Monthly Archives: February 2017

Province ready to discuss arbitration…now what?

Well…that escalated quickly.

In mere hours today, we went from having no negotiations planning in place all the way to the composition of the OMA Negotiations Committe being announced and Premier Kathleen Wynne announcing that the government is “committed to the principle of interest arbitration”.

Ladies and gentlemen, the game is afoot.

A few things to address right off the bat. Some have questioned what exactly interest arbitration encompasses, and whether this would meet the “binding arbitration” requirement that was agreed to at the General Members’ Meeting. Interest arbitration is a form of binding arbitration, and is exactly the type of 3rd party dispute resolution mechanism that physicians have been clamouring for. Here is a primer on interest arbitration for OMA members.

Others have questioned the timing of the announcement and why the ministry is suddenly  interested in discussing an agreement. It is likely as simple as the election drawing near. Recall that the rationale of many rejecting the tPSA was that the ministry would be more likely to improve their offer as an election draws closer. Well here’s your opening. We need to keep in mind that Wynne’s language toward arbitration was more definitive than anything we’ve heard from the provincial Conservatives.

I have also heard it argued that the OMA should not enter into any negotiations without binding arbitration mechanism in place. The simple response to this is that you need to negotiate the terms of arbitration before you can negotiate a contract. Two different negotiations: one for the framework, one for the contract. The only way to negotiate the framework is by actually….negotiating.

I think it will be important for the OMA to set a timeline for the negotiation of a binding interest arbitration agreement. The OMA cannot allow the ministry to draw the process out for months as a distraction. Tight timeline and come to an agreement on a framework, or the OMA returns to internal deliberations on job action.

My preference for binding interest arbitration? Conventional interest arbitration, where the arbitrator can make any award that they deem appropriate. I think both parties have far too much to lose if they go for a final offer selection mechanism (where the arbitrator would select one party’s proposal in its entirety). The ministry cannot afford the fiscal disaster that would come with a loss in final offer selection, and the OMA will be challenged to effectively deliberate internally to allow for many concessions in a divided membership. Conventional interest arbitration allows for the ministry to maintain fiscal balance, and allows for the OMA to maintain the faith of its members.

One small request to both parties: while the negotiating process plays itself out, I think both parties need to commit to avoiding any emotional reactions to any strikes launched from either of their disliked newspapers. Physicians committing to not reacting to any material in the Toronto Star, and the government not reacting to any material in the Toronto Sun. Let the newspapers say what they will, and let’s get down to actually finally sorting out this mess.

Low back pain in the South West LHIN

It should come as no surprise to any health professional or patient in Southwestern Ontario that when it comes to low back pain, our region is a chaotic mess. Patients struggling to access adequate care, languishing on wait lists, with physicians powerless to provide them any help. The situation is a combination of many factors, including the aging demographics of the region, a disorganized primary care and specialist system, and underfunding of physiotherapy and spine surgery operating time. Where it has left us is with surgical wait lists approaching 3 years, with patients falling into severe disability while they await appropriate care.

The South West LHIN has begun work on initiating the Inter-professional Spine Assessment and Education Clinics (ISAEC) program in the region as a means to begin to address the local crisis. The program has been implemented with success at the University Health Network in the GTA, improving surgical wait times and improving patient satisfaction. The model includes an initial assessment by an Advanced Practice Clinician (physiotherapist or chiropractor) in the program assessing and educating the patient, and returning a consultation note with recommendations. Some patients are given self-management education, while some patients will be referred on to a Practice Lead (physiotherapist or chiropractor) at LHSC who would make recommendations for more complex patients (imaging, injections, or surgical consultation). It is being proposed as a pilot project in the South West LHIN, starting with a small group of physicians in 2017-18, and expanding to the entire region for 2018-19.

I agree with the principles in theory, but given the current complexity of the problem in the South West LHIN, there are a number of added issues that must be considered.

We need to be very careful not to create multiple competing referral streams that all inevitably compete for the same surgical resources. CBI Westmount has already initiated a referral program in conjunction with a couple of the spine surgeons, where physicians can refer their patients to be seen within a short period of time. An ISAEC program working alongside the CBI program would end up at a bottleneck of the same scarce surgical and injection resources.

Here’s what I would propose:

  • A LHIN-led analysis of the current referral burden to all spine surgeons in the South West LHIN. This may include a complete re-design of the existing referral forms, which are currently inadequate for conveying relevant information from the referring physician to the surgeon. The referral form could include an area for the referring physician to designate why they believe the patient is a surgical case, with an educational component to the form that would dictate what constitutes a surgical referral and appropriate management/evaluation of back pain. Once an appropriate referral form is agreed upon, it may be necessary to ask referring physicians to re-refer patients using the appropriate form to be able to properly work through the existing glut of patients. This would also allow for the LHIN and surgeons to determine the exact magnitude of the surgical backlog and what surgical resources will be required to reduce surgical wait times expeditiously.
  • An analysis of the capacity in the South West LHIN for back injection services and existing wait times for epidural and facet injections. A majority of potential surgical cases are being sent for diagnostic injection by the surgeon, which ends up causing a frustrating delay for the patient because of the inadequate local resources. The LHIN needs to work with local interventional radiologists to ensure stable capacity.
  • Offer educational sessions for local family physicians on the CORE Back Tool, similar to the sessions presented by Dr. Hamilton Hall. I personally found this program to be transformative in how I diagnose and treat mechanical back pain, decreasing the number of unnecessary referrals. Identify physicians who refer a disproportionally high number of patients to spine surgeons, and encourage those physicians to attend the educational sessions.
  • I would suggest that the ISAEC model be revised for the South West LHIN whereby referrals are made by physicians directly to the Practice Lead, and that all interested local physiotherapists and chiropractors are provided complimentary education in the ISAEC model.
  • Work towards having ONE spinal surgery stream in the South West LHIN that flows through the Practice Lead, rather than allowing multiple competing streams to develop.
  • Ensure that patients with acute back pain, who do not have private benefits, have adequate access to a brief course of physiotherapy with a focus on transition to self-management and home exercise programs.
  • Focus on increasing the ability of family physicians to competently diagnose, triage, and manage acute and chronic mechanical back pain, rather than pushing resources towards creating more chronic pain clinics.
  • Develop a free local Spinal Stenosis Boot Camp, similar to the program offered at Mount Sinai, to support the increasing prevalence of spinal stenosis among the elderly. Participate in this program should be mandatory (with appropriate exceptions) for those seeking either surgery or ongoing epidural injections for pain relief.
  • Opening up FHT-led chronic pain self management programs to non-FHT patients, and advertising these widely.
  • Ensure that our local libraries have an abundance of copies of “A Consultation with the Back Doctor” by Dr. Hamilton Hall. This book has been invaluable for my patients with chronic back pain to understand the nature of mechanical back pain, and gives many patients the confidence to self-manage their pain.

Just a few ideas for now, but we need to have open discussions about our current local challenges before we move forward with an ISAEC pilot program.