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.

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.

Referral Etiquette

Family doctors refer to specialists in ever increasing numbers, but aside from observing how this is done by their preceptors during residency  training, there aren’t a lot of hard and fast rules about referrals.  A referral means a request from one physician to another for the consultant to see, assess, and possibly offer treatment and ongoing follow up to a patient. Now I am a surgeon who receives dozens of referrals every week.  I also do referrals for patients myself when it becomes clear another specialist or surgeon could offer better management of the patient than I can, or for follow up treatment after cancer surgery. It is clear that while most family doctors know how to refer appropriately,  some do not, and so, here are my basic rules about referrals.  I am only going to cover elective referrals here, not those that come from inpatients or the emergency room.  The referral system in Ontario is random, with no structure or guidelines which, in my view, are badly needed.  An online specialist compendium is coming to Ontario, which will help educate family doctors in which specialists see what problems.   But as fewer family doctors and specialists work in hospitals and do not have face-to-face relationships with each other, the system is becoming more dysfunctional.  So here is my general advice (with a surgical perspective, as usual).

  1. Who should the referral go to? If you have a specialist who is covering on call for your geographical area, generally not only emergency, but all elective referrals should be going to that person. That’s the deal. The person is putting their life on hold to offer on call services and therefore should also receive all the easier elective referrals for their operating room lists (and to justify the expense of running their offices). Having a patient somebody else has operated on show up in emergency room (because patients will always be told, and will always go to the closest geographical emergency room) with a complication you as the on call person then have to deal with is completely unfair. You should not be referring your patient a two hour drive away to see your med school buddy from 30 years ago. Not cool. As people join practices, retire, and practice patterns change, referral patterns need to change as well. If there is more than one person covering a service, divide the elective referrals up evenly.  Just FYI surgeons love referrals that actually involve surgery. We do the other ones (sometimes referred to as garbage referrals), but don’t send us the garbage without the good stuff coming our way as well.

2. Who sees what? This becomes very difficult as specialists sub-sub-specialize within their fields to very narrow areas of practice- neurologists who only see multiple sclerosis patients for example. If you are not sure what someone sees, ask! Even sending the referral will sometimes get you the name of an appropriate person to contact. Some specialists refuse to see referrals from out of their geographic areas, but that is not part of my practice. I do not mind an email, text, or call from family doctors about whether or not referrals are appropriate or for urgent stuff. Don’t assume what people do and do not see in their practices- again ask. While large teaching hospitals with huge marketing budgets would like us to think community generalists do not give as good care as they do, this is simply not true most of the time. Most problems are straightforward, and most physicians are pretty good at recognizing complex problems or patients that need to be referred on to a larger centre.

3.  Multiple referrals to the same type of specialist. Specialists generally screen their referrals pretty carefully (I go through mine individually) and see urgent stuff, well, urgently. If you think it is urgent, put that on the referral. I HATE it when GPs refer the same patient to multiple surgeons to see who will “get the patient in first.” While I realize this may come from good intentions it is just a complete waste of everyone’s time and a lot of money. It is totally unprofessional, inappropriate and should not be allowed within our socialized health care system. Most of these multiple referrals are done for non-urgent problems in vocal patients. This then uses up a spot in which a patient with an urgent problem could have been seen as most of these patients will no show for one of the two appointments. If they do show up to both appointments they are either getting redundant care, or end up confused if they get different advice from two specialists. Second opinions should be just that, second, AFTER a first opinion has been given.

4.  Patients should know why they are being referred. Some of my patients have no idea why they are coming to see me in the first place which can result in a lot of confusion and anger. And this happens not just in older or cognitively impaired patients.

5.  Send the information.   A lot of patients tell me they are having gallbladder problems with a normal gallbladder on their US. I can’t take a patient to the operating room based on their knowledge of what they think their investigations showed. I need the reports that are relevant to the problem I am seeing them for in order to make a decision. I also need their demographics, health care number, and contact details.   I do not need cholesterol levels for someone having biliary colic though.

