Making physician billings public? Here’s my proposal.

It’s an issue that predictably rears it head during any labour impasse between a government and physicians. Provincial governments calling for physicians to disclose their billings, in an attempt to characterize them as overpaid and greedy in the eyes of the public. The media often joins the action, looking for a juicy story. Members of the public will often chime in, asking where their health care dollars are being spent.

In Ontario, Minister of Health Eric Hoskins has raised the issue, offering to potentially exchange public disclosure of physician billings for the binding arbitration process that physicians are seeking. Putting aside the fact that physicians should be entitled to a fair dispute mechanism without having to make these concessions, I wondered whether there is a solution to be found (assuming that Dr. Hoskins is genuine in his offer).

Let me start by stating unequivocally that simply providing a list of total yearly billings sorted by physician should be a complete non-starter. That type of list, like the Blue Book provided in BC, gives us virtually no useful information. Doctor X made $250,000 in 2015. So what? That tells us nothing about what volume and type of service Doctor X provided. It’s a shaming exercise, and nothing more.

The argument often made in favour of disclosure of physicians billings is that it would provide a degree of accountability in the system that is currently lacking. However, providing only a total billing figure by physician does not provide enough detail to make any form of meaningful analysis.

Here’s what I would propose.

An online database where any citizen can search for any physician (search by name, specialty, billing number, or location), and view a itemized listing of what fee codes were billed by each physician by date. This database would not include any dollar amounts, either by code, date, or totals, again because these totals can be inflammatory without providing any value. The OHIP schedule of benefits is a separate document available to view for anyone, which lists the dollar amount for each fee code. The details in that document is where a debate can be had as to the relative appropriateness of each fee amount. The online database I am proposing should be solely focused on outlining what services physicians are claiming through OHIP, for full disclosure.

(An important exclusion to this disclosure would be fee codes involving abortion and medical aid in dying, in order to maintain the confidentiality and safety of the physicians involved).

I want to know how many patients Doctor X saw on Date Z, and what they were seen for. That is the information that we need to identify outliers. Was the volume and frequency of billing reasonable? How much the physician made should be of secondary importance, and can be debated fee code by fee code as a profession, but not by looking at a physician’s total billings. If an investigative journalist wants to data mine to determine what total amount each physician billed for a given time frame, they can certainly do so, but ethically they should be expected to describe the details of the thousands of services provided by the physicians to earn their billings.

I would also propose a database where patients can search, by their health card number, for what services were billed in their name, by fee code, date, and physician involved. There would need to be some additional security measures to ensure that only the patient themselves can access their billing history, as certain billing codes can easily disclose elements of their medical history. The current process for patients to access this information can take weeks, and is quite tedious, discouraging patients from inquiring about any questions about OHIP claims made in their name.

At this point, anyone proposing simply listing total yearly billings by physician is either doing for political gain, or through ignorance of the inadequacies of such a system. Many physicians are indeed open to system of disclosure of billings, but only under a carefully thought-out methodology that provides accountability without inappropriately vilifying hard-working physicians.

A few thoughts from last weekend’s OMA Council meeting…

With most of the Ontario medical community feverishly discussing the Auditor General’s report from Wednesday, I wanted to spend a bit of time reviewing what transpired at this past weekend’s OMA Fall Council meeting.

All of us in attendance knew that it would certainly be an eventful meeting, being the first Council meeting following the tPSA rejection, and with the backdrop of the Coalition of Ontario Doctors’ active petition to call for another General Members’ Meeting. I am always pleasantly surprised when the polarization and hyperbole of social media is replaced with generally cordial and thoughtful dialogue. I thought the meeting was productive, with a litany of provocative motions passed and the OMA board and executive seemingly committed to major changes.

However, reading many of the online posts and comments both during and after the meeting, it felt like I had attended a different meeting than a few of my fellow members. I understand that the primary goals of the Coalition remain the removal of the Executive and the voting of the President by membership (not Council), but painting the entire meeting with deceptive and misleading brushes does everyone a disservice, particularly engaged members who simply want to know the facts.

