Fee-for-service medicine, referrals, and the gender pay gap.

A recent quote in the Dallas Medical Journal made by a male physician stated that the well studied difference in pay between male and female physicians was due to an simple gap in hours worked, or a personal choice by female physicians to work slower and see fewer patients, or both.  Sadly it is a view likely held by the majority of male physicians, and although it provoked social media outrage, it was largely only from female physicians, with a very muted response from male physicians.  It was also somewhat misdirected rage at only the individual who made the unsurprising (to me anyway) statement and not at the wider patriarchal system which has allowed this pay gap to be perpetuated. Perhaps the only mildly surprising thing about the doctor’s attitude was that he allowed the quote to be published.  The data on the gender pay gap (the fact that female physicians earn less than male for the same work) in medicine is clear.  The gap is NOT explained by differences in work hours, speciality choice, seniority, or other factors.  It mirrors gender pay gaps in other areas of the workforce as well.

The argument has been put forth that this medical gender pay gap does not exist in Canada due to our largely fee-for-service model of billing (hereafter referred to as FFS and not meaning the other acronym it sometimes stands for).  70 % of physician remuneration paid in Ontario is FFS.  A doctor of either gender sees a patient, bills a code, (usually irrespective of the time taken to actually do the work the code represents), and the total dollar value of your codes is your monthly income (minus expenses).  There are time based billing exceptions like psychiatry and anesthesia, and capitation billing methods for family medicine but I’m not going to discuss those. Therefore, the reasoning goes, FFS is an entirely gender neutral, equitable way of paying physicians, which is completely blind to the gender of a physician. Do the work, get paid, and therefore no gender pay gap!  It’s completely fair!  Except that it’s not. This blog is my opinion and will not be referenced- the studies mentioned you can look up yourselves.  I think it is extremely likely as more data is generated on the gender pay gap (not that any more data should be needed at this point for our medical organisations to go ahead and address it), it will confirm what most female physicians already know (and the data confirms)- the system is rigged unfairly to pay female physicians less than men for equal work.  Yet another reason (among the many) that we need to be exploring better ways of paying physicians than straight FFS.

Reasons fee-for-service is not a gender neutral payment system.

  1. Not all payment and other benefits received by physicians are FFS. Women often negotiate poorly or not at all when they start jobs, leaving them behind at the starting line financially in terms of accessing perks like clinic and OR time, assistance of ancillary providers like medical scribes, physician assistants, and nurse practioners, and other hospital based resources.  Transparency and protocols for payment at the hospital and other administrative levels would of course help to even this out, but this is hard to come by in hospitals in Ontario.  As an aside, while the fee schedule in Ontario is completely transparent, the total billings are not and in fact nobody in Ontario, least of all other physicians, largely has any idea what anyone else makes aside from specialty averages available. This lack of transparency has the role of keeping those making less (females) uninformed, and therefore less likely to raise a protest.  It has also been my observation that female physicians seem to be asked to do jobs such as committee work which are not associated with stipends or any payment, while male physicians are more likely to apply for, and be awarded, roles associated with extra income. I gave CME talks for no payment, only to find out another male specialist was in fact paid to do the exact same thing I had done for free. In academic centres female physicians are often asked to do tasks which are less associated with being promoted up the professorship ladder, therefore decreasing their income. Data shows female physicians are less likely to be approached to consult for or to accept industry payments from pharmaceutical and other medical device companies, a sometimes not insignificant source of income which is currently not transparent.
  2. Time spent with patients. It’s a well studied fact that female physicians, on average, spend more time with patients than male.  It’s been studied comprehensively- I invite you to go look up the data.  There are some female physicians who spend very little time with patients, and some male docs spend a lot of time explaining things, but on the whole, FFS will lead to women earning less as they spend more time talking with patients.  FFS  financially rewards volume over anything else including quality.  This is a big problem with increasingly complex patients, the era of googling medical information, and shared decision making, where more time should be taken to ensure the patient fully understands their options.  I would note that getting rid of FFS would be more fair for all physicians who spend more time with patients, regardless of gender.
  3. Maternity leave.  It shouldn’t be a surprise to anyone that female physicians sometimes must take maternity leave, and that if you are billing straight fee-for-service and running an office this is going to leave you in the hole financially. Maternity leave for physicians is often for very limited lengths of time, due in part to the fact is a lot of physician work arrangements have little to no maternity leave allowed for- a problem in itself.  Again the old fashioned system of physicians running private offices with expenses paid for out of billings leaves female docs financially behind here. Medical organisations should have policies on the books around office expenses, locum coverage, and parental leave which support female physicians during maternity leave. And while we are at it, breast feeding support including dedicated space for feeding and pumping in the hospital and workplaces would be nice. There should also be the option for male physicians to take time off as well.  In Iceland there is mandated “use it or lose it” parental leave for both parents.  It means employers can expect that both male and female employees will take time off after kids are born, therefore lessening discrimination against female employees who are often assumed to be the only ones who will take parental leave. Female physicians also spend more time doing child care and housework than male physicians, even when working similar hours thus decreasing the time available to work. There are mechanisms to save for maternity leave with incorporation (a poor substitute for proper maternity leave policies in my opinion) and also a modest parental leave payment available for up to 17 weeks in Ontario for female physicians.  Employers need to plan for some flexibility for both genders to take parental leave without requiring those taking the leave to make up call before or after.  The fact is though, females bear the physical brunt of bearing and then breast feeding children, so poor parental leave policies will continue to disproportionately affect women for the forseeable future. A spinoff of this is that offices expenses tend to be somewhat fixed, not generally increasing that much based on volume.  So if you are earning less because you as a female parent are the one doing the majority of the childcare, a larger proportion of your income goes to office expenses than your male counterpart who can work longer hours.
  4. Referral bias- specialists depend on referrals for their practice income.  A lower number of referrals equals less income, but also the mix of referrals is important.  Physician remuneration generally rewards procedures over cognitive work, and this occurs within specialties as well as between them.  A recent study showed after a poor surgical outcome, referrals to female surgeons dropped, the authors postulating that the GPs drew the conclusion that it was due to a surgeon factor such as lack of clinical judgement or skill. Whereas in the same study, referrals (from both male and female GPs) went UP to male surgeons after a bad outcome, with the assumption being that the bad outcome was a related to something that made the patient a higher surgical risk, as opposed to a lack of clinical or technical skill on the part of the male surgeon.  This sort of gender bias affects referrals in other ways and it’s naive to think that it doesn’t.  Female surgeons often receive a disproportionate amount of non operative referrals.  The fee schedule tends to reward procedures much more than consults, and so if you do more clinic hours seeing fewer patients than your male colleagues, and also fewer patients who require surgery, that results in being unable to fill your OR lists (or unable to fill them with the quicker, lucrative cases) and you make less money.  As an example-breast surgery is an area of general surgery which deals largely with female patients and often with breast cancer especially, making the consultations take quite a bit longer than other issues. This results in decreased income if you are seeing a lot of these patients. It is one of the few areas of surgery where there are more women than men choosing to subspecialise in this area. It is not known as being particularly lucrative with respect to the fee codes.  In other areas of the workforce, as women migrate to a job the amount being paid for that job has tended to decline and I suspect that is what we will see with breast surgery. In addition, female surgeons will tell you (as will I) that there are referring doctors who routinely send them non operative but complex or extremely anxious (or both) time consuming patients as referrals while they can’t seem to find their number when it comes to an easy slam dunk surgical case.  While these patients all need to be seen, it certainly could be a source of increased burnout in female physicians when they  see a disproportionate number of patients with complex challenging problems for which there are no quick or easy answers like an operation. Female surgeons operating lists sit unfilled, while waiting lists for those operations rise.  This would of course be a problem with gender bias at least partially solved by centralised referrals, which are already in routine use in many settings, including DAPs (diagnostic assessment programs) and oncology centres.  The excuse used by referring doctors protesting the idea of centralised referrals is “I need to select the best consultant for my patient” can in fact often be a thinly veiled excuse for- consciously or subconsciously “I want to continue to discriminate against female doctors by sending them fewer or less lucrative referrals.”  (I will need to save a more complete takedown about the other meretricious arguments used against centralised referrals for another time.) There are some community based specialists who refuse to see referrals for conditions for their specialty which are known to be less lucrative- cherry picking is the name of this practice. This of course is unfair to those specialists who then have to see increased numbers of patients with a given time-consuming clinical condition.  As well it is unfair to the patients referred who have to wait longer to see the fewer number of specialists seeing that condition and also as an FYI contravenes CPSO policy on accepting referrals.  While this practice is not exclusively seen in male physicians, it certainly predominates there- in my opinion and recent experience. The old boys club sometimes lends a hand here as well with established referral patterns hard for a new physician to overcome.  I feel the need to say here that no physician in Ontario should be accepting payment or gifts in exchange for referrals, regardless of gender. Please see my blog on referral etiquette for more guidance.

