Why the OMA dispute and the UK Junior Doctors Contract Dispute are the same but different.

Yet another person has commented on the fact that they believe the labour disputes in Ontario and the UK between the governments and physicians in the respective jurisdictions are similar situations. They are actually more different than they are similar.
Firstly to acknowledge there are some commonalities. Bargaining talks over pay issues broke down between the government and the doctors in both situations. In the OMA’s case, the Ontario government has chosen unilateral action, meaning it has decreased the amount paid to doctors (practising physicians, NOT trainees) without a PSA (physician services agreement) in place- in other words, the Ontario docs didn’t agree to the pay cut. In January of 2015 2.65 % was cut across the board for all physician services by the Ontario government, and another 1.3 % in October of 2015 for fee for service payments. There may be more cuts on the horizon in Ontario, we just don’t know. In the junior doctors UK (JDUK) case, the British government has threatened to roll back paid overtime for after hours and weekend work, and also wants to legislate lightening up on the surveillance of the hours that junior doctors work.This has also been done without the agreement of the organization representing the junior doctors. The hospitals in the UK are financially penalized if trainees work over a certain number of hours a week, and a softening of these rules has been proposed, meaning trainees will likely have to work longer hours without the hospitals being punished.
Now I was not paid a penny of overtime for either after hours or weekend work when I did surgical residency in Canada, and it is the same in the US. Trainees in North America currently receive the same salary based on their year of training, regardless of the number of hours they work. I can guess what probably happened here. There was some sort of international conference on medical training, and program directors or some sort of health administrators from the UK and North America started comparing notes over tea on trainee compensation- “What do you mean you pay for overtime, weekend, and night work for trainees?” says the guy from North America- “Ridiculous, we don’t pay any overtime, that would get expensive!” A light bulb went off in somebody’s English head, this revelation trickled up, and ultimately the information ended up on Jeremy Hunt’s desk.
I worked in the UK for a year in a medical research lab, and while I was not doing any clinical work at the time, I interacted with a lot of physicians, including a lot of people who were either training or had recently completed training to be doctors. I then went on to work in Australia, which has a very similar system to the UK, for four years. The system in the UK and Australia for trainees is a lot nicer than it is in Canada. Paid overtime, enforced limits on work hours- these are things physician trainees in Canada and the US can only dream of. And just to be clear, I absolutely think trainees should be paid for overtime and have limits put on their working hours. The system as it exists now in North America is completely in the hospital’s favour to allow the abuse of residents. And I think we should all be advocating for improved working conditions for residents- including and especially those of us who have finished our training. So if you want to support the junior doctors in the UK in their fight for continuing to be paid overtime and restricted working hours, maybe we should be advocating for the same benefits for our trainees closer to home?
There are huge differences between being a trainee and being a consultant physician with your own practice. Firstly, consultants get paid a lot more than trainees- right? Or do they? As a junior consultant in Australia, I was paid a flat salary (kind of like a Canadian trainee is). It did not matter how many hours I worked, the pay was the same. As a new consultant in Australia I was on the lowest rung of the pay scale at the hospital. This meant some of the senior registrars I worked with- who were at the top of their pay scale and paid for overtime- were making more money than I was at the end of the year, even though I carried more responsibility than they did for the care of the patients. How do I know? Because firstly, I also worked in Australia as a senior registrar for a year, where I did get paid for my overtime and secondly, I can count. So I think we have to ask ourselves if it is a fair system when the senior doctor supervising the care of the patient given by the trainee is being paid less than the junior trainee doing the care? Of course the vast majority of trainees are paid significantly less than their supervisors, but it is an interesting quirk of the system of physician remumeration when you salary physicians but pay overtime to trainees. It is the opposite in Canada, with trainees on flat salaries and a lot of consultant doctors paid via fee for service.