Failed motions that were posted on social media by members were chosen specifically to feed the narrative that the OMA is out of touch with membership. In many cases, the issue with the motion was simply a matter of word-smithing, and other motions with similar intent passed with near-unanimous support. The overwhelming tone of the meeting was in opposition to Bill 41, with many motions opposing Bill 41 in various iterations. However, when one motion about Bill 41 failed after a vigorous debate because of a concern about how it may be manipulated politically, it was posted online with the clear intent of misleading members into thinking that Council was somehow in favour of Bill 41. On one particular occasion, the original mover of the motion stepped into the social media discussion to point out that the dissenters actually gave a very good reason for opposing the motion. The debates around motions are so important to understanding the context of the issues, and members seeing only what motions were approved or defeated provides them virtually no meaningful information.

I am quite excited to have the Council meetings broadcast online in their entirety. If the events of Council are going to be manipulated by certain groups in how they are presented to members, then the benefits of transparency far outweigh any potential strategic advantage in keeping Council private from the eyes of the MOH. They need to be broadcast to remove the selective editorializing that is happening, because it is far too easy to disseminate misinformation and inflame existing tensions.

One of the more contentious debates was surrounding the Code of Conduct suggested by the Strategic Working Group. Many Council delegates raised concerns about whether inviting the CPSO to be further involved in the personal activities was wise, but the message that I heard from Dr. Athaide was that this was a policy in evolution. Members would be surveyed as to how a Code of Conduct should look (eg. should CPSO be involved, etc.), which was approved through a motion.

It was striking to me how different the overall tone was of this meeting compared to previous Council meetings I had attended. At previous meetings, I was a bit taken aback by how abrasively the Executive dealt with questions from members that they clearly disagreed with. It was very much a “We know best, please sit down” mentality. Now some may argue that they still saw some of that this past weekend, but I certainly felt that it was a marked change in overall tone. Much more conciliatory, much more willing to support motions rather than pick nits. I am still shocked that the Executive gave its support to the motion that called for “equal time and equal money” to opposition groups during any future general members’ votes. There were also a number of votes on motions where the recommendation of the Executive was ignored, which was also a  relatively new development. There is certainly no shortage of independent thinkers on Council, which is great for the strength of our organization.

Two new board members were elected, Dr. Silvana Bolano and Dr. Nadia Alam, both of whom have been sharp critics of the OMA and supporters of reform. Ousted were a current member of the Executive and a former member of the Negotiations Committee. Somehow that doesn’t count as “real change” in the eyes of some. We heard from the Strategic Working Group which provided 114 recommendations for how the OMA needs to move forward and learn from the disastrous events of this summer. We saw the report from Pricewaterhouse Coopers which detailed the chronology of the tPSA events, and a very clear signal from Council that many were hoping for more of an analysis rather than a simple chronology. We saw a motion approved that would see the “Moving Forward, Moving Together” document put together by Dr. Graham Slaughter’s grassroots group of physicians used to inform the work of a future Negotiations Committee. There was news that a governance map would be drawn up for the organization, to outline to members clearly how the labyrinth of the OMA is to be navigated. There were also promises for clearer instructions to members on who their reps are and how they can contact them. A motion passed that would have the OMA outline on their website the progress of all of the motions from Council, and another motion that would have the Board post their minutes on the OMA website.

Now of course these motions were mostly non-binding, but they show at least a general movement towards a more progressive organization. I’m optimistic.

The OMA still has a long way to go before re-establishing trust with many of its members. I hope that members who didn’t have a chance to attend Council continue to follow ongoing developments, and to ensure that the OMA follows through on their promises, but to do so by following sources that are committed to presenting objective information.

To quote an Ontario surgeon who was very active at Council: “I have seen the change firsthand over the past 18 months. It is slow and frustrating, and at times downright obnoxious, but is happening”.

