Monthly Archives: May 2016

“Hey doc, why aren’t we doing physicals any more?”

It’s a conversation we’ve all had with our patients. That difficult discussion where we explain why they don’t need annual physicals any more.

The patient’s initial reaction usually involves questioning why they aren’t getting the same level of care they are accustomed to. Will their health be compromised? How we deal with this complex discussion will resonate for years in the patients’ eyes, and will impact the trust they have in their physician.

We need to be quite familiar with the evidence that does not support annual physicals, and reassure patients that this has been studied at length.

Choosing Wisely has put together a very useful page for patients explaining a lot of the concepts that we want to communicate to patients around the topic of annual health exams. (Here’s the Choosing Wisely page for all of the patient pamphlets that Choosing Wisely provides, it’s quite a good collection.

Make it crystal clear to patients that even though they may not be having physicals any more, that all aspects of their care are still being monitored. When they come in for another issue, be vocal that you are simultaneously re-assessing their cancer screening, whether they need bloodwork done, reviewing their immunizations, addressing their risk factors, and evaluating whether you would make any general health recommendations or order any tests. Tell them that with our EMRs, this process is taking place in real-time, not just once a year like it was in the pre-EMR age.

If a patient doesn’t come regularly for other reasons, you may consider bringing them in every year or two, for what is sometimes being called a Periodic Health Examination. Patients should understand that this isn’t a physical, and for them not to be concerned when you aren’t listening to their heart or lungs, or looking in their ears. The purpose of this visit is to review their history including immunizations, family history, and social history, make sure screening is up to date, check a blood pressure, get a weight, and take care of other health-related measures that are appropriate for their demographic.

Bottom line: don’t quickly gloss over the fact that patients aren’t receiving physicals any more. This needs to be carefully explained to them, and physicians should also educate their staff to communicate the message equally clearly, not framing it as a potential decline in care, but rather an evidence-based change in how care is delivered.

(As an aside, I think it’s time that the “Annual Physical”, billed in Ontario as an A003, is completely de-listed as an OHIP service. Patients can still request their physical, and we can go through the motions of doing a physical exam on them, but it’s completely out of pocket and billed at OMA rates. And make it quite clear that the Periodic Health Examination is not a physical, but rather a comprehensive health review, ideally with this messaging coming centrally through provincial advertisements.)

Specialists, send your stable patients back to primary care

In most communities in Canada, we are seeing the same struggles of access to timely specialist care. While some of this can be attributed to a lack of OR time for surgeons, and under-funding of cognitive-based specialists leading to fleeing for greener pastures, some of our access issues could potentially be helped through some re-thinking of who does what in our physician system.

In primary care, we frequently have patients being followed by specialists for long-term issues that can easily be managed by their family physician. I am proposing that we all make a concerted effort of re-directing these stable patients back to primary care to allow easier access to specialist care for our challenging cases that are currently languishing on wait lists.

These efforts are already taking place specifically around cancer care follow-up, as a response to the recognition that oncologists (or other physicians involved in acute cancer care) only have so many hours to devote to active new cases, where their skills are the most valuable. Delegating long-term follow-up to family doctors has eased the burden on our cancer centres, and has been generally embraced by primary care. Family doctors are often already seeing these patients for other medical issues, and in many cases it has only added a few minutes per patients to ensure that they are receiving proper follow-up for the issue that was being managed by the specialist. Remember, family doctors are experts in managing complex patients with multiple comorbidities in an absurdly efficient manner.

The areas that require this sort of re-distribution most urgently are the cognitive specialities, and most specifically psychiatry. Access to community psychiatrists for adults, adolescents, and children, is dismal across the country, and in many areas, that is partly a consequence of some psychiatrists holding onto stable patients for far too long, and refusing all consults for new cases. Certainly some patients with a history of rapid deterioration, or who require ongoing specialist monitoring, would benefit from ongoing care with a psychiatrist, but I question whether every patient currently under the care of a psychiatrist requires specialist attention. I also understand that part of the satisfaction of psychiatrist is in developing  longitudinal relationships with patients, but psychiatrists need to understand that our deteriorating patients who are challenging the depths of our clinical expertise need their help far more than our patients  with stable conditions.