Another big issue of course is that after a very long road of medical training, employment in medicine post training is no longer guaranteed. This has been a problem for decades in the UK, which trains far too many doctors for its needs and exports many of them, and is sadly a now established problem in Canada, where we have legions of un and underemployed physicians churned out by training programs who need them to fill call schedules as trainees, but not to employ as consultants. England currently has over 53 000 junior doctors, a far higher number of trainees per capita than Canada. The NHS hospital system has allowed itself to become almost completely dependent on these trainees, where they perform a lot of functions that overlap or replace nursing care (blood draws and IV starts as two quick examples) as well as looking after patients.But I digress.
Well over 90% of Britons support the JDUK in their job action according to polls. The UK is a country where people turned up at Margaret Thatcher’s funeral just to be able to turn their backs on her casket because of well remembered decades old grievances with her actions toward unions. The people in the UK are also extremely proud of the NHS, a national system of socialized health care. I think on some level, most people understand that being a medical trainee involves a lot of long hours and poor pay, which then morphs into still long hours but better pay when you practice independently.  I also think most people understand that up the food chain from that trainee is a consultant physician, who will step in to fill the void if these junior doctors do go on strike. While I’m not going to get into the somewhat sticky ethical world of who is responsible for what in the apprenticeship which is medical training, striking trainee doctors are not the same as striking consultants and I think the public is smart enough to know this. And since the Ontario healthcare system runs largely on community based doctors outside of large teaching hospitals where trainees work, the public sentiment toward physician job action in Ontario would not be nearly so kind as it is in the UK.
While I wish the JDUK all the best in their efforts for a fair resolution, I don’t see these two situations as being all that similar. The exception being both have dragged on for far too long without a satisfactory solution for anybody, not least of which includes the patients.

Lice policy

I have three kids (they are not with Toronto District School Board, but Halton District School Board ) but changes in TDSB policy with regard to lice may be adopted by our school board, so I thought I would weigh in. It’s not really a surgical condition but anyway.

We had a problem with lice about 4 years ago. I was looking at my 4 year old daughters head one Sunday afternoon and saw one of the bugs crawling out of her hair. She was heavily infested. It was disgusting-I’m a surgeon and I’ve seen a lot of disgusting stuff but lice are just gross, even for me. Even worse, she had just been to a birthday party with 10 other girls. I called the mother of the girl with the birthday party to warn her feeling just mortified and found out she knew her own daughter had lice the week before, had treated her (once) and sent her back to school (to then infect my kid and others as it turned out). My younger 2 yo daughter was infested too, although not as heavily. My husband and I did not have lice and I did not even check my son’s head- I shaved his remaining (very short) hair off on the spot. I then called the school to let them know (something parents avoid because they know what will happen). My daughter was not allowed to return until given clearance by a public health nurse who at any given time, could be at any one of the Halton schools doing lice checks. We had to chase her down all over Halton Region to get her to check our daughter and give us the all clear to go back with a note. We had to take her four times before we got clearance.

I really do not believe the chemical shampoos work (although we used one anyway- toxic smelling stuff) and I tell anyone who asks that it takes mechanical removal, mechanical removal, mechanical removal to get rid of a lice infestation. Cut off as much excess hair as your child will allow, (hey if you want to save yourself the trouble just shave it all off) then buy a large bottle of inexpensive conditioner, wet and cover the remaining hair with lots of conditioner in the tub and wait a few minutes. Do not rinse out the conditioner but comb it out with a fine tooth comb (it does not need to be a nit comb. The drowning lice are immobilized in the conditioner. You will be able to see them in the conditioner which comes out. Rinse the whole mess down the drain. Lice do not survive very long away from the warmth of the human head- they are not like bedbugs in that respect. The problem is the remaining live eggs and you have to know something about the life cycle. Lice cannot lay eggs for 10 days after they hatch. You have to repeat the conditioner every day (or every other day) for the next 10 days as the eggs which have been laid hatch. You are then removing the junior lice before they have a chance to mature and lay more eggs. You can try getting rid of the live eggs (they are the ones which are brownish in colour and very close to the scalp) but this is difficult. My daughter was not allowed to return to school until every single nit casing had been removed from her hair. She missed 8 days of school total over a period of two weeks. Having two essentially healthy children at home (we took my younger daughter out of daycare until she was clear) while my husband and I worked full time was not fun for anyone and there were lots of testy moments. Lots of TV was watched as our usual limits on screen time went out the window. The nit picking companies are extremely expensive and expecting all parents to pay for that kind of service is not viable as a way of eliminating lice from schools.