2016: My year with the Cleveland Indians

I’m not sure the sting of losing in the 10th inning of Game 7 of the World Series will ever wear off. Getting so close to a championship and not closing the deal is excruciating, but over the past few days I’ve reminded myself of the importance of the journey rather than the destination. Even before the playoffs began, this had been the most memorable Indians season for me personally, and our playoff run was simply the cherry on top.

I want to remember the 2016 season vividly for the rest of my life, so it’s time for a diary of sorts. My own personal memories and interactions with the 2016 Cleveland Indians. (Warning: if you’re not a family member, or a really close friend, or an Indians fan, this post is going to bore the hell out of you. Even if you fall into those categories, you’ll probably still be bored. I’ll let you know when I write something more exciting.)

 

  • First decision to be made to start the season is about MLB.tv. Do I get the yearly subscription or the monthly subscription? Yearly ends up being cheaper over the course of the season, but if the Indians are out of contention by mid-season, it’s a huge waste. Verdict: I went for the yearly. I’m all in for 2016. I feel it, this is going to be the year.
  • May 31: Indians finish the day in 3rd in the AL Central, 2.5 games back of the Royals, after a 7-3 loss at home to the Rangers. Next night? Yan Gomes walk-off to beat the Rangers in 11 innings. Night after that? Come from behind victory 5-4 over the Royals. Momentum building just in time for me to arrive in Cleveland for the next 3 games against the Royals.
    •  Friday, Salazar is dominant, Cleveland wins. Oh, plus I got these cool sunglasses.

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    • Saturday, game starts with a 1-hour rain delay, during which I have my first interaction with Frankie Lindor. I’d heard plenty about how great he is with fans, and he didn’t disappoint. Oh, and the Indians win again with a stellar start from Tomlin. And a free retro Indians jersey. And Tyler Naquin’s first career home run!
    • Sunday we weren’t planning on going to the game since it looked like it would be rained out. We were having breakfast at Denny’s just outside of Cleveland, and as I was scanning the weather at around 12:30pm, the forecast looked clear for game time, so we decided to chance it. Let’s make it 3 for 3. Again, the Indians didn’t disappoint. Naquin, Santana, and Lindor all homer to right field in the 5th inning. The rain eventually did descend on Progressive Field for a lengthy delay, during which we started the drive back home. We listened to Tom Hamilton on WTAM for the end of another Indians victory.
  • In late June, I made the trek to St. Mary’s for the Canadian Baseball Hall of Fame inductions, where I had a chance to meet Dennis Martinez, hero of Game 6 of the 1995 ALCS for the Indians.

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  • July 1st: Canada Day. Jays vs. Indians in Toronto. We get some seats in the nosebleeds, literally sitting above the light standards. Before the game I had an interesting chat with Trevor Bauer about what he wanted to see happen after Roberto Perez returned from injury. He made a grimace that I will never forget (didn’t get a picture of it), since he had developed a close relationship with Chris Gimenez.

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Massive Canadian flag during the anthem, Edwin Encarnacion and John Gibbons ejected in the 1st inning, met up with an old med school buddy, our friends left in regulation, then the longest game in Blue Jays history, 19 innings. Pompey and Goins pitching for the Jays. Multiple chances to win for both teams. Bauer with 5 shutout innings, and a Santana homer to win it. 14th straight win. Elation.

  • Spent the next couple of days wandering around the Indians hotel looking for autographs. Yes, I realize I am an adult. But I’m a kid at heart. And hey, I have this neat souvenir now.