In addition to the above, no approach to eliminating the medical gender pay gap can be successful without addressing relativity, which is the term for the fact that doctors in Ontario earn widely varying incomes depending on what it is they actually do for a living.  5 fold differences are seen and the higher paying procedure based specialties like surgery tend to be male dominated, whereas the low paying specialities are female dominated (paediatrics).  A lot of this reflects the hidden curriculum, where female medical students are discouraged from pursuing high paying specialties in medical school, being warned of tough working hours, difficulty negotiating work life balance, and of course a dose of good old sexism.   Until more women are represented in medical leadership and at negotiating tables, and more attention is paid to gender bias and its negative effects on society, both male and female physicians, and our patients, we will continue to have problems with this issue. I’m going to postulate here that if women had been present in leadership and negotiating tables proportionate to their numbers we would have had a lot more progress on the corrosive issue of relativity pervading our profession and also that we might have moved farther away from straight FFS billing, a move that would likely benefit both genders of physicians and our patients.

I can think of other issues related to the gender pay gap (lack of mentoring of females with regard to billing, hiring practices, lack of success securing research funding, getting published, receiving awards etc).  This has given you an inkling that when you say to a female physician that we don’t have an issue with a gender pay gap in Canada due to fee-for-service billing, that is an incorrect assumption.  While getting really ,mad at Gary (or any other male physician who publicaly disputes the gender pay gap) may be therapeutic, it isn’t going to change anything until a critical mass of physicians, both male and female, get up, get mad, and say our payment system needs a massive overhaul.  We need to start voting people into medical leadership positions in the PTMA (provincial territorial medical association who negotiate pay for physicians in Canada) who firstly acknowledge the problem of gender pay gap in medicine, and secondly are prepared to do something about it.

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Tackling the issue of surgical mesh infection and a background on surgical implants.

There has recently been some media attention surrounding the use of surgical meshes, not only for hernia repair but also the TVT (transvaginal tape) and other meshes used for prolapse surgery and stress incontinence.  In the UK a ban on implantation of vaginal mesh has been called for.  See the following links- https://www.theguardian.com/society/2017/aug/31/vaginal-pelvic-mesh-explainer  and http://www.independent.co.uk/news/uk/vaginal-mesh-scandal-transvaginal-procedure-mps-debate-parliament-tvt-thalidomide-emma-hardy-a8006101.htmland   Also closer to home in Canada-  http://www.ctvnews.ca/health/growing-concerns-in-canada-over-surgical-mesh-usage-recalls-1.3372733

Surgical mesh for hernia repairs came into common use over two decades ago.  There are now a wide variety of meshes available on the market. It is recognised that use of mesh decreases the risk of hernia recurrence, particularly for large hernias and in overweight or obese patients.  I do use mesh for my hernia surgeries, but not all the time.  The basis for deciding to use mesh or not is based on a lot of different factors (is the hernia large? recurrent? for example)  but also on a discussion with the patient.  It must be stated that the consequences of a mesh infection (which are rare) are often devastating for the patient and a very expensive strain on the health care system.