I don’t believe children with live lice and/or unhatched eggs in their hair should be allowed to attend school. My daughter had several recurrences and we never got rid of the problem until she switched schools (we were moving anyway), but it suggests that the kids were passing them back and forth. Halton school board’s policy when our daughter had lice was that ALL eggs had to be gone from her hair- even obvious dead egg sacs (which are usually white not brown) and which stay attached to the hair and grow out with it. This is not necessary and children without live lice or eggs should be allowed to attend school. While lice do not carry disease, children who are bitten enough will develop allergy to the bites and that is where the itching comes from.

It is disappointing parents will send kids to school knowing they are going to pass on an uncomfortable and embarrassing condition. There is obviously more pressure on families to keep their kids in school now that a lot of families have two parents working (or single parent families). The letter (sent home to every kid in a class where lice has been discovered) from the school after I advised the school of my daughter having lice gave some very good advice- girls should have their hair tied back in ponytails, or even better braids. I was dismayed to go in to the school for a parent teacher conference and find every single girl in the classroom, bar my own kid, with free flowing long hair, not a barette or pony tail holder to be seen AFTER the letter went home. You can lead a horse to water….. My girls now have their hair tied back at school most days and I also now spray them with hairspray before going to school, as lice do not like hair which has a lot of product in it. We have been lice free for over four years, although I fully expect a recurrence at some point. I’m ready, I know what to do now!

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My Dad and the walkin clinic

So a few days ago I posted a link on Twitter about a clamp down in Nova Scotia on physicians, who will now not be able to practice exclusively in walkin clinics. I got some profanity laced comments back defending the care provided by walkin clinics. There is a terrific article on the website healthydebate.ca about walkin clinics, outlining some of the pros, some of the cons, and also discussing that there is an awful lot we don’t know about what is or isn’t happening in these clinics. So while I encourage everyone to go and read the article on the website (here is the link-http://healthydebate.ca/2012/08/topic/quality/walk-in-clinic), sometimes a story helps. So this is the story of my Dad, a diagnosis, and a walkin clinic.

Dad was single and retired.(Spoiler alert-was, so you know how this one ends) He decided to move from Toronto to St. Catherines where he could still visit a university library and not have an astronomical cost of living. Like many people who move in Ontario, he kept his family doctor, even though that doctor was now almost 2 hour drive away. Dad liked his doctor, felt he knew him well and also liked having his yearly check up in Toronto, which he would turn into an outing for the day. Dad had no major health issues which needed to be addressed on a frequent basis, was on no medications, never smoked, drank rarely, was not overweight, and was generally a pretty fit guy.