6.  Do not refer me someone else’s problems. Particularly surgical. Several times a year, I am asked to see reasonably early complications from another surgeon, and the patient has not even followed up with the original operating surgeon. Surgeons should be looking after their own complications, in general, particularly for elective outpatients in the short term, or should at least have a go at it before someone else has to step in if the relationship breaks down. I am really unhappy to get these referrals and will generally send it back to the GP with a request to contact the original surgeon. If you want me to see them, send them to me in the first place. If you are referring to someone who is not following up their own surgical complications, maybe you need to rethink your referral pattern.

7.  When a perfectly healthy person has seen 17 specialists in the last 18 months and nothing substantive has been found after exhaustive investigations, you (and your patient) need to rethink things. You, the GP, is the one with the knowledge of the patient from a broad perspective and an ongoing relationship. A lot of mental health problems masquerade as physical complaints due to our society’s disdain of psychiatric issues, and it is pretty obvious when this is happening. Sometimes the tough conversation is needed. I see this in my office on a regular basis and I know my GP colleagues do as well.

8.  What should you and your patient expect from your referral? An appointment in an appropriate period of time, or a note saying why you will not see the referral and ideally a suggestion as to whom to refer the patient to. GPs should also expect notes on the encounter and its outcome for each visit to a specialist; this is just standard of care. The notes also give the specialist opportunity to educate the GPs on treatments or guidelines. The note should outline the specialist’s thoughts on ongoing treatment, investigations, or procedures necessary, and what they expect the GP to do. This avoids confusion and the ball being dropped. Along with this, I would like it if GPs actually read my letter. It is fine with me (although not necessarily all people would agree) if the patients read the letter/note. I think the day is fast coming where patients will have full access to their medical records.

A new eConsult service has started which allowed online referrals (usually questions as to whether a referral is appropriate) to various specialities in Ontario. This is a terrific service, avoids a lot of unnecessary visits and I would encourage all GPs to sign up for it. Until then, happy referring.

The emergency room four hour wait rule explained or How history teaches us that history teaches us nothing.

Now I have worked in a lot of different health care jurisdictions and this gives me a different outlook on our system than someone who has only worked in one place, seen things done only one way.  The ridiculous concept which has followed me around the globe is the idea of a rule that governments (who have little idea about how to run a health care system, but a pretty good idea of how to get elected) always seem to trot out around election times.  That is the concept that somehow, their government is going to, or has already, dramatically reduced emergency room waiting times.  That and operating room wait lists are the two health care election items they know, or think they know, will get peoples’ attention.  You want that sound bite that is going to hit home.  The problem of emergency department (ED) wait times is a complex problem,  and you are welcome to refer back to my blog on “Why you need a family doctor.” to examine one of the main causes of inappropriate ED use which is that a lot of people don’t have access to a family doctor.  Of course ED’s will always be needed for car crashes, heart attacks, perforated bowels, appendicitis,  burns, broken legs and so on, and if all they saw was stuff that was ED appropriate, I’m sure my emergency room colleagues would be pretty happy.  But you can’t send everybody to medical or nursing school, or teach everyone how a health care system should be used appropriately.  EDs are overrun with ingrown toenails, narcotic seekers, people seeking work notes, colds, prescription refills other stuff that really should be dealt with anywhere but an ED.   The four hour rule (called pay-for-results in Ontario) is a band aid approach to the much deeper problem of why there is SO MUCH inappropriate use of emergency rooms.  People in our society do not want to wait, for anything, be it their appropriately named fast food, or their health care.  But do you really want a fast food approach to health care? One could argue that one way to discourage people from being in EDs inappropriately is to have long wait times, but there are problems with that for sure.