But implanting foreign materials for long term use into the human body surgically has been around for a long time.  Ever increasing numbers and types of devices have been put into increasing numbers of patients since the implantation of the first pacemaker in 1958.  We now use metallic heart valves, cataract lenses, surgical clips, staples and sutures, artificial blood vessels (grafts), prosthetic (artificial) joints, orthopaedic hardware such as plates and screws to fix fractures, pacemakers, dialysis lines, and artificial sphincters- the list goes on and on.  The development of these medical devices has allowed people to live longer, happier, and healthier lives for those vast majority of patients where the operation goes well.  But every surgeon knows that infection of an implantable device usually means a long and difficult journey ahead for the patient.  As an aside- the surgeon usually has a pretty tough time with it too, just not nearly as tough as the patient.  While the recent focus has been on TVT and hernia mesh infection there are lots of examples of infection causing severe disability in other implantables.  Infection after cataract lens implantation can result in permanent blindness in that eye- see here https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2377381/.  Prosthetic joint infections (hip and knee replacements which become infected) are a devastating and costly complication- see here- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3993098/.   The list goes on, the point being, infection (usually bacterial) in implantable devices is a rare but very serious risk in modern surgical care, and that risk should never be taken lightly by surgeons, patients, or the public. Infection of an implantable device can be heralded by pain and fever- other symptoms depend on where the device is implanted and for what reason. These implantable devices themselves such as pacemakers, and artificial joints do not have any blood supply.  Blood supply is crucial to healing and once an infection has set in to an implantable device, there is little or no blood supply to bring in cells from the immune system to fight the infection.  Often treatment with antibiotics alone is a losing battle for these infections.  The infection can usually be brought under control by removing the device, but sometimes that is a difficult process in itself.

What do patients and the public need to know about not just surgical mesh, but all of these devices?  Firstly to ask questions, lots of them, BEFORE having surgery if there is a chance they may need to be used in a procedure.  Often there are few or no alternatives to using a prosthetic but occasionally there are.  Patients should ask what the risks are?  And what they can do to minimise those risks before, during and after the procedure? Patients should ask what happens if I choose not to have this procedure done?  Infection is more common in smokers, diabetics or those with immune system problems.  Also, even without infection, symptoms such as chronic disabling pain or other complications can occur without an implant infection. Quitting smoking and having good sugar control (if you are diabetic) are two obvious things patients can do around the time of surgery to decrease the risk of an implant infection and infection more generally as well. Ask the surgeon or other clinician what precautions will be taken to minimise infection and what signs and symptoms to look out for post op that may indicate an infection is developing and what steps to take if that happens.

Banning the use of implants of whatever type will decrease if not eradicate all cases of implant infection.  But it would also prevent thousands, if not millions, of patients from accessing life altering, and in some cases lifesaving surgery.  I have mesh in a couple of different places and I’m delighted by the results of my surgeries. And while anecdote does not equal data, hopefully the fact that a surgeon willingly asked for mesh to be put in her body is somewhat reassuring to those who may have to weigh the option of mesh or another implant in the future.

And so for medical regulators, the tricky balance of risk and benefit must be weighed when deciding to licence different products for various purposes. Mostly in Canada the bar for allowing medical devices to be implanted is very high- Health Canada has a comprehensive list of all devices and any recalls which have happened. We must do all we can to prevent implant infections from occurring, and continue to study and try and improve outcomes for our patients.  A good outcome will never be guaranteed as no surgery is risk free but it should certainly be strived for.

 

Incorporation Anger

Bill Morneau, Justin Trudeau, and the federal Liberal government have proposed tax changes to corporations and some physicians are outraged.  In Ontario, the ability to incorporate was granted in 2005, in lieu of fee increases, during negotiations between the Ontario’s Ministry of Health and the OMA (Ontario Medical Association).  It could have been predicted at the time that the Ontario government was giving something away which could be then be taken back at the federal level. Physicians could incorporate to shelter income from high personal tax rates and save for retirement, among other things, and around 70 % of us did (including me).  Justin Trudeau alluded to changing theses rules during his election campaign in 2015 and has now formally signalled that he intends to follow through on that promise.

The unintended consequences of closing these loopholes are completely unknown- “Without data you are just another person with an opinion”- W.E. Deming.  Prior to 12 years ago there were very few incorporated physicians in Ontario.  Cries of “Doctors will work less!” “Doctors will work more!” “Doctors will leave!” “Doctors will burn out!” due to these changes alone are grounded in opinion and not fact.  Each individual physician will have to firstly wait until the legislation is passed, and then carefully review it’s effects on their individual situation with a trusted financial advisor. I think it behooves our medical leadership to be truthful about what is known and what is not about the proposed changes and any downstream effects (or lack of them) on the broader health care system.

The amount of risk taken on by the average physician opening a practice in Ontario (or in Canada for that matter) is usually minimal.  Opening up a restaurant or a boutique- that’s risky.  So let’s not pretend about the amount of risk there is to financial failure of the vast majority of physician practices. To do so is insulting to other small businesses who do in fact take on large financial risks to establish their profit streams.

Physicians do not have benefits, pensions, sick time or disability leave.  Tax shelters and loopholes masquerading as pensions and parental leave payments leave doctors at the mercy of both governments and public opinion.  If there is one thing I have learned being involved in medical politics over the last few years- the general public does not care that doctors pay overhead!  And they shouldn’t have to.  The longer we stick with the model of doctors funding health care infrastructure out of billings, the more we get behind with public opinion every time the profession starts trying to win the public relations battle by arguing that we pay overhead.  The same goes for tax policy- arguing that tax savings are a way for physicians to fund maternity leave, pensions, benefits etc are not invalid, but don’t carry a lot of weight when jobs which include these things are becoming rarer and rarer in the job market for all Canadians, most of whom are paid a small fraction of what physicians earn.