Around the end of August, 2008 Dad began feeling not so well. His apartment was easy walking distance to a large hospital in St. Catherines, but was also close to a walkin clinic, which was about the same distance in the opposite direction. After a week or so of headache, anorexia (lack of appetite) and generally feeling pretty crummy, he headed to the walkin clinic to see if someone could sort out what was wrong. There was no calling his daughter (me, a physician) for advice, no way, wouldn’t want to worry me. For my Dad to go to a doctor meant things had to be pretty bad in terms of the way he was feeling. This was a guy who rided out an episode of chest pain in favour of an outpatient visit to his GP and then a cardiologist. While that time the diagnosis turned out to be heartburn, I was furious when I found out he hadn’t headed straight to an emergency room. Anyway, this time Dad certainly wasn’t feeling up to a four hour round trip to see his regular doctor and hey, maybe it was just the flu, which he had had a bad bout of a year or two before. I don’t know how many visits to the same walkin clinic ensued, but it was quite a few. A CT head was arranged, done and reported on. The CT of his head was normal, but the headache persisted and now Dad’s pants were becoming looser, his energy levels flagging. I called my Dad just after Labour Day with my own news. I was pregnant (again) and having my own issues with severe morning sickness and a new surgical job. We compared notes on our nausea- mine lasted all day, his grew worse as the day went on.  But I really didn’t like what my Dad was describing to me in terms of his symptoms and grew increasingly concerned through the course of that conversation and others that followed. I pleaded with him many times over the phone to go to an emergency room which he refused saying- “I think this guy(referring to the walkin clinic doc) is close to putting his finger on whatever is wrong with me.” The problem of course would be there were no booked visits at the walkin clinic. If Dad’s guy wasn’t there he would simply try again a few days later. Another visit to the walkin clinic led to bloodwork and an ultrasound of the kidneys being ordered (but the date he was given for the US was toward the end of October). The bloodwork came back as some degree of renal failure- but my dad either couldn’t remember the number of his creatinine to tell me, or he had never been told. Dad was what we call in medicine a terrible historian, truth be told, so it can’t have been easy to try and figure out what was going on with some pretty vague symptoms.
At this point it was close to my Dad’s birthday at the end of September and I decided to drive down from Oakville and take him out for lunch, trying to hatch a plan to move things in his workup along and see just how bad things looked. He looked awful, clothes hanging off him, even though he had been fine when I had seen him in early August.
Over lunch Dad(who usually cleaned his plate, but today just pushed food around) told me a story about the previous day that made steam come out of my ears. His bloodwork had been repeated by the walkin clinic doc earlier that week and his kidney function had worsened considerably. This explained some of his symptoms, for sure, but the cause of the kidney failure was unknown. A common cause would be an enlarged prostate at his age but the US (still many weeks away) was needed to rule that in or out as a cause of why his kidneys were packing it in at this stage.
The walkin clinic doctor responsibly called my dad in to review the results of his bloodwork, gave him a note and told him to go to the emergency room of the hospital I mentioned. It was a Saturday and the waiting room was empty. He handed in the note which apparently mentioned renal failure and contacting a nephrologist. Dad (who I’m not sure ever used an emergency room in his life)then sat in the waiting room for four hours, while watching people with sore toes and all kinds of minor complaints be led in to be seen by the doctor on duty. He never saw the inside of the emergency room that day, only the waiting room. Dad was told by someone that the emergency room did not arrange for patients to see nephrologists (kidney specialists) but was also not told to just go home. Four long hours later, he gave up and shuffled home, exhausted and frustrated. (Sidenote-If you were working in the emergency room of the St. Catherines General Hospital on the afternoon of Sept 27th, 2008, and had anything to do -or not to do as it turned out- with my Dad that day, your care fell well short of what I would consider the most minimum of standards. While I contacted the ombudsman of your hospital, Dad was too sick to sign papers to allow a proper investigation. And as usual he didn’t want to ruffle anyone’s feathers.)
At the end of his story I lost it, as a daughter, as a physician, and as one angry hormonal pregnant lady. Anybody who got within shouting distance of me got a rant about what had happened (sorry work colleagues). It was Sunday and after a lot of convincing, my dad agreed to let me arrange to have his kidney US urgently done at Oakville Hospital. He drove up for the test 2 days later on a Tuesday. He had had symptoms for over 6 weeks at this point, and had lost almost 20 lbs. I got a call from the radiologist reading the ultrasound -Dad’s kidneys didn’t look blocked, but did appear abnormal, but more concerningly, they had noticed fluid in his chest cavity and had picked up a large mass in his chest. A urgent CT was arranged, along with admission to hospital for dialysis. An over two month admission to hospital followed, with a thoracotomy (big surgery) to diagnose a particularly agresssive type of lymphoma(a blood cancer) which was neuroblastic (yes I had to google it) and normally diagnosed in much younger people. The lymphoma had invaded both kidneys, putting him into renal(kidney) failure and filling his lung cavities up with fluid. Dialysis continued, although the chemotherapy he received did mean his kidneys recovered dramatically. He would be one of the few people who will ever come off hemodialysis without the aid of a transplant. He was able to be discharged home in early December, although he would never be really well again.
My dad died of the lymphoma less than 6 months later, at the age of 70 on Star Wars Day- May 4th, 2009. It was 7 days after my daughter, his third grandchild, was born.