This concept would extend to other specialities, with my hope that cardiologists would focus on consults and diagnostics, while leaving cardiovascular risk management to primary care. Endocrinologists to send stable diabetics back to primary care, and allow quicker access for our unstable diabetics. Respirologists to send back the stable COPD and asthma patients, etc. I would also exempt multiple specialties from this concept, including opthalmologists who have technical expertise that exceeds anything that a family physician can provide.

I understand that this concept will get some pushback from some specialists, who feel that their simple, stable follow-up patients offset their complex patients that require a disproportionate amount of their time. But specialists must understand that they are a skilled, finite resource in our communities, many of which are in crisis with wait times, and they have a responsibility to our communities to ease their burden in any reasonable way. And if a specialist truly feels that they are the best and only person who should be following up a patient, then I will allow that it is their right to continue seeing that patient.

I also know that this concept will receive some raised eyebrows from some of my family medicine colleagues, who currently may already feel overburdened in what is expected of them. I will gently remind them how much time we waste navigating local wait times, and how much of an emotional toll it takes on us when we see patients waiting for specialists while we desperately try to keep them stable clinically. A few minutes of work added on to a few patients here and there will pay huge dividends in our overall practice satisfaction when we see our patients receive timely specialist care when they need it most.

My message to specialists: don’t hesitate to send stable patients back to their family doctor for follow-up, perhaps including a small note that this is part of an effort to open up spots for new referrals.

My message to family docs: don’t hesitate to send a note to your specialist colleagues offering to take back specific stable patients, making it clear that you are doing this to lighten their load, not to infringe on their turf.

My response to the Medical Post article on homeopathy

As a member of the Physician Advisory Board for the Medical Post, I sat down to read the May 10 issue and looked at the front page headline.

“The Dilution Solution”, with the subheadline stating that nearly 50% of physicians believe that homeopathic products can be helpful in certain situations.

(drops coffee mug onto the floor, shattering into a million pieces…)

For anyone who has read any of my writing, you can guess where I stand on this issue. Despite the special pleadings of the horribly misguided physicians cited in the article, homeopathy is a pseudoscience, with the overwhelming weight of the evidence showing its lack of effect compared to placebo, and its implausibility as a theory.

Evidently, 10% of physicians in Canada believe homeopathic medicine has well-established efficacy. That’s a pretty horrifying number, but probably in line with the proportion of physicians who slept through their critical appraisal classes in medical school, so I’ll believe it.

But if you’re one of the 50% of physicians that believe that homeopathic products can be helpful in certain situations, I’m directing this to you. You truly owe it to your patients to understand what homeopathy is, and why it is not harmless.

First, the story of Samuel Hahnemann. His infamous “experiment” with cinchona was deeply flawed of course, as we know that cinchona cured malaria because it contained quinine, not because “like cures like”. He also believed in miasms, which I would encourage you to read about for sheer entertainment. Thankfully, we now have 200 years of scientific discovery that disproves many of his postulates, but that has not stopped proponents of homeopathy from clinging to the theories of their founder.

It is important to distinguish homeopathic remedies from herbal remedies. A typical herbal remedy, although likely of highly questionable efficacy and safety, is still a real potential medicinal option. There is still potentially something measurable and tangible in the treatment. In a homeopathic preparation however, dilution after dilution is done, often to the extent that there is a near-zero likelihood of any active ingredient being present. The idea floated in the article that homeopathy is somehow working through nanomedicine is pseudoscience at its worst.  The thermoluminescence studies cited by Dr. Malthouse have not survived any degree of scientific scrutiny. As for Dr. Bell’s hypothesis that “low-level environmental stressors physiologically cross-adapted in varying degrees to the allostatic overload to which the individual has previously developed maladaptive responses”, I applaud her proficient use of a thesaurus.