The only thing which IS clear about the proposed changes effects on mat leave is that the way maternity/parental leave is provided to physicians (at least in Ontario) is silly.  Female (or male) physicians forking out office expenses are under a lot more financial pressure during maternity/parental leave that those who are not, and yet both groups receive the same payout from the Ministry of Health.  At the very least, there should be different treatment of doctors who run offices on parental leave versus those who do not.  Maybe physicians deserve parental leave, benefits, and pensions simply because these are things that doctors (and our patients) should have? Funding these things for only a specific group through tax loopholes leaves doctors in a precarious position when taxation policy changes like these come along.

I’m an incorporated physician- and it’s a wildly expensive, complicated, painful enterprise which I would rather not have to deal with.  A large start up cost and then yearly fees to lawyers, accountants and financial advisors. On top of that, investments haven’t done all that great, certainly not as well as much larger pension plans. 30 % of physicians are not incorporated and there are others who are who will be minimally affected by these changes, or in fact have ended up worse off from incorporation.  What our profession needs is a collective pension plan which would serve to lower administration costs and increase returns.   Ad hominem arguments about Bill Morneau’s (or anybody else’s) pension plan and benefits are really just not appropriate in this debate either- it’s simply an irrelevant way to argue your case.

My reading of this situation, having followed a lot of what is being written and having listened to all of Jane Philpott’s speech at the CMA, is that theses changes will go through.  A majority government in a democracy is powerful. Should there need to be concessions for doctors who have put all their eggs in one basket with the corporation?  Sure that would be nice but it’s not guaranteed. The outcry, social media and otherwise, over unilateral action against physicians in Ontario in 2015 resulted in exactly nothing changing except perhaps to further damage the professions’ relationship with both government and the broader general public .  Given this fact, the medical profession needs to ask itself how many bridges it’s willing to burn with the federal government over this issue?    I’ve seen this movie before and there is no happy ending if we keep going down this road. Avoid personal attacks and keep your arguments fact based, or you serve to undermine legitimate points yourself and others may make. Undisciplined bullying of others, on social media or otherwise, does nothing to advance your cause.  The CMPA has an excellent handout on advocacy and I suggest everyone getting involved in this argument read it entirely and follow its advice.

There has been minimal member consultation around the approach to these tax changes, and physicians who support them are now afraid to express their opinions for fear of being shouted down. The CMA’s position on these tax changes is questionable with a pretty big conflict of interest, given MD Management’s (a CMA subsidariary) large role in managing thousands of incorporated physicians’ finances. While it’s easy to rally opposition around a cause like this, I have seen no useful ideas or policy coming out likely to improve burnout amongst physicians, although it seems to come up a lot when discussing these changes. While you can make some physicians very angry by paying them less (or taxing them more), you simply aren’t going to improve physicians work-life balance or burnout rates by getting the suggested tax changes overturned- in fact it would more deeply ingrain the status quo. This is the ideal time to get rid of fee for service, which is, in my opinion, a huge contributor to physician burnout, and which would then obviate the need to incorporate. We need to establish a group pension plan, and allow restructuring of physician remuneration in a way which would better serve both doctors and patients.

 

 

Why I don’t support conscientious objection to MAID

Bill 84 has been passed into law in Ontario and outlines the legal issues surrounding medical aid in dying (MAID), which has been legal in Canada since last year. The patient’s death must be “reasonably foreseeable” and their suffering “grievous and irremediable” to qualify for the service.  Groups such as those with advance directives, mental illness, and minors are left out, and whether they should be allowed access to this service in the future is an issue for another time.   One of the most contentious aspects of Bill 84 is the requirement for the treating physician in Ontario to provide a referral for a patient who has requested MAID to a physician who provides it.

I’m a surgeon and I do not provide MAID as it is not within my skill set, but I absolutely support patients who qualify having access.  Multiple surveys have been quoted in the press using statistics of the % of physicians willing to provide MAID as a surrogate marker for the % of physicians who support their patients having access to this service. The two are not the same. You don’t have to spend a lot of time in my job on the wards of a small community hospital to see suffering, often profound suffering, in the dying.  Discomfort that medical science hasn’t been able to relieve, certainly not completely, and a lot of the time and especially near the end of life, not even close, even with access to the best of palliative care.  The struggle of breathlessness with incurable but maximally treated lung or heart disease, the unrelenting pain of a locally recurrent rectal cancer, or the ongoing nausea of an untreatable malignant bowel obstruction.   A lot of patients whose death is “reasonably foreseeable” on the ward (and an even higher number at home) simply cannot even get out of bed, much less find their own way to the very small number of physicians who are providing MAID in Ontario.  This group of patients are sick, suffering, and vulnerable. While the group of patients requesting MAID, to be eligible by definition must be of sound mind, in a lot of cases they are not going to be physically even able to self refer.   While allowing both conscientious objection and effective referral for MAID would be great in theory, the reality is that in some situations, the two are going to be mutually exclusive.  You simply can’t have both and not expect that in an unknown number of people who would have wanted MAID, you are going to prolong suffering.  Whether or not you are able to access a legal health service in Ontario should not depend on which institution you are admitted to, who your doctor happens to be, and even less on what that physician’s religious beliefs are.