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  • The next two games in Toronto were awful, two losses, we blew through our bullpen, which eventually would lead to the releases of Chamberlain, Gorzelanny, and Hunter. I sat through a 17-1 Blue Jays win, which was probably karmic punishment for sneaking down to the expensive seats. Plus it was quite sunny, I didn’t wear sunscreen, and spent the whole game trying to hide in the shade created by the man sitting to my left. It certainly was not a Party at Napoli’s.
  • August 19th: Celebrating my wife Jess’s birthday a day early at our house. I was following the game against the Jays on my phone as she blew out her candles. Jose homers to tie the game in the 9th! Now we’re eating cake, but there’s no way I’m turning the TV on to watch the game. Phone loading….loading….Naquin inside-the-park home run to win the game. Um…pardon me? Indians fans would watch the highlights from this moment dozens more times this season. Incredible.
  • We were in Italy for the end of August as the Indians were heading towards the division title. With the time change, I was often up until 4am following the play by play on my phone. Everyone wondered why I was always napping so much in the car as we drove between cities…
  • September 26th: Indians clinch the AL Central! The next night my clinic finished a bit early so I drove down to Detroit to spend some time with what would be a hungover bunch. We lost 12-0, which meant the Indians had lost a combined 29-1 in the last two games I had attended. Eek.
  • Then the playoffs. Vanquished the Red Sox in 3 games. ALCS against the Jays. Watched all of game 1 on my phone at a friend’s wedding. Lindor with a 2-run blast to win it. Next day, Jess and I headed to Cleveland for Game 2 with some friends. Tomlin with a performance for the ages to put us up 2-0.
  • Game 5 in Toronto. I found some cheap tickets, and went to watch from the 500s with my brother-in-law. I was expecting the worst with Ryan Merritt on the hill. Instead, we’re leading 3-0 going into the late innings. We snuck down to the 100s for the last two innings (thanks for the heads up for the open seats to Kevin Hopper). Cody Allen in for the save and Santana with the catch in foul territory to end it. Pure elation. Dozens of Indians fans at the dugout celebrating the victory with our team. Being 10 feet away from Lindor seeing his tears of joy celebrating with family. Here I am after the victory.

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  • World Series Game 5. Chance to win the World Series on the road, but unsuccessful. Carved this pumpkin to let off some steam.

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And sure, the World Series didn’t end as planned, but I had one hell of a time with this team. They fought hard all season, dealt with injuries to multiple key players, and gave us moments to cherish for a life time.

Here’s hoping for a great 2017.

Spotting pseudoscience on social media

It sometimes feels like a tsunami. As social media becomes an integral part of our lives, scientific misinformation is being propagated at a faster rate than ever before. Videos, articles, memes, all cleverly designed to trick unsuspecting patients and consumers into thinking that their information has a grain of truth to them. Some are selling products directly, some are selling books or talks, and most are creating an environment of fear and mistrust of the medical system, which indirectly is used to sell various products and services.

So here are a few basic guidelines I want my patients to be aware of when trying to sift through what information is likely true and what is likely rubbish.

1) Look for the “store”

If you are reading something on a page that has a “store” button anywhere on it, it is likely that sales are driving the editorial policy of the website rather than any dedication to science. Supplements and herbal products are the usual products they sell, but these websites will sell just about anything that vulnerable patients will buy. They post information to create a disease or condition that needs treating from the products they sell, or just create a general mistrust of authority, which will result in higher long-term sales. Bottom line, if you see the “store”, it’s likely a terrible source of information.

2) Look for the buzzwords

Thankfully, most sites and sources with poor quality information give us a few obvious clues as to their motives. Many use the same marketing keywords that are designed to steer patients towards pseudoscientific treatments. In no particular order, these words are: natural, naturopathic, homeopathic, organic, toxins, detox, antioxidant, holistic, integrative, inflammation, functional, and wellness. There are hundreds more, but these are the main culprits. It is possible to be a reputable site and still use one or more of these words periodically, but when you see them, it should be a big red flag to be wary of the quality of information from that source.

3) Look at other information from the same source

Does every piece of information from the source follow the same basic narrative? Does the site that is telling you not to vaccinate your child also pushing 9/11 conspiracy theories? Does the chiropractor’s website telling you to go for routine adjustments also claim that doctors are maliciously hiding the cure for cancer? Sometimes it’s unfair to label all of an organization’s information as questionable based on one flawed belief or claim, but in many of these cases, if you do even a basic search, you will see that they have an agenda that goes well beyond that 2 minute Youtube video you just watched.