So this raises questions for me about what would have happened? Make no mistake, I don’t really believe the outcome would have been any different for him in the end, but the early journey should not have been that rocky and difficult for everyone involved. Not everyone has a relative who is a physician or healthcare provider ready to step in and navigate the healthcare system when it’s not working properly.
And make no mistake, what happened in my opinion was a SYSTEM problem, not a problem with individuals. The walkin clinic doc was doing the best he could under the circumstances of not really knowing Dad and having very few resources. And for sure the vast majority of people going to walkin clinics do not have extremely rare forms of lymphoma waiting to be diagnosed. BUT….what would have happened if my dad had chosen or been able to find a regular family doc close to him? What if he had driven back to see his regular family doctor, who maybe would have realized more quickly a visit from my dad meant something serious was going on? Would Dad have been treated differently in the emergency room if he hadn’t had a note from the walkin clinic? Or if he had gone to the emergency room first and not the walkin? Did the walkin clinic doc ever learn what had happened to Dad and what the diagnosis ended up being? How many variations of this story are there? Of course there will be no answers to these questions but the debate about the utility of walkin clinics in the care of patients needs to be had. It would be nice to think that had I not chosen to move back to Ontario 6 months before Dad got sick that the healthcare system he paid into as a taxpayer would have been able to sort his problem out without me having to get involved.

We are looking at badly needed reforms to primary care in Ontario, and all aspects of walkin clinics need to be part of that discussion, the good, the bad, and the ugly.

If I were the health minister I would….

  1.  Go back to the table with the OMA with binding arbitration as a last resort if no agreement met. In the meantime accept the OMAs offer of a two year freeze on fees retroactive to January 2015.
  2. Immediately reverse the decision to have doctors fund increased growth in healthcare via clawbacks.
  3. Immediately convene a committee to look at the advantages and disadvantages of fee for service (FFS) billing and its alternatives. Delist codes which are not medically necessary and tackle relativity (income discrepancies between specialties) in a meaningful way. Implement changes to physician compensation as needed. Some of those changes will be unpopular, but necessary to sustain a publically funded health care system.
  4. Reform primary care WITH input from doctors and other stakeholders. Again, some changes necessary are going to be unpopular, with both patients and doctors, as well as other health care providers, but necessary to ensure a fair, accessible, and sustainable system.
  5. Immediately convene a committee to work with all stakeholders regarding physician and healthcare human resource planning in Ontario. Realize that stakeholders sometimes (always?) have conflicts of interest.

If the Minister and government really believe that fee for service (soon to be free for service) is a form of institutionalized fraud, then they need to reform it, not just continue across the board cuts, which punishes all doctors, not just those billing inappropriately. My husband (an accountant who does my billing) finds it astounding there are very little checks and balances in the (mostly) honor FFS system. The suicide of a doctor audited and asked to hand back a huge portion of his billings retroactively some years ago seems to have made the auditing of FFS almost a no go zone. The amount of wasted $ and manpower simply in administrating the FFS system is astronomical, with a nearly 800 page document full of codes and rules, and ZERO, NONE, ZIPPO training to teach you how to use it at all, much less appropriately. Across the board cuts to FFS means physicians (especially those who run offices) must work harder to maintain their incomes. This is not good for patients as less time is spent on each visit , and is also patently unfair to physicians, who cannot refuse to work, and cannot participate in any job action.

A Doctor’s Dress Code Dilemma

I have received an invitation to a event.  It’s a retirement cocktail party, but as usual in Canada, there was no dress code on the invite and now I am not sure what to wear.  I lived in Australia for 5 years, and rarely received an invite to any event, professional or otherwise, that did not include some sort of dress code.  Business casual,  black tie, cocktail, etc.  Something to let you know you weren’t going to be the only one in a sequined dress.  Remember the tarts and vicars dress code debacle in “Bridget Jones’ Diary”? My husband and I did attend one wedding in Canada some years ago that specified black tie for the reception.  I raced around to find a black tie gown that would fit my post pregnancy, breastfeeding body and a tux for my husband.  The dress code was roundly ignored by most people at the reception, with most of the men in suits, not tuxedos, and certainly most of the women not in what I would consider black tie attire.   A few years later I shared a summer birthday party with my twin brother and decided to put a dress code on the invites.  I was putting on a catered dinner and a full open bar and wanted the night to be special. The invite said, “no shorts, no jeans, no ballgowns.”  It was an ill-advised attempt at humour.  I really just wanted people to dress up a bit, without looking like Cinderella.  All I got was a lot of confused guests phoning and emailing me asking what it meant.

