Regional Governance Renewal-A Chance for a Primary Care System

The are lots of rumours floating around about what the Ontario Government is going to do about regional health governance.  It seems clear that the current LIHNs or Local Health Integration Networks are in for some kind of change. 

I don’t know if that’s a good or a bad thing, but I do hope that it is a chance to take a fresh look at how primary care is organized in this province.  More accurately it is a chance to improve on the almost total lack of organization and put a true primary care system in place.

Whatever the local governance model, we need to establish a set of principles that will define the core elements of a true  system.  Once we have those principles in place each community should be given permission and direction to create a system that works for the people who live in that community.  As always in this vast, geographically unique province, no one solution will work everywhere.  But the principles of a good system should be the same in Toronto and Little Current.

I have some suggestions about what some of those principles should be.

Every person needs to have access to a family physician, a primary care nurse practitioner or even better, an integrated team of professionals all working in collaboration to provide the best possible care to a community.  Each professional should work to their full scope of practice and people should have some choice as to who they see for a particular issue.

Professionals within a community need to make a commitment to work cooperatively with others to service the needs of the community as a whole, not just a subset of people.  

In return the government needs to put sufficient resources in place to make sure that no individual physician or other profession faces an unreasonable burden of work.  Burnout is real.  None of us is superhuman and we need to acknowledge this.

People are not always available to see a health professional during business hours.  Best efforts must be made to accommodate people’s work, school and family obligations.  This is not to say that any individual needs to be available 24/7.  We do need to be flexible.  As professionals we should be expected to work together to establish a plan to provide care outside the traditional 8-5 office hours.

Quality is important.  Groups need to have tools and protected time to define and implement quality improvement plans.  Quality improvement is not work that can be done on the fly or during meal breaks.

Professionals in a community should commit to having a shared electronic medical record.  It should be available to other providers and to patients. This sounds expensive.  The government is going to have to fund this like any other public utility.  It’s like roads and hydro lines.  Don’t expect small businesses to fund this alone. 

Practices cannot develop their own IT systems.  Come to them with workable, affordable solutions. 

Primary Care must integrate with Public Health, Home Care, long term care and hospitals.  We must work with social agencies and schools.  And visa-versa.  There is only one tax-payer and only one patient.  They don’t become someone new when their provider changes hats.

We need to work more formally with families of very ill people.  We all know what a crucial role families play.  Let’s involve them in system decision making.

Professionals need to be paid appropriately for their clinical work.  At a provincial level, we need to review primary care payment models to remove any barriers to good care.  We need to reward people for all of their work.  Lets reward excellence and innovation.

Leadership in primary care is important.  Let’s pay people to lead.  Each hospital pays VPs Medical, Chiefs of Staff and Chiefs of Departments.  Universities pay Deans, Department Heads and Program Directors.   I expect that they get real value in return.  Why on earth would we expect family doctors and other community based professionals to do similar work pro bono.

Leadership should be local.  Don’t put some know-it-all from University Avenue or Stoney Creek in charge of primary care in Peterborough.  Let the folks who live in a community choose their own leaders.

Finally let’s agree that any changes have to be focused on making patient care better.  We’ve seen what happens when we focus on institutions and providers.  It ain’t pretty.

This is one list of principles.  It’s my list and I like it.  I expect others would loath this list.  I don’t care.  Make your own list. What matters is setting goals, establishing principles and getting on with building a primary care system.

Right now we have no principles and no system.  We need to put energy into building.  It will not happen spontaneously.

And it’s long overdue.

Scott Wooder, MDRe

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Mom, Bill Barilko and Me

“Bill Barilko disappeared that summer (in nineteen fifty one)

He was on a fishing trip (in a plane)

The last goal he ever scored (in over time)

Won the Leafs the cup” – The Tragically Hip

Bill Barilko was a young man who played on four Stanley Cup championship teams with the Toronto Maple Leafs.  Most famously, on April 21, 1951 he scored the Stanley Cup winning goal, in overtime, against the Montreal Canadiens.  Later that year he died in a plane crash while on a fishing trip.  His plane was not found until 1962 and in that same year the Leafs won the cup again, for the first time since Barilko disappeared. 