My son was once being admitted to hospital, but we remained in an ED bed, as no ward beds were available.  We had arrived in the ED, having driven from another smaller hospital, around 930 pm.  The ED waiting room was packed, with people hanging off the rafters.  Our son was quite sick and we were almost immediately assigned an ED bed, but not before noticing the people around us in the waiting room.  At 8 am, a parent and child I recognized from the waiting room (who had registered  before us and therefore had been waiting a minimum of 10 ½ hours) were led into the stretcher beside us.  The kid had something in his ear. I didn’t see what happened, but they were in the bed for about 3 seconds and on their way out the door after a nurse or doctor scooped out whatever was causing the problem.   I do feel sorry for anyone waiting overnight in an ED to be seen for such a minor complaint which was so easily fixable, but at the same time I think we can all agree that patients with more serious problems should be seen and treated first.  Did the parents think whatever was in there was going to damage his hearing?  Or erode into his brain?  Did they not have a family doctor? Or couldn’t access their family doctor?  Were they immigrants who didn’t know about walk in clinics? Or Telehealth? I don’t know what the thinking was, the kid certainly didn’t look distressed, but one family now has a horror story of an ED wait, and therefore any election propaganda which involves reducing ED wait times will likely hit home with them.

Enter the four hour rule (or eight hour rule, or six hour rule, depending on what country or province you are in at any given time.)  This is a rule that states from the time a patient gets into a bed (NOT the time they present to the ED, the time their bum hits the stretcher) or sometimes from the time of their first interaction with an ED physician, they must either be discharged home, transferred to another hospital,  or admitted within four, six, or eight hours, depending on where the dart landed while the administrators were thinking up this rule.  The number of hours chosen is random and not based on any science or studies.  It is a number based on what politicians hope will get them elected.  If it was the 8 hour rule last election, it’s the six hour rule now, and now we have, you guessed it, the four hour rule.  Some of the funding for emergency departments  in Ontario is now punitively based on the percentage of patients who are seen and allocated under the set time.  Meaning emergency departments who are performingly poorly get LESS funding than those performing well.  Kind of like giving the kid who is already getting A’s in school the extra tutoring, instead of the kid who is failing.  More than a little backward, but that’s the approach.  The idea that extra staffing (which would mean extra beds) would help to ease the problem has not been put forward as a solution, not surprisingly, as this would cost money.  The idea that a hospital does not have a bed is occasionally true.  More often though, there are beds which are not funded to be open because of the cost to staff them with nurses.  It would be more accurate to say- “There’s no funding for nurses,” instead of “there is no bed.” Basically this is the government saying, do more with the same or less resources, or we will make it harder for you.  This will be an ongoing theme in healthcare in the years to come.

The idea that a certain percentage of patients presenting to the ED should be seen and a definitive decision made as to what should happen to them sounds good on paper, and that would be fine for a trial run in Ontario if this approach had not failed so abysmally when tried in multiple other countries with socialized health care in the past.  I admit that I like the idea that everything should be just done quicker when I use an emergency room.   But, remember the kid waiting 10 ½ hours?  He would qualify as someone seen and treated in an acceptable length of time, in spite of the fact that he waited over 10 hours just to be seen.  He would be a success story by this measure.  Remember, the clock doesn’t start until you are in a bed, and he wasn’t in a bed for very long- he was in the appropriately named waiting room.  We now have our emergency departments twisting themselves in knots to keep as many patients under the guideline as possible.  Is this good care?  I would say no.  Is faster care good care when it comes to emergency departments?  Sometimes,  but not necessarily.  A lot of unnecessary testing and admissions could be avoided if watchful waiting was allowed to be employed as a strategy.  Maybe the kidney stone will pass, the ventolin will kick in, or the abdominal pain will resolve on its own (meaning it is unlikely to be appendicitis) as three quick examples.