Now there seem to be two different camps when it comes to dressing. Those that believe it’s what on the inside that counts, and those that believe it matters what you put on your body.  The older I get, the more I fall into the second camp.  Fuddy-duddy-dom here I come. I don’t even like the F.C.U.K. t-shirts that were popular when I lived in England.  FYI that stands for “French Connection United Kingdom”, but is supposed to be provocative. Now I am a surgeon, and spend a great deal of time wandering around the hospital in a pair of what essentially looks like ill fitting pajamas and a pair of comfy running shoes.  Scrub greens are one size fits none basically.  So it may seem counterintuitive that I think it matters.  But it does.  I will confess that I am a fan of the show “What Not To Wear, “ which I think makes a good point with their message that it does matter what you wear, even if only to make you feel better about yourself. Over the years, dress codes have become more and more scarce.  There is usually a social media story somewhere about how some girl has been sent home for wearing something inappropriate to school.  I agree with having dress codes in schools- there has to be some guidelines, or eventually, someone pushing the envelope will show up at school naked, which I think we can all agree would be inappropriate.  And we know how teenagers love to push the envelope. In fact, I would love it if there were uniforms in all schools in Canada, including public, but that looks unlikely to happen soon.  Uniforms are the norm in Australia. What is school if not a practice for the real world?  I agree that not hiring someone because of sexual orientation, gender, race, age, or disability is inappropriate from a human rights point of view.  But just going to be brutally honest here, I would not be likely to hire someone to work for me who is covered in visible tattoos or piercings, or dressed inappropriately.  These are choices people make, not human rights issues.  All sorts of vulnerable people pass through my office, and I need them to trust not only me, but also my staff, who represent me.  As for youthful stupidity when it comes to tattoos, maybe the decision to get that full face tattoo speaks to your judgement about other things?

For physicians, the dress code represents a dilemma.  Pediatricians have been told NOT to wear the white coat, it intimidates their young patients.  I KNOW my older patients would not appreciate me trying to be more relatable by wearing jeans to my clinic, but my teenage patients might.  If you have a diverse practice, like I do, you’re between a rock and a hard place.  But hey, at least I’m allowed to wear flats to work if I choose to. (Shame on you Cannes film festival).

Now in Australia, in spite of being sticklers for dress codes in social events, I have never seen more inappropriate attire in a professional setting.  Ripped T-shirts worn to a hospital setting by resident staff, exposed flesh over the top of  too tight pants by hospital staff, and swimwear underneath cover-ups to work.  I was the examiner for a clinical exam some years ago, where medical students had to come into a room where both a simulated patient and I were waiting to assign them a task.  They had to perform an appropriate abdominal examination, the idea here being to simulate an office setting.  A female medical student opened the door, and my first thought was that someone had gotten lost and was looking for their friend in the nearby emergency room.  Huge celebrity style sunglasses were perched on top of her head serving to keep her bedhead hair off her face. She was wearing a undershirt style tank top, through which you could clearly see her bra, somewhat appropriate trousers, and plastic flip flops.  The eyebrows of the simulated patient shot up (as did mine I’m sure).  She proceeded to perform completely competently during the exam and we bid her goodbye.  The simulated patient shook his head from side to side once she’d left- “Didn’t think she was in the right room!”  We had a laugh as I confessed I had been thinking the same thing.  Now what would have been his opinion of her if it had been a real clinical setting?  Would he have been able to take her advice seriously?  I’m not sure.  Maybe she dressed that way because it wasn’t a real patient, who knows.  I asked the dean about it and turns out there is no dress code for medical students.

Unfortunately, a lot of our interactions with people will be brief and people are judgemental.  First impressions matter and your appearance, as well as your demeanor, counts.  I didn’t say that this is right or wrong, it’s just a fact.  Now it has been a long while since I have worn the doctors’ white coat.  I’m not even sure I own one anymore.  We don’t have a formal dress code at the office or at the hospital where I work but there are some unwritten rules I follow.

  1. I don’t think someone wants to discuss their breast cancer with someone wearing yoga pants. Exercise gear should be out of the question.
  2. Open toe shoes/sandals- I don’t know why, but I just find toe cleavage inappropriate in a professional setting. Possibly unsafe as well for those working with sharp objects, although that could be a slippery slope to all of us working with patients walking around in HazMat suits.
  3. While we are talking about cleavage, butt and chest cleavage should also not be on display at work.
  4. Cutouts, tank tops, crop tops, sheer tops, camisoles, ripped jeans, visible undergarments (male or female). Just not appropriate.
  5. I do dress down on the weekends and evenings. I do on call, but it’s my weekend too, and I think it’s ok to send that signal to the patients. I can’t sit around in a pair of pumps and business suit in case I get called in. Worst case scenario, I get into scrubs before hitting the ED to see a sick patient if I’m in something inappropriate, like a tennis skirt (that happened once).

