Category Archives: Government

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.

Ontario Ombudsman and Twitter: Why cooler heads need to prevail

I truly believe that the “controversy” that has erupted between the Ontario Ombudsman and two professors in the Department of Political Science at Western University is merely a product of multiple misunderstandings, as well as ineffective communication on a medium that is being misused by many.

Let me start by affirming that I think what Andre Marin is doing with the office of the Ontario Ombudsman is truly revolutionary. One of the great frustrations of the public is a difficulty in airing grievances about their public services and officials. Marin’s use of Twitter has already given a voice to thousands in the province who would have not otherwise been heard.

Going back in the Twitter record, this controversy appears to have had its genesis in a Professor Andrew Sancton tweet in late September where he stated “”Investigations” of informal mtgs of municipal cllrs must stop. This is craziness with no legal justification or benefit.” He was referencing investigations by the OO aimed towards municipal councillors, and his belief that the number and character of these investigations were increasing unnecessarily. What followed was a civil academic argument where both Sancton and Marin made their points, and the discussion ended.

On November 26, 2014, Sancton spoke to an Ontario Legislative Committee looking at Bill 8 (the bill to expand the powers of the ombudsman), and argued that that power of the OO should not be extended with respect to open municipal meetings. Marin responded by blocking Sancton on Twitter, and all hell broke loose. Sancton responded by making a complaint to the Information & Privacy Commissioner about being blocked.

Here’s where the unfortunate series of miscommunications begins. Sancton, by his own admission, does not have tremendous experience with social media. He referred to Marin’s Twitter page as an “official website”, and believed that only Marin’s “tweets and retweets end up on his website”, where in fact any reply to his tweets would end up on his page as well. Sancton was obviously unaware that being blocked does not completely prevent someone from reading one’s Tweets (just log out of your account and search for that person), it only prevents the blocker from having to see the blocked’s Tweets and replies.

Marin unfortunately has to deal with a lot of “trolls” on his Twitter page. There are at least two individuals who respond to nearly every one of his posts with extremely vulgar language and personal attacks. Language that I would rather not repeat on this blog, but suffice it to say the words should never be uttered in public. This has understandably made Marin quite sensitive to dealing with any attacks on Twitter. What Marin has been accused of recently is being hypersensitive to any attacks, and to label any dissenting opinion as being a “troll”. I think there is some merit to this criticism, as I believe some honest critiques by intelligent individuals have been inappropriately dismissed as being abusive. But this brings me to the point I really want to make.

Twitter is not an effective medium for any rational debate. Marin’s critics are using Twitter to engage him on various legitimate policy issues. Sancton tweeted on December 4th “Can we debate public policy in this format? I hope so.”. The answer to this question is that issues as complex as closed door municipal meetings and the jurisdiction of an ombudsmen are not going to be resolved on Twitter. If anything, opinions on either side will become more entrenched through a “Twitter debate”. Names will likely be called, oversimplifications will be used, and a whole host of logical fallacies will be used to debate opposing opinions. But be sure, no resolution will ever come from debate on Twitter, as I have honestly never seen someone make a 180-degree turn on an opinion as a result of a discussion on the medium.

This fact is difficult for many to digest. Marin is a lawyer, as are many of his supporters and critics. Having rational debate and making cogent arguments are part of their lifeblood. And the instant communication that Twitter offers is too tempting to ignore for many. Get an instant opinion out there, and defend it. But unfortunately it provides no practical medium for quality argument. The sooner the world realizes this, the more harmonious our society will become.

So how can this situation improve moving forward? I would start by suggesting that any critic of Marin respond through an Op-Ed or their own personal blog, rather than engaging in a back-and-forth on Twitter. I have no problem with Marin restricting who can follow him on Twitter as a means of keeping things civil. Any member of the public has the ability to contact the OO through their phone line, and I trust that Marin will not allow criticisms of his office from the public to colour any future investigations regarding that individual or group.

Marin has been accused of making the office of the OO too political through his often-pointed public and online comments. I trust that as he continues to settle into his role that he will realize that personal attacks (eg. the Chicken Little comment in November, linking the current Western poly sci department with Rushton’s penis-measuring racial IQ theories) don’t further his cause, and that a more nuanced approach will go further. I truly believe that he does not make any of these comments out of any malice, but out of frustration for the abuse he receives on Twitter. In the end, the results of his thorough investigations will lead to recommendations, and those with the power to implement these need to be confident that his impartiality was never in doubt. That isn’t to say he can’t be opinionated, because his opinion is often invaluable, but he needs to be careful not to make premature declarations when avoidable.

I look forward to seeing what Marin will continue to achieve for the citizens of Ontario. His office is, and can continue to be, an indispensable asset for the province, and I hope these misunderstandings over the past few months will recede to being just a blip in the road to progress.