I worked through the introduction of this rule in NSW, Australia and it was a disaster, particularly in the large teaching hospital where I was a consultant surgeon.  The administration was so keen to have as many patients as possible meet this benchmark (KPI or key performance indicator in administrator speak), the emergency physicians were allowed carte blanche to admit any given patient to whatever service (surgery, cardiology, geriatrics etc)  was their best guess (and these patient were so incompletely assessed it really was a guess) as to who could fix whatever ailed the patient .  Not surprisingly, a lot of the time this was the WRONG service. The consultants were furious.  We would arrive in the morning after a night on call with multiple patients under our care we had no idea about.  The rest of the day would then be spent sorting out who needed what, pretty much starting from scratch as if the patients had not even been seen by a physician before.  Length of stay times went up dramatically. There was now no motivation on the part of the ED to come up with a diagnosis or even a treatment plan before the patient left the ED, much less communicate it to anyone. The patients also had not had complete workups, meaning testing like ultrasounds and CT scans, were not done before they went to the ward.  The next day, that patient had to wait in line behind ED patients, who were given priority over ward patients for imaging studies- because of the 8 hour rule.  Again, this extends length of stay and overall cost to the health care system, but the most important point is that it just leads to bad patient care. There has been heavy criticism of this rule from the people actually working in the emergency departments- the doctors and nurses. The irritating thing about the introduction of the rule in Australia was that the approach had already failed in the UK, yet still followed me there, and now has followed me on to Ontario.  Now, one could write a Phd on this topic based on the contradictory numbers and statistics out there surrounding this rule and still not really get anywhere. This blog is my opinion and you can take it or leave it.

There is a lot of cognitive dissonance at work here.  The more something is proven wrong, the more those who promoted it in the first place will dig their heels in to insist it is a good approach. The data which is being collected will always look good.  Isn’t it funny how administrators and politicians usually find what they are looking for when crunching numbers?  Our emergency room healthcare workers will inevitably fatigue of being on this pointless treadmill though (this is what happened in the UK) and hopefully go back to doing what they do best-looking after patients.  As a surgeon, patients and families often ask me “How long will the operation take?”  I do give them a ballpark figure, and then I always tell them- “It takes as long as it takes to do a safe operation.”  It should be the same with an emergency room visit.

Is the 8/6/4 hour rule likely to be repealed?  I hope so, but something tells me no, since there is always an election on the horizon. I’m all for democracy, but the problem with elections every 4-5 years means the long term issues are quite often secondary to doing quick fix, media friendly initiatives which will get the government positive attention.  Our health care system, and our emergency rooms in particular, have some serious challenges and the 4 hour rule isn’t solving any of them.   But then again, nobody’s asking me.

A good death

The Supreme Court of Canada has recently struck down the law making assisted suicide illegal in Canada, and the federal government has now just slightly less than one year to introduce new legislation governing how this is going to be handled.  There has been a lot written about this change and what it will mean for Canadians.  Disability groups are up in arms, believing that this is the beginning of a slippery slope into genocide of disabled people.    The reality is that this law will likely only affect a miniscule number of Canadians.  For assisted death to occur, the person must be of sound mind, and I’m hopeful and reasonably confident it will be a rigorous process to go through, with many checks and balances along the way.  And while science, and fiction, and science fiction, continue to explore the possibility that we may all one day be immortal, death will continue to be the great leveller in all societies.  “Why do people die?” our 5 year old son asked the young lady sitting next to him on a long flight a few years ago.  My husband and I looked at each other with a smile and waited for the answer to the question he had never asked us.  “Because if nobody died, the earth would be too crowded” she told him.  He nodded and accepted this as a pretty good answer.