My advice would be try and wear clothes that fit, make you feel good, and give you some confidence in yourself.   I will follow that advice myself when figuring out what to wear to that cocktail party next month. Females in particular will have all aspects of their appearance scrutinized and commented on.  This gets 10 X worse if you get pregnant, but that’s a story for another time.  Learn to take a compliment graciously and ignore (ok try to ignore) the rest.  Think about what message you want to send to those you are going to meet for the first time today.  I cringe when I think of the horrible getup (to call it an outfit would be offensive to the word outfit) I was wearing the day I met my future husband for the first time in a hotel lobby in Nairobi over a decade ago.  We fell in love over the next two weeks in spite of it. I guess what’s inside does count sometimes.

The problem with Shouldice or The most dangerous phrase in the English language- “We’ve always done it this way.”

I have just been chastised online for daring to criticize the Shouldice clinic on Twitter.  So I’m going to outline some of my problems with the Shouldice clinic, which is held up around the world as a great Canadian healthcare success story.  I am not going to comment on specific cases, just generalities here.   I have never worked at, or been involved with the Shouldice clinic, so this blog comes from my own professional opinion as a general surgeon/hernia fixer and defender of evidence based medicine and socialized healthcare, discussions with many patients who have gone or are considering going to the Shouldice clinic, going to a talk some years back given by a surgeon who worked there, and the Shouldice clinic website.

The Shouldice Clinic is a private clinic operating in the Toronto area which has been open for decades.  It was originally founded during World War 2 to allow for young men to have their hernias repaired before going off to fight.  It was then allowed special licence by the Ministry of Health to continue operating.  It has been repairing hernias for decades.  It was recently taken over by a private company and is no longer in the hands of the original Shouldice family.  The clinic sits on luxurious grounds and offers one thing and one thing only.  Hernia repairs at the Shouldice are done with local anesthetic, no mesh insertion, and with a long stay in their hospital to recover.

Now as a confession of a conflict of interest here, I am a general surgeon who does lots of hernia repairs at a hospital about an hours drive from the Shouldice.   I think 3 or 4 tomorrow in fact.   The standard of care when the Shouldice was formed was a primary (suture) repair and lots of days in hospital recovering from the pain of having your own tissues reamed together to repair the hernia.  I really don’t want to get into a lot of detail about the complex world of hernia repair here, but the world surgical community has moved on from primary repair with lots of inpatient days and the Shouldice has not.  Is this because Shouldice thinks this is good care?  Is it because they make lots of money off the patients and the taxpayers?  Or is it because, here it comes, that dangerous phrase “We’ve always done it this way”?  Likely some of all three.   Another confession, I also make money doing hernia repairs, but I don’t make nearly as much as the Shouldice does off their patients.  The “standard of care” now is to do hernia repairs with mesh, a plastic like substance which allows for less pain (if inserted properly), earlier return to work, and decreased recurrence rates.  If I was doing the Shouldice repair with no mesh and keeping my patients in hospital for 5 days after hernia surgery, I would probably have my competence questioned, and with good reason.  I would also, I hope, be getting angry calls from our hospitals administrators asking what the hell I was doing keeping patients in hospital for so long after such a simple procedure.  Groin hernia repair is a day surgery procedure in Ontario (anywhere but the Shouldice clinic) with no overnight stay required, unless complications arise or in very frail or sick patients.  I cannot recall a patient ever having been in hospital for 5 days after elective hernia repair.  The Shouldice clinic admits patients the day BEFORE their surgery.  I find this mind boggling- this approach was abandoned in the rest of medicine decades ago.  I honestly cannot recall the last time I admitted a patient the night before surgery, except when I was a clinical clerk, and that is going back a long time now.  The vast majority of procedures are day surgery, or what we call same day admits, where they are admitted (usually after a lot more major surgery than hernia repair) after their operation.  Being in hospital has its own set of complications, with hospital acquired infections, pneumonias, blood clots in the legs or the lungs, and other problems.  But my main problem with this approach as a taxpayer is that this is a huge waste of healthcare dollars.  The Shouldice clinic charges patients for a private room for up to 5 days (this adds up to many hundreds of dollars).  Sometimes this cost is paid out by private insurance companies if the patient has a health benefits plan, or by the patients themselves.  The Shouldice then also bills the Ministry of Health for each inpatient day a patient stays overnight.  So yes, that is you, the taxpayer, footing the bill for unnecessary care being provided by a private company.  Now some of the Shouldice clinic patients come from out of country and should be paying for all of their care but what this percentage is, I do not know.  Shouldice also does not require a doctor’s referral to see patients and bill the Ontario health care system.  As a specialist, I am not allowed to bill OHIP to see patients without a referral from another doctor, and so we see the double standard growing.