These doctors who object to doing these referrals are not being asked to provide MAID, to be clear.  They are being asked to provide an effective referral for a patient who has requested it.  It will be the case sometimes that patients referred may not qualify for MAID.  “Let’s set up a hotline! And a website!” people say.  That way patients requesting MAID can do what is called “self referral”. Meaning they can just call the doctor who provides MAID themselves.  Doctors who find the idea of being involved, even very peripherally, in MAID, would be off the hook, their consciences clear. Well that would be great, if it weren’t so obviously unreasonable in the reality of these very ill patients day to day lives.  The sad fact is that many of these patients can’t pick up a phone, or go to a website, usually by virtue of the very illness which is causing them to want to be referred for a medically assisted death in the first place.  In remote and rural communities, allowing conscientious objection could mean the difference between weeks or months or suffering, or the patient being able to access a legal medical service. Another big issue of course, is that the physician involved with the patient may be the only one with access to information about whether or not the patient qualifies for MAID, thus creating a catch-22 for the doctor trying to assess for suitability in the first place.

Life is a condition with a 100 % mortality rate- cure sometimes, treat often, comfort always, in the words of Hippocrates.  There are other instances, such as abortion, where physicians’ personal or religious beliefs come up against the expectations of patients, their families, government, or society generally.  In requiring physicians to honour patients’ reasonable requests for access to legal health services, the government has got it correct to err on the side of legislating for patient access. I can’t even imagine how much distress a patient has to be in to even broach this subject with their physician.  I imagine the bar is pretty high, given our propensity to treat aggressively into the last embers of life. Raging against the dying of the light is ok, if that’s what the patient wants. When what the patient wants if to be referred for MAID, it’s our duty as physicians to provide it. The government of Ontario has got this one right.

 

The compelling case for salaried physicians

It is a well known and accepted economic theory that once you get a minimal level above the poverty line in terms of household income,  increasing levels of financial compensation are associated with decreasing returns on happiness.  When you go from a household income of $30000 a year to $60000- large increase in happiness.  Double $60000 to $120000 and again your happiness level goes up.  Just not as much as the original jump from $30000 to $60000.  And so on.  Until you get to a point where you have so much your money is actually causing you some stress and happiness levels actually decline.  (See the terrific read “The Happiness Myth” by Jennifer Michael Hecht for a fuller explanation of this and other insights into happiness) .  So on to physicians.  While residents and medical students are often under some financial stress, particularly with heavy debt loads, most physicians do ok from a financial point of view, I think we can all agree on that.  Almost no physician is going to end up under the poverty line, aside from serious illness or addiction resulting in an inability to practice or other personal calamity (Get disability insurance doctors!).  I cannot explain the number of unhappy (and sometimes downright miserable) physicians in Ontario right now based on absolute income.  We have had cutbacks, which nobody likes, so some of it comes from that, but not all of it. Fee for service motivates physicians to work lots of hours, see lots of patients and do lots of procedures.  Burnout levels are high, in part due to what I refer to as the “fee for service treadmill”, which results in no work, no pay, but also a lots of work, lots of pay motivator which I think is contributing a lot to making physicians miserable and possibly (likely) not being that great for patients.

The vast majority of payments to physicians in Ontario are paid on a fee for service basis (FFS), around 70%.  As a physician, you see a patient, or in my case, do an operation, then bill the government for the service provided.  The collective total each month is your billings or gross income. This is the figure rolled out to the media by the government to defend their cuts to the physician services budget over the last few years. But out of these billing totals comes the cost of being in practice, running an office, paying ever increasing fees and administrative costs from an ever increasing number of organizations (CPSO, OMA, CMPA, and CME organizations like the Royal College and CCFP, to name a few of the mandatory ones).  FFS has an intuitive appeal, in that docs who work more, get paid more.  That seems fair, and bonus- it’s easy and simple to understand.  Or is it?  FFS has a number of upsides and downsides.  The upside is that physicians are motivated to provide care- lots of care.  That is good for patients in that, in theory, wait lists are reduced. The bad news is that sometimes it doesn’t lead to care that is all that good in terms of “quality”.  Another issue is that as across the board fee increases have been applied to the entire fee schedule over the years, specialties who bill lots of codes have had their incomes rise out of proportion to those who do not, magnifying relativity differences.

Other compensation models have become more common in Ontario. APPs (alternate payment plans) are used often in academic settings or cancer centres to account for a lot or work which does not involve direct patient care and is therefore not compensated, such as administration, research and teaching. It is not unusual for per diems to be used in emergency rooms, and of course some physicians receive salaries.  Capitation was introduced into primary care in the last 20 years, along with multidisciplinary teams of social workers, nurse practioners, dieticians, etc.  called family health teams. Capitation for the physicians in these groups is a form of salary where the physician get paid per patient per year.   Those patients “rostered” or signed up in family health teams have free access to a wide variety of services, while those who have a family doctor outside of one of these teams, often end up paying out of pocket (or sometimes not using the service at all). Patients today are becoming more chronically ill, with complex health problems and long lists of medications.  Capitation allows GPs to spend more time with patients sorting out their problems and getting to know them, which is just sooooo important for the types of patients we are seeing now and increasingly in the future. And that’s just good relationship based primary care (which everyone should have access to).  The problems with it are that a lot of people aren’t rostered with a family health team.  FFS family docs are paid a pittance, around $33 minus cutbacks for an A007-which is called intermediate assessment, and is the backbone fee of primary care. FFS family docs have to churn through a lot of patients to make their practices viable, which results in not so much time to spend getting to know patients and sometimes the “one issue per visit” rule in doctors’ offices. Since the Ontario government stopped allowing doctors to sign up for family health teams (outside of designated “high needs” areas) there are few new graduates setting up family practice.  Which is a shame with 800000 people in Ontario without a family doctor.  Capitation has had problems with after hours access not being available to patients in these teams and other issues I won’t go into, but I think the principle is a sound one.

Which begs the question- if capitation works in primary care for complex patients why not use a salaried model for all physicians?  Overhead, benefits, and sick leave would need to be negotiated of course. It would a long, complicated and messy process.  Would it save money overall?  Probably not and that wouldn’t be the point. Physicians spend a lot of time setting up and running an office (not doctor work).  Why not have offices run in larger group settings with the overhead covered and let doctors be doctors?  That’s what most of us want to do.