4) Look for citations

It’s too easy to make claims on the Internet without an ounce of solid evidence to back up those claims. If you encounter information that may change your beliefs on a certain topic, you need to spend ample time looking for whether proper studies have been done. A link to another questionable website or opinion piece does not count as reliable evidence. There is just too much of an incentive for quacks to spread misinformation that you cannot simply assume that all claims are equally deserving of your trust.

5) Ask a professional that you trust

There is nothing that I appreciate more than when a patient, friend, or family member, sends me a link to something that they want me to look over. Is it legitimate? Can it be trusted? In a time where ordinary citizens don’t have the time or expertise to sift through available reams of information, yet have tremendous access to both good and poor quality information, it is more important than ever to develop relationships with health professionals you trust. Professionals who can be looked to for critical analysis of any scientific topic, without bias or prejudice.

 

So go ahead, click on the link. Click on the video. But before you share it, or use it to guide you or your family’s health care journey, please apply these basic principles to decide whether it is likely accurate and trustworthy. We all need to play a role in ensuring that only high-quality information is propagated through our social network.

When World Series returns to Cleveland, time for game ops to show common sense

Year after year, every Cleveland Indians postseason appearance is predictably met with a few individuals who feel it is appropriate to show up to a game at Progressive Field wearing red face paint. These individuals are always shown prominently during the TV broadcast, and many of us with any sensibility squirm in our seats. The next morning’s sports shows inevitably re-litigate the appropriateness of the logo and nickname, and Cleveland fans are left trying to justify their team’s marketing strategy to friends and family, rather than basking in our team’s success.

I was optimistic after Game 1 and 2 of the ALDS in Cleveland, where it looked like the usual suspects had traded in their red face paint for white face paint in the design of a baseball. Sadly, I was at ALCS Game 2 in Cleveland, and was horrified to see multiple fans donning headdresses and wearing red face paint again. One particular individual wearing a headdress, walking up the aisle to his seat, thought it would be appropriate to put his hand to his mouth to make what he likely interpreted to be an “Indian war call”. The Jays fans next to me sat with their mouth agape as multiple fans joined the man in his mockery.

I understand the dilemma the team faces. Every time the topic of phasing out Chief Wahoo comes up, a large segment of the fan base threatens to “boycott” the team. And for a team that struggles at the turnstiles like the Indians, they have to be sensitive to any public relations issues with any fans.

But with the World Series returning to Cleveland next week for Game 6 and 7, I hope that the Indians game operations team can take a simple first step towards decency. If fans are seen at the entrance wearing any costume including red face paint, or a headdress, they can easily ensure that those materials aren’t allowed into the stadium. Is that somewhat hypocritical given that Wahoo’s face will still be everywhere? Sure, but baby steps.

Am I being too politically correct? Maybe. But I want the focus of the sports world to be on this terrific baseball team, not its logo, and I want to be able to enjoy our first championship since 1948 without spending every conversation discussing the nickname and logo. Let’s not bring any more negative attention to what should be the best week of our baseball lives.

Engage with LHINs? It’s not black and white.

No doctor is happy with Bill 210, let’s get that out of the way first. It ignored all of the feedback that was given by official physician groups, and proposes many changes that deeply concern all of us.

But what now?

First, I would encourage every physician to actually read the initial analysis provided by the OMA. It outlines very clearly potential problem areas in Bill 210, and articulates that large portions of the bill undoubtedly violate the Representation Rights Agreement. I understand that there has been some criticism that OMA leadership has not provided their editorial opinion on the analysis, but I’m a bit confused as to how that would add to our current understanding of the situation. I trust that the OMA executive agrees with the analysis until I hear otherwise.