The false balance in the article of those pro- and anti-homeopathy must be strongly condemned. Those promoting homeopathy as a legitimate treatment option are a vocal minority, and the scientific concensus showing no evidence for homeopathy is overwhelming. The U.K. and Australia have spent considerable money and resources doing high-quality analyses of the homeopathy literature, and have found no rigorous evidence to support the efficacy of homeopathy. Of course the response from homeopaths will likely be a combination of anecdotes and accusations of bias. They’ve already decided that homeopathy works, the evidence is just wrong. Those of us with a shred of scientific literacy and honesty know why their deduction process is backwards.

The pro-homeopathy physicians quoted in the article are sadly misguided when it comes to their views on homeopathy.

One physician stated that her patients use these agents to deal with physical pain, emotional stress and situations where they feel they require an “immune boost”. I completely understand the sentiment to not rock the boat when a patient with challenging, non-specific symptoms is actually doing well. But in a majority of these patients, these alternative remedies carry a significant financial burden, which we cannot ignore as their most trusted health professional. Please at least respect your patients enough to give them an explanation of why their placebo appears to be working. But don’t actively participate in the charade.

The same physician sings the praises of the placebo effect, and I’m sure she would also argue that some other common treatments in medicine are also barely more effective than placebo. But when it comes to actively recommending what you know to be a placebo, you cannot ethically recommend something you know to be inert without disclosing the relevant evidence to the patient. And remember these placebos are never free!

Another physician claimed that “there is no doubt that homeopathy works”. How any health professional with any meaningful standards for evidence can claim that is beyond me. He predictably proceeded to cherry pick a few favourable studies which supported his beliefs, while ignoring the fact that the majority of robust research has shown no benefit.

I would also warn physicians that, although some of society has embraced the inertness of homeopathy, thankfully our regulatory colleges have not been so naive.

“Allopathic medicine” was used in the article repeatedly to describe non-alternative medicine, and I hope this is the last time that I see this phrase used in the Medical Post. The term was coined by none other than Samuel Hahnemann to disparage what he viewed as mainstream medicine at the time. To continue to use this meaningless term in 2016 is insulting. There are only two kinds of medicine: medicine that the evidence shows to be efficacious, and medicine without strong evidence. As a physician, I recommend exercise, relaxation techniques, a healthy diet, and quality sleep, because the scientific evidence supports those measures. Any terms like integrative, allopathic, and holistic, are meaningless and create a false dichotomy amongst practitioners, and only serve to confuse our patients.

What is driving this inability of practitioners to honestly tell patients that there is no evidence-based treatment for their ailments? Why have we reverted back to the days of snake oil? I think much of it is rooted in the modern-day expectations of our patients, who expect answers and cures for any disease or symptom, because “it’s 2016 already”. And physicians, often on the defensive, feel a need to offer something, anything to make the patient feel better, even if it’s unproven or inert. One physician in the article stated that he “prescribed homeopathic products for patients with chronic conditions when the medical model has failed them”. But we can’t fall into that trap. We need to be the defenders of science, and evidence, and honesty. We need to be the professionals who are skilled enough to explain to our patients in an empathetic manner that we may not have definitive evidence-based solution for them, but we will continue to support them through their medical journey, and we will always look out for their best interests.

Our patients trust us as physicians to manage their health and respect their pocketbooks. We cannot allow ourselves to be dragged into the pseudoscientific world where scientific rigour appears meaningless, and anecdote trumps evidence every time. Be honest with your patients, and explain to them exactly what homeopathy is. And tell them what the evidence shows. The majority of them will make the sensible decision.