It’s a fantastically tragic story.  I know it not only through The Hip’s song but also because my mother was at that game in Maple Leaf Gardens.  My father told me this story years ago and my mother confirmed it.  I wish I asked more questions.  I wish I was more curious about my parents when they were around to ask questions.  For instance, what was a 14 year old girl from a poor family doing at the Gardens in Game 5 of a cup final?  I’ll never know now.  My father died 10 years ago and my mother died just before Christmas.

Mom developed early symptoms of Alzheimers a couple of years ago.  It progressed but she functioned well enough to stay at home.  With help from my brother, her grandchildren and other family members, she continued to live independently in the house my parents owned when I was born.

She got very sick in August of this year.  Ironically I was on a fishing trip up north when I got a call asking for advice.  She was obviously ill but did not want to go to the hospital.  She had not had food or water for several days.  I told my family to call an ambulance and take her to the hospital.  In retrospect, she was hours away from death.  

I’ve lost a lot of sleep since that phone call wondering if I did the right thing.  Mom wanted to die.  None of what came after made her happy.

She was delirious from septicaemia when she went to the hospital.  That was easily treated with antibiotics but her ability to think was severely compromised.  She had some recovery but was never the same.  Her cognition would wax and wane over the next several months as a cascade of complications followed.

She told me many times she wanted to die.  In the end she quit eating and her condition spiralled downward.  I asked her once if she was trying to starve herself on purpose.  She looked at me for a long time before finally saying “No, but I knew someone once who did.”  I’ll never be sure if she said that to spare my sensibilities or because she was worried that I would somehow force her to eat.

Which brings me back to The Fifty Mission Cap.

I was driving in to see my mother one recent Sunday morning.  The traffic was light and I made the trip from Hamilton to Toronto in under an hour.  I had watched the Leafs the night before.  Auston Matthews and John Tavares both scored and the Leafs looked like serious championship contenders.  It made me think of Bill Barilko and my mother watching him score that goal.  I was very happy.

I got to the hospital and my mother wanted to tell me about a dream she had the night before.  She dreamt that I was speaking with Bill Barilko in a corner of her hospital room, “over there” and we were deciding what to do with her.

It shocked me that both my mother and I were thinking of the same person out of the blue. I doubt that she had seen a hockey game in decades and she never talked about sports.  I’m usually more interested in basketball than hockey.  But we had overlapping and seemingly random thoughts about the same hockey player at one of the most important junctions in her life.

The symbolism seemed clear to me.  My mother wanted me to make decisions about her life, health and death if she was unable to do so.  I was her sole Power of Attorney for medical care.  I’m a doctor, and in my mother’s eyes, an important doctor.  She had given me strict instructions while she was still competent and trusted me to do the right thing.  And one can imagine how a young teenager would regard a hero like Bill Barilko. 

We were two authority figures, deciding her fate as her life spun out of her control.

I guess that the rest is a crazy coincidence.  But it did shake me up.

For Mom, her biggest loss at the end of her life was the loss of independence she suffered.   She did not have a lot of physical pain.  But she was wracked by emotional pain. Not being able to look after herself or make decisions upset her.  She had no control over her own life.

I’ll never forget that loss at the end of her life.  I hope the end is gentler for the rest of us.

Scott D Wooder, MD

I’ll write again soon about the lessons I learned about end of life care from the perspective of a caregiver and how that differs from my usual perspective.

Uncertainty and Family Medicine

I was out at a social event last week with my adult daughter. Her mother, my wife, was not present. She was working. Lori is a tertiary care Respirologist with special expertise in Tuberculosis. I’m a journeyman Family Physician. I don’t have any special clinical expertise.

A friend of ours, who is a nurse, asked my daughter what it was like to have a mother who has such a difficult job. People have been asking my daughter about having physician parents for over a quarter of a century. By now she is an old pro. She is also a natural diplomat.

“Well my Dad has a difficult job too”

“Of course, but your mom’s job is much tougher. She’s a specialist”.

I don’t think about our jobs in quite those terms. Over our careers there have been times when I have worked very hard in very trying circumstances. I don’t recall a time when this has not been true for Lori.

If Bob, a left handed space alien, walked into Lori’s office with a positive TB skin test and a fever, she would know exactly what to do. She would take a perfect history and leave nothing relevant out of the physical exam. She would order the right tests, reach the right diagnosis and prescribe the right treatment and follow up for Bob and his extended family.