Is the initial analysis all we are going to get from the OMA? Of course not. The bill needs ongoing analysis by OMA staff, with consideration from a legal, PR, and negotiations perspective. But this takes time. There has been some consternation that the OMA is not moving quickly on this issue, but I think this is a situation where expectations may not match a reasonable reality. The legislature is not sitting. The legislation will not move forward for many months. I would much rather that we have a cohesive strategy by the end of the summer rather than moving haphazardly too early. It is the not the role of OMA staff or OMA leadership to give off-the-cuff editorial opinions on an issue of this magnitude. I have personally pressed OMA staff that they provide membership with timely analysis on Bill 210 as soon as it becomes available. They’re well aware how anxious physicians are about the ramifications of the legislation, and the negative effect that the uncertainty has on our collective morale.

Now what about our involvement with the LHINs? The OMA is encouraging physicians to continue to attend LHIN consultation sessions. Some physicians disagree with this position, and feel the best course of action is to completely disengage from any LHIN discussions.

I understand where the disillusionment from physicians is coming from with the LHINs. The consultation sessions were a political sham, of course. The ministry did not take physician input into consideration in crafting the legislation, and physicians feel disrespected.

Some have asserted that physician involvement in the consultation process gave the ministry the ability to claim that they consulted physicians in crafting the legislation. But we have to realize that the ministry will engage in public deception no matter what our involvement. If even one physician participates (which we are guaranteed to have, with the Primary Care Leads), they will claim that physicians were involved. We can publicly disagree, but that public argument will be fruitless. We can collectively shun the LHINs, led by the OMA, but that makes it too easy for the ministry to accuse physicians of being obstructionist against legislation intended to “put patients first”. Again, good luck winning that battle in the media. It’s a lose-lose with this government. The minister of health’s press secretary flat-out lied on social media that the OMA didn’t respond to Patients First, despite an actual document proving him wrong. We are not dealing with reasonable people here.

We can’t make decisions based on how we plan on spinning this is the media over the next few years, whether we helped, or didn’t help, or how much we helped. We need to make decisions based on what we think is in our best professional interests, and what will improve patient care.

Every special interest group of health professionals in the province has outlined their positions on Patients First. Everyone is lobbying the government. And many of their interests directly conflict with our interests as physicians, and conflicts how we view system reform transpiring. Those groups will be thrilled to fill the vacuums at the LHIN tables, guiding the development of their implementation plans.

It’s important to distinguish between planning and implementation at the LHIN level. Most of the LHINs are still largely at the planning level. Their proposed plans were largely a disorganized mess, and the ministry has admitted that they did not give the LHIN adequate direction in that process. So most of the LHINs will be going back to the drawing board. Many of them proposed ideas that are unrealistic, and some illegal. The ministry has “assured” physicians that the LHINs will have to go through a “readiness evaluation” before they are given the green light.

What does that mean for us? It means we need to have our eyes and ears on the ground at the LHIN level. We need to know where each LHIN is in its individual planning, and we need to be vocal with opposition to LHIN proposals that are unreasonable, and remind them when they are overstepping their bounds. We need physicians at LHIN meetings telling the LHINs, “You can’t do that. That needs to be centrally bargained. We will complain publicly when this blows up. Be careful what you implement.” Look at the Toronto Central LHIN, and the “Primary Care Model Draft” that has been circulated on social media. We only have access to that document because physicians continue to be involved in their process.

Here’s what I would tell physicians. If you feel that your time is limited, and don’t want to be involved with your LHIN, I respect and understand that. I don’t know the circumstances of all of your interactions with LHINs in the past, and I understand if you don’t want to spend your valuable time with an organization for whose mere existence you fundamentally disagree with.

But for the physicians who are on the fence, I would warn you against taking some form of moral high ground by disengaging. Ignoring the LHINs between now and the fall will have no bearing on our success in getting back to the negotiating table. This legislation will likely be eventually moving forward in some form or another. It is the political reality of our current dysfunctional government. We can work to provide our input and attempt to intelligently guide the process, which yes, may end up being in vain. There are no guarantees here. But I for one am more comfortable going down swinging right now, pointing out problems and providing possible solutions, rather than be left trying to fix a potentially unfixable mess with our next government.

“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.)