The BBC recently featured an article about a surgeon struggling with his father’s death.  I was flabbergasted at his attitude that death and the whole dying process were excruciatingly painful to him. I would hope my expertise with the dying process would make me a good resource and voice of reason with my own family.  As physicians, we should be supporting and treating our patients throughout their lives, up to and including the dying process.  Myself and a lot of my colleagues who deal regularly with dying patients have pretty strong attitudes as to what we want for our own end of life care.  What is usually wanted for end of life care by medical personnel is a lot more hands off in terms of medical interventions than what we put our own patients through. Sadly, trying to back away from our usual aggressive investigation and treatment of every symptom is not something we are trained to do, but are actually trained to fight every step of the way (and get compensated for while doing it).  While we are all dying a little bit every day the actual process of dying has been demonized so much by our society that it is hard for us even to say the words.  You do not hear “He died” so much as passed on, is gone, passed away, went into the arms of the Lord, cashed out, bought the farm, etc.  The euphemisms are endless, and there are so many of them is because we are so uncomfortable with the idea of death and dying.  When we do use the term “He/she died” it is usually to describe the death of someone we were not close to.  We cannot even say the words to each other, and that is a real problem.

For what is going to be a universal experience, we don’t do much, if anything, to prepare for it and so it seems it is inevitably a struggle against the inevitable, for the patient, the family, friends, and caregivers.  There are now fewer and fewer people dying suddenly from unexpected causes.  Our dying and death experiences are being extended into years and decades, or if you flip it around, our living experience is being adversely affected by the fact that we are dying slower.  This is called “adversely affecting quality of life” in medical terms. While the occasional patient faces their imminent death with acceptance, the vast majority do not. Even the way death is described in the obituaries suggests our conflicted relationship with death- “a valiant battle with cancer”, or “after struggling with (insert disease here) for many years…….”  People put more thought into what car they are going to buy than what they would like their own experience of death to be.

As a surgeon who looks after people who are dying, it is hard to reconcile active treatment and good palliation most of the time. While you never want to take away hope, the cost of not taking it away is, a good part of the time, continuing on with procedures, tests, and interventions which run counter to good palliation.  Palliation refers to treatment offered by the health care system to ease symptoms, and is usually offered to patients who have begun a more active phase of the dying process.  This includes pain and nausea control, hydration, and emotional support, often in addition to backing off of testing and all of the needle pokes, appointments, and fasting that more active treatment often entails.  Continuing to actively treat patients is often used as a surrogate marker of hope by patients and their families that all is not lost.  Healthcare providers sometimes continue to treat because it is easier than having the tough conversations, and sometimes because we are forced to, by the patients or families’ wishes.  This ongoing active treatment has its own costs in terms of complications, side effects and increased mortality though.  I am often asked to see extremely ill patients with very limited life expectancies in the hospital, often to assess for operations, procedures, or investigations which are clearly futile.  Our astounding ability to focus on our own area of expertise becomes a good excuse to not deal with the obvious issue that the person in front of us is dying, rapidly.  I am guilty of this myself, although I have become better at seeing the forest instead of the trees as I get older and more experienced.

Most people die in hospital and so media headlines trumpeting how dangerous being in hospital is in relation to your risk of death really anger me.  We all have to die sometime, and the reality is a lot of us are going to pass away in a hospital setting, and it is going to be an expected event.  Very few people die at home anymore.  Families are all too often not equipped to deal with both the physical and emotional burden of a loved one dying at home.

At lot of physicians have a problem with the concept of DNR, or do not resuscitate.  The acronym AND, or “allow natural death” has been suggested as a better term, as it implies the healthcare team is not withholding care as much as letting the inevitable happen, hopefully while continuing to support the patient.  Competent patients’ wishes in regards to what they want for end of life care should be respected by all healthcare providers, the judiciary, and most importantly, friends and family. So while I believe the Supreme Court decision is long overdue, the upcoming tsunami of the problem of a good death is the elephant in the room in many health care discussions.  As medical technology which increases our quantity, but not our quality of life and rapidly outpaces our ability to want it, much less pay for it, the question most often will be not “Can we?” but “Should we?” We need more conversations to take place a lot earlier between healthcare providers, families, and patients.  There is nobody who is not a stakeholder here.