Overdiagnosis and overtreatment are an increasingly recognized problem in medicine.  It takes time to explain the possible outcomes of tests and procedures-sometimes a lot of time. Often more than the time to do the actual procedure and certainly a lot more time than to fill out the requisition!  Patients are being subjected to an ever increasing number of diagnostic tests and procedures without understanding the cascades and vicious circles of ongoing investigation and treatment which can result.  I think shared decision making with patients around what their care plan is for any given complaint is mandatory, but this takes time!

Gender problems exist with using FFS as well.  Female physicians must work an average of 2 full time weeks longer each year under FFS to earn the same amount as male physicians.   Mostly the problem lies in the fact that lots of female physicians spend more time talking to their patients, something which is not rewarded in our current system. I myself, and other female colleagues I have talked to, are often referred patients after procedures have been done to “talk” to them about the procedure.  Since surgeons make little to no money running their offices, stuff like this puts the female surgeon behind.

Academic institutions are increasingly going toward a salaried model, and in other countries (Europe, UK, Australia) salary is a common way to pay physicians.  In the US Relative Value Units, or RVUs, are now used to determine productivity and compensation, or both.  For a discussion of RVUs, see here-   https://www.merritthawkins.com/pdf/mharvuword.pdf .

We are living in a time of relative physician oversupply, allowing that some rural areas and specialties are undersupplied. A lot of specialties, especially surgical ones, are oversupplied, with under and unemployed specialists becoming commonplace.  FFS does not provide impetus to let others into your call schedule or operating room time. Flat salary may not be the way to go, blended models of compensation which provide some motivation to keep volumes relatively high and are generally thought to be the best way to compensate physicians. Financial remuneration serves to influence behaviour, and we should design the system so that physicians can look after patients properly. I don’t believe the way forward for our profession lies in fee for service.  I’m not the only voice saying this, and I hope someone is listening.

What Canada can learn from the US healthcare system.

I have just returned from a weekend in Dallas, Texas, where I spent the last weekend at a breast oncoplastics course.  It was an incredible course, with surgeons from all over the US, Canada, and the world gathered to learn surgical techniques from experts to improve cosmetic outcomes for our breast cancer patients. In spite of all the problems in our healthcare system, I had always considered (and still do) that our system is far superior to the US, which spends far more of its GDP on healthcare (17 % vs around 11-12 %for Canada), yet has millions of people unable to access even the most basic of care, largely due to cost.  I went to a talk some years ago by Dr. Otis Brawley, the chief medical officer of the American Cancer Society.  One memorable line from his talk was (paraphrased) “To call the US healthcare system a system is offensive to the word system.”  And nobody is more surprised than I to be writing the above headline. But after spending three days interacting with surgeons from the US and discussing how healthcare is organized there I think there are a few things we can learn from them.  Make no mistake, I don’t think we should be abandoning our one tier system, but we do need to make changes, and not small changes, BIG changes.

I am involved with the OMA, the organization which negotiates physician compensation with the government in Ontario.  So different mechanisms of how physicians are paid interest me- what IS the best way to pay doctors? I asked a bunch of surgeons at the course about their work, how much call they do, how it’s set up, and how they get paid.  Like most Canadians, I find asking people about how much money they make distasteful, so I avoided specific questions about actual income amounts.  We also attended lectures and small groups on coding for Medicare and were able to ask lots of questions about those systems (it’s not dissimilar to the fee schedule in Ontario).  Surgeons in the US have a menu of options to choose from (largely by having a larger market) regarding how they get paid.  A minority worked on salary- a fixed income per year regardless of how much or how little clinical work they did.  Overhead was covered, and benefits provided (this was particularly nice for maternity leave apparently).  There were still expectations and accountability for these surgeons though- they didn’t sit around all day drinking coffee.  I was on a salary when I worked in Australia and could relate to a lot of what they were saying- it had it’s advantages and disadvantages.  There were a lot of surgeons there in “private practice”.  This is largely the system used for surgeons in Canada, where you are an independent contractor (not a hospital employee) who has operating room privileges. The myth that I think we have in Canada is that surgeons who work in the US can charge whatever they want for a given procedure.  This is largely untrue- it is not a free market but a regulated one.  There are base medicare rates which have to be respected- for example $500 for a mastectomy (I don’t know if that is true but just as an example).  Rates are then negotiated with insurance companies based on multipliers of those rates.  Surgeons might receive 100%, 200%, or 300 % of the medicare base fee, depending on the insurance company, some health insurance companies being more generous than others.  300 % is almost unheard of apparently. The point of this being, the idea of having surgeons (and physicians more broadly) self select into different options as to their compensation seems to me like a good idea.  Physician compensation should serve to motivate the provision of appropriate amounts of medically necessary healthcare.  Fee for service (which is 70 % of what the Ontario government pays out to physicians) motivates lots of care (whether appropriate or not).  Putting all physicians on flat salaries may lead to long wait lists if not appropriately structured.  Per diems and capitation have similar issues.  Most evidence points to a blended model of payment being the best.  Of course in Canada most surgeons bill almost exclusively fee for service and don’t have a choice.

Innovation is another area we are weak on in Canada.  In Dallas we learned about techniques of intraoperative radiation therapy for breast cancer, were able to work with special newly developed cavity markers, and saw machines which allowed breast cancer specimens to be xrayed within the operating room- saving OR time.  Often these innovations actually provide better care while saving money- goals that are not always mutually exclusive (but can be).  Too often we get into the argument in Canada about which pot the money is coming out of, which is ridiculous because in a publicly funded system IT’S ALL ONE POT! We in Canada sometimes get into the situation where one area of the hospital will not spend a dollar of their budget to save $100 dollars to the system from another budget.   There is no doubt we in the north benefit from these innovations going on south of the border.   The money needed to innovate in Canada seems to be in very short supply.