Now the Shouldice clinic does do something I agree with in part.  Patients are required to be within 20 % of their ideal body weight, and are refused surgery at the Shouldice if they do not meet this criteria or lose the weight.  The average North American is gaining 1-2 lbs per year, and obesity is a clear risk factor in hernia recurrence.  The more you weigh and the more weight you gain after hernia repair, the more your risk of recurrence rises.   Now I do on call, a lot, at a smaller hospital, and it is not my practice to refuse hernia repair to overweight patients, unless it is a very large, recurrent hernia, in a very obese or frail patient, where there is little risk of bowel obstruction.  Odds are, I am going to be the one digging out a blocked or gangrenous piece of bowel from this hernia in the middle of the night if I do not fix it electively.  So while I agree with patients having to lose weight for some surgeries, I cannot on a practical level be that picky about it. Shouldice of course sends most of the patients it sees back to where they came from, and does not have to worry about complications or ongoing issues from their repairs.  They do not have to do emergency general surgery, ever, how convienient.  Most general surgeons will tell you that they cannot get patients to lose weight before surgery, and that has certainly been my experience.  Shouldice effectively skims off elective procedures in a very healthy, wealthy, and slim segment of the population that is extremely motivated to get their hernias repaired at this private clinic.  This makes any numbers they publish about their recurrence rates completely out of touch with the reality of what myself and other general surgeons are dealing with in our practices.  The other thing about hernia repairs is that recurrence rates have always been very hard to measure.  You have to follow patients for decades to know your real recurrence rate, and patients also are not likely to go back and see the same surgeon (or a clinic) once they have had a recurrence.  This makes anyone’s numbers on hernia repair difficult to interpret, but the Shouldice’s number in particular should be viewed with a grain of salt.  One patient told me he didn’t want to go back to Shouldice with his recurrence because he couldn’t afford it.  I wonder if they know about him, or does he go into their success pile?

Now patients will generally think that more care is better care.  So five days in hospital must be better than no days in hospital, right?  We know that asking patients about their satisfaction with their care has nothing to do with the quality of care provided.  In fact, the most over investigated, over treated patients are likely to think they have great care, when the opposite is the truth.  The Shouldice clinic is a good example of that.  I am also not a fan of the idea of “Centres of Excellence.”  The idea that high volumes of doing one thing only makes you better at it.  I went into general surgery because it’s well, general.  I love doing a variety of different procedures in patients of all ages, sexes, shapes and sizes.  It’s one of the great things about my job.  If I was doing only one operation, the only thing I would be is bored. There is some evidence that using generalists is a cheaper, better way to run a health care system and I believe that.

This is a microcosm of what happens when you introduce private interests into a socialized health care system.  In Australia, the introduction of private healthcare has resulted in exactly what has happened here, albeit on a much larger scale.  A skim off of the healthy and the wealthy to the private system, leaving the public system to deal with the emergency, unhealthy, and poorer patients.  I do not believe in the argument that the Shouldice doing so many repairs allows for more hernias to be repaired in our public system.  The amount of money being drained away by this clinic from the public system is opportunity cost, not just for hernia repairs, but all healthcare spending.

So one last confession.  I had two hernias repaired in November last year.  I got a colleague to do it, with mesh, and a general anesthetic, as day surgery, in one of our local hospitals. I went back to work in less than 48 hours and I am very happy with my scar.  I would recommend this approach (and frequently do) to anyone, including my patients.