The LHINs need more central guidance for primary care reform

Health Minister Eric Hoskins released the Patients First discussion paper in December 2015, detailing the government’s plans for primary care reform in Ontario. Like most individuals involved in primary care, there were a number of aspects of the paper which concerned me, but none more so than the shocking lack of detail provided to guide implementation at the LHIN level.

The ministry invited feedback, albeit within a disappointingly tight timeline. The OMA and OCFP both provided very detailed responses to the paper, which can be found here and here. I agree with many of the positions and concerns of both organizations, and was perhaps naively hoping that we would see the ministry refine its plans in response to the detailed feedback from experienced organizations.

Nope.

Instead, what we have now is 14 separate LHINs actively moving full steam ahead with their own distinct plans for how to manage primary care in their regions. Having read detailed summaries of each LHIN’s implementation plan, I was struck by how needlessly different each implementation plan is, even in the most basic of principles.

As someone who is generally supportive of the need for primary care reform, I am frankly horrified at the degree of variability I’ve seen in the plans. As sharply as the Price Report has been criticized, at least it could be argued that it attempted to provide a unified plan for a province-wide framework to move forward with. What we have now is essentially 14 separate LHINs each creating their own version of the Price Report.

Many of the LHINs reference “current performance standards accountability”, or “performance and outcome framework with associated accountability and services agreements that reflect common dimensions”, or other variations on this theme. They make the erroneous assumption that we are anywhere close to being able to implement a consensus accountability framework for physician activity. We’re not even close! This needs to be negotiated centrally, and there needs to be significant consistency province-wide. The LHINs should not, and cannot, be allowed to negotiate these accountability agreements locally with physicians, as it violates the Representation Rights Agreement (RRA) that exists between the OMA and the ministry. LHINs will likely, by default, use AFTHO and HQO indicators to rely on for any accountability measures, which have not had appropriately broad physician consultation. (On a separate note, there are hundreds of RRA violations to be found in these implementation plans).

Most of the LHINs reference the types of patient-level, practice-level, and population-level data that they want access to. This again needs to be negotiated centrally, and physicians (and patients) need to be consulted on who should have access to what data, where it will be stored, and what will be done with it. This is not a trivial point by any means. One LHIN has asked for “direct access to detailed data for local analysis”. Who is dealing with this data at the LHINs? Do they realize that most of the practice-level data is generally of poor quality? They suddenly have the resources to be dealing with reams of complex primary care data? And each LHIN will be staffed to deal with this data?

Some of the proposals, in an effort to increase “access”, promote fragmentation of care in the community, which directly conflicts with the establishment of patient-centred medical homes. (Patient-centred medical homes have been fully endorsed by nearly all physician groups, including the CFPC, OCFP, and the OMA).

I will give deserved credit to a few of the LHINs that have been candid in the possible hurdles that have been encountered in what they have been tasked to do. One LHIN stated that “without a standardized incentive approach, variation in incentive methods across the province may have a negative effect on relationships and trust with physicians”. Couldn’t have said that better myself.

Other LHINs have actually put forward completely reasonable components of what could be a good framework moving forward. But it’s a patchwork of some LHINs with good ideas, others with unpractical ideas, and some with ideas that will instantly draw the fiery rage of physicians.

Here is my fair warning to the ministry and to the LHINs, as someone who has been often accused of being too “pro-LHIN”. This is shaping up to be a complete disaster. 14 solutions to similar problems will prove to be a enormous waste of time and resources. It’s already proving to be a partial waste, as we have 14 separate implementation plans that have taken thousands of hours of time to put together, much of which will likely be tossed aside prior to any meaningful implementation.

The LHINs need to walk before they can run. The ministry needs to stop this process immediately, re-engage with the OMA and the OCFP, and develop basic principles for primary care reform that most of us can agree on. Some of the good ideas in these implementation plans can even be used in a master plan. But a basic framework for accountability and human resource organization, bargained centrally (not at the LHIN level), is essential to guide the LHINs before they add their own customized local touches for their local implementation.