Moving on to a different issue, I asked one surgeon in private practice how much he operates.  “Three days a week.”  he said.  THREE days a week?? I could only dream.  I have often expressed the view that for myself as a surgeon, one day a week of elective OR time is simply not a good use of my training and expertise, and contributes to wait lists.  That is a big problem in Canada- many of us surgeons would like to operate more than we do but the system is not set up for it- “under resourced” in political parlance.  I asked another surgeon about what % of her referrals are patients that actually need surgery. I asked this sbecause a big problem for me is that I have to see a ton of patients, most of whom do not need surgery, to fill up my OR time. She looked at me- “Almost all of them.”  “Almost all of them???”- I was incredulous.  “Where do the non operative ones go?”  “I don’t know” she said, “they are screened out well before they get anywhere near me.”  You could have knocked me over with a feather, IMAGINE! A system where surgeons see mostly surgical cases and spend most of their time doing what they are trained to do- operate.  Nirvana for a surgeon.  As we have no screening process for referrals here in Canada (and are somewhat constrained in what referrals we can reject) we are obligated to see these patients.  The eConsult service in Ontario is attempting to solve this problem by allowing primary care doctors online access to ask specialists if referrals are appropriate.  This is an amazing service which needs to be utilized more widely.

Which leads me to the thing I most admire about the US healthcare system.  Surgeons’ time (and OR time more generally) is thought of as VALUABLE.  Surgeons in the US bring business (patients requiring surgery) into hospitals, and the income that comes with it. Myself, the equipment and nursing staff I require to operate (and by extension the patients I bring for surgery) are often seen as a drain to my hospital.  This makes my goal as a surgeon (providing patients with appropriate surgical care) in direct conflict with the hospital’s goal of staying under budget.  This happens in other areas of the hospital as well.  This is a quote from Shawn Whatley’s book “No More Lethal Waits- 10 Steps to Transform Canada’s Emergency Departments”- “An efficient ED keeps physicians busy doing things that only physicians can do, all the time.” (The book is thought provoking and a worthwhile read- avaliable here-  https://www.amazon.ca/dp/B01B6KFTQ2/ref=dp-kindle-redirect?_encoding=UTF8&btkr=1  ) Our ED has physicians doing paperwork and printing out forms- this is not doctor work. But because the ED docs are paid out of a separate “pot” from the hospital budget, it is “free” to the hospital (not to the system) to have the physicians do what is unit clerk (secretary) work, instead of the hospital paying for another clerk when the workload gets too high.  Ridiculous.  This issue is being addressed (slowly) with the funding of hospitals in Ontario moving away from global budgets to what is called “bundled payments” and other funding formulas. There is a good explanation here- http://www.cfhi-fcass.ca/Libraries/Hospital_Funding_docs/PolicyBrief_Hospital_Funding_ENG_Final.sflb.ashx  I’m just a dumb surgeon, but it seems that aligning my goals with the hospitals would be a good thing.

It was clear from the weekend that surgeons, regardless of nationality, are united in the goal of providing the best care to their patients.  The course recognized that while the number 1 goal of breast cancer treatment is to save lives, cosmetic outcomes are important, VERY important.  And while I think the Canadian healthcare system with its universal access is worth fighting for, we need to be taking ideas and evidence from healthcare systems around the world to make ours better.

The pregnant surgeon

A recent article on Kevin MD (originally from the New York Times) discussed “The Plight of the Pregnant Surgeon” http://well.blogs.nytimes.com/2012/02/23/the-plight-of-the-pregnant-surgeon/?smid=tw-share&_r=0 . While the article makes good points, it doesn’t actually give any insight into what it is like to be pregnant and a surgeon at the same time- the actual day to day mechanics.  I had three different pregnancies while a surgeon at three different hospitals in two different countries, so I thought I would share some insights.  If one pregnant (or thinking about being pregnant) female surgeon reads and identifies with this, and feels slightly less alone because of it, then my work is done.

Over ten years ago, I was sitting with 2 female surgical colleagues.  I was recently married, one colleague engaged, and the other in a serious relationship.  We were discussing the best time to have children as a female surgeon.  Before medical school? As a medical student or resident (registrar)?  Or as a staff surgeon?  We discussed pros and cons of each, mostly focusing on the financial implications (never good) but ended up deciding unanimously that there basically was never a good time to be pregnant during a surgical career. We really had at that point very few senior female surgeons to look up to who had managed to combine having kids and a surgical career. (We recently reunited 10 years later, now having 8 kids between the three of us). Having said that, most women who choose a career in surgery will also choose at some point to have children as well, so this is something that we are all going to have to get used to.  While I realise having children is a choice, being a surgeon and a mother should not be mutually exclusive.

A month or so after that conversation, I found out I was pregnant.  This was a wanted pregnancy, make no doubt about it, we were elated.  There was about a 3-4 day gap between figuring out I was pregnant and the morning sickness hitting.  At the time I was working in a full time surgical position with 1/3 on call.  We knew the stats on miscarriage and we decided to keep the news to ourselves until after the pregnancy had passed 12 weeks.

I am normally a busy, active person but the fatigue associated with my pregnancy was not something I was prepared for.   One Saturday at about 8 -9 weeks pregnant I remember having the day off and my husband leaving at 6 am for golf.  The only things I managed to do in the 6 hours he was gone were go the bathroom and make a piece of toast.  He returned, grabbed his sailing stuff and headed out for another 6 hours.  At 6 pm he came home to find me still in bed, not having left the house all day and still in my pajamas from the night before.  It felt like someone had strapped a 50 kg weight to my back.  My bed was constantly calling to me to come lie down, and like Sirens calling to the sailors, it was irresistible.  I yearned to be lying down 24 hours a day.  This feeling, however, is largely not compatible with surgical life.  While a 40 hour work week is routine for a lot of jobs, a busy on call week for me was 60-80 hours.  And that was working, not just the on call.  I struggled to get up for work in the morning and loved hitting my bed at the end of the day.  I dreaded my pager going off. I don’t particularly recall being less attentive or churlish with patients, but I could have been.  I would also look back fondly on that day I spent in bed, as once you have young children, they don’t care if you have morning sickness, (or any other kind of sickness, bad call night, hangover, etc).

