to have the vaccine and came back and a week later, got a tremendous fever, got very, very sick, now is autistic”. He knows that there is likely a tremendous overlap between devout anti-vaxxers and his supporters. Both groups value dogma over evidence, emotion over reason.

So what’s the lesson in all of this? Most physicians have accepted that our patients who are staunchly “anti-vaccine” cannot be reasoned with. Providing them evidence and explaining the benefits, is often futile, although most of us will still try. It is the parents who are “vaccine-hesitant” where there remains hope for evidence and science to triumph. And for Trump? I think his opponents will concede that the majority of Trump’s supporters are beyond reasoning with. But thankfully, the majority of Americans are still logical, reasonable, and open to the objective evidence of his complete lack of presidential qualities.