Work did provide a distraction from the constant nausea (which lasted all day). Particularly bad were some of the smells that come with working in a hospital, and some especially bad ones that come with general surgery, where one whiff would set me off, hurrying down the hallway muttering some lame excuse to whoever I was with.  But I soon discovered if I allowed my stomach to become even partially empty, the nausea would build until I started retching up bile.  I then learned to eat almost continuously to keep myself from retching and keep the nausea under control (cue massive weight gain and jokes in the lounge about getting checked for an insulinoma).  This approach worked provided I was not in the operating room.  The times I couldn’t get something into my stomach during a long case, I would dash into the nearest bathroom at the first opportunity once scrubbed out to retch into the sink.  I knew where every toilet was in the hospital and my pockets and purses were filled with sleeves of soda crackers. The idea I might vomit in front of my colleagues, or even worse into a surgical mask,  mortified me enough that while scrubbed I would swallow the bile down and soldier on.  One late evening while waiting to go into the OR for an emergency case, hypersalivation (another charming pregnancy symptom) started, probably because I hadn’t eaten dinner.  I stood dripping over a sink in the women’s bathroom hoping 1. that nobody would come in, and 2.that this would not continue once the case was called for (it didn’t). I liked the nausea in a way though. Morning sickness would become my frenemy in first trimester. While it was there, and the stronger it was, the more I was reassured I was not going to miscarry.

Around 14 weeks the nausea and fatigue faded to a bearable level and we started telling people about the pregnancy. The administrators, nurses, and colleagues I worked with were extremely supportive (for all of my pregnancies actually). In fact one of the first things I did after 12 weeks was apologise for my odd first trimester behaviour to my work colleagues, who assured me they had no clue I was pregnant (I think more likely that they were just being kind).  A new problem then emerged over the next few months.  Fainting- mostly in the operating room.  If I was the primary surgeon doing the case, my adrenaline would largely get me through.  If I was assisting or supervising somebody else though, and not the primary surgeon, within a few minutes of scrubbing in, my blood pressure would drop, the nausea and drooling would come, and I would have to scrub out or sit down.  The hat, gown, gloves, and mask worn in the OR, combined with the heat from the lights, the surgical wound, and the Bair hugger (essentially a large blow dryer used to keep patients warm on the operating table) was just too much.  I never actually fainted and hit the ground, but I came very close dozens of times.   I tried eating and drinking before cases but that just made the nausea worse when it did come on, as well as making my bladder feel more uncomfortably full than it did already. I tried  wearing tight special compression stockings to get the blood supply out of my swollen legs, but they just made me warmer. Moving my legs around during cases just caused me to jostle around and annoy whoever I was working with.  Nothing worked.  Like an athlete upset they have to leave the field after being injured, I would have to scrub out swearing at myself under my breath, feeling I had let everyone down.  Eventually the OR nurses started complaining about the number of new sets of gloves and gowns they had to open as I tried repeatedly to scrub back in for cases.  The further along the pregnancy got, the shorter the time between when I would scrub in and have to scrub out to avoid collapsing.  I ended up finishing work by mutual agreement with the hospital administration at about 31 weeks, as the only thing I was able to do was see patients in emergency and look after ward patients.  I was given paid leave for about 6 weeks, even though I had only worked at the hospital for 10 months, which I remember thinking was quite generous.  The second pregnancy I worked full time until 36 weeks, including call and then did admin only until 38 weeks.  I worked full time up to 38 weeks with the third as well.

The second pregnancy I developed excruciating left leg pain.  It would come on like a lightening bolt unexpectedly, and I would have to hold onto something to avoid falling down (the grab bars on the side of the hospital hallways were very useful).  It felt like someone was using my nerve as a guitar string. It would disappear within seconds, only to come back again a few minutes later.  Luckily these episodes were usually with walking around and not in the operating room. I later figured out this was probably the beginning of a hernia which later needed to be repaired.

Now some women have way rougher pregnancies than mine- hyperemesis, pre eclampsia, pre-term labour with bedrest etc.  I had a lot of the things pregnant women put up with, including constant guessing about the baby’s sex based on my belly shape and continuous comments on my weight and appearance. These aren’t particular to surgery.  But surgery is tougher physically than a lot of jobs.  It involves a lot of long days and even longer nights with responsibility not only to make decisions, but also to be there to physically DO something.  You just can’t phone it in.  The entire surgical system (and in some ways medicine in general) is NOT set up in layers where backup can be called in when surgeons are sick.  Even now I live in dread of getting sick from my kids and having to cancel operating or endoscopy lists, or asking a colleague to have to cover my call.  Although again, when this has happened, my colleagues have been very supportive, and mostly patients as well.  Surgery is hard and so is being pregnant, to varying degrees for different women.  There is lots of room for improvement in how we handle both illness and pregnancy leaves in surgery, including options for part time work, and surgical “supplies”  like the education system has for teachers. But even asking for help is tough and trying to push through the surgical culture to ask for help is ridiculously hard.  Harder than it should be.

So now to answer some common questions.  Yes, I could still reach the operating table (even operating at close to nine months). I would just turn to my belly to the side. No I did not have a C section for any of my pregnancies, even though I am a surgeon.  Would I want to be looked after by a pregnant surgeon?  Absolutely (although I never have been). And yes, I would do it all again in a heartbeat for my three beautiful kids.