If Bob told her about his panic attacks and his wonky ankle, she would advise him to see his family doctor or arrange a specialist referral. And no one would think twice about it. It’s outside her area of practice. Why would she know about any of those things?

She would know exactly what to do in any clinical circumstance and if she didn’t, she could pass on the responsibility to the most appropriate person.

I contrast this with a real visit that occurred in our clinic 2 days later. A woman in her 40’s with no significant health problems, who was on no medications and who did not smoke, presented to my partner with sudden onset shortness of breath. My partner was uncertain about the diagnosis but the possibility of a pulmonary embolism was one of the things she thought about.

One of the advantages of group practice is that one can ask for the opinion of other group members. My partner ran the facts by me. Not because I’m smart or wise, but just to give herself a sounding board.

There are a few facts ever physician knows about Pulmonary Embolism (PE). It is a very easy diagnosis to miss. It is impossible to diagnose in the community. It can be deadly or to put it in a positive light, it is a chance to save someone’s life.

My colleague and I both knew that referral to the emergency room was inevitable. We both knew that the likelihood of the woman with the shortness of breath having a PE was low but that it was not zero. Once we thought about PE, we had to assume it was PE until we proved it was not. All our talk was to justify a low probability referral.

We did not want to be seen as Chicken Little, crying the ‘sky is falling’ over an acorn. We were embarrassed and perplexed by our uncertainty. We did not have access to the resources or the expertise we needed to make a certain diagnosis.

Inevitably, we ended up doing what was best for the patient. My partner called the casualty officer, who agreed to see her patient.

In family practice we are faced with these diagnostic and treatment dilemmas many times every day. We usually get things right and we usually don’t send people to the emergency room. We deal with things on the spot or arrange to gather more information so we can make good decisions.

I’ve heard people talk about burnout in family medicine. I’ve heard them talk about low compensation, long hours, paper work and lack of system support. Uncertainty is also a major problem.

I still don’t know who has the hardest job, my wife the sub-specialist or me the generalist. I do know that uncertainty is a special challenge for every family physician.

Scott D Wooder, MD

Jack-of-all-Trades, Master-of-None

An Interest Based Approach to Small Business Tax Changes

In any discussion or negotiation each party will have both interests and positions. For simplicity’s sake, think of interests as goals and positions as specific pathways to achieve those goals.

Most of us think of negotiations in terms of staking out a position and bargaining our way to the best possible outcome.

In one live recording of “The Magic Bus”, by The Who, two singers keep countering between “one hundred English pounds” and “95”. They never do make a deal even though their positions seem so close.

This form of bargaining is about dividing up a pie with a fixed size.

In other discussions, the parties explain their interests or their needs. They hope to understand everyone else’s needs and find a way forward that satisfies everyone’s interests in the most efficient way.

This form of bargaining is about increasing the size of the pie and then determining how it will be divided. It is truly beautiful when it works.

Let me illustrate by using a domestic example that is so close to home that my family may feel uncomfortable.

My wife and I have hard jobs with long hours and we eat out way too much. We have decided that each spouse will take a turn in deciding where we will eat.

On a particular Friday night, it’s my wife’s turn to choose. She wants Italian food and decides that Restaurant A will be perfect. In this case her interest is Italian food and her position is Restaurant A. Notice she has only put forth her position when she tells me she wants to go to Restaurant A.

I don’t like Italian food. I reject her position and lobby for another restaurant, Restaurant B. I put forward my position, but neglect to tell her my interest, which is a nice meal.

She holds firm. I get sulky; I tell her that she doesn’t love me after all. She holds firm. I threaten that when it is next my turn to choose, I will take her to a roadhouse with loud, live music for burgers. She has a hearing problems and the loud music will cause her problems. She holds firm. At this point we are both angry.

Finally our daughter suggests Restaurant C, which serves very good Italian food, but also serves a number of dishes that I will enjoy. We go to Restaurant C and everyone has a good time.

Notice that my wife’s position, that we go to Restaurant A is not satisfied. My position that we go to Restaurant B is not satisfied. But both of our interests are satisfied. My wife gets good Italian food and I get a nice meal, which I enjoy.

We would have been much better off and avoided a lot of conflict if we had started with an interest-based discussion.

I see many similarities in the current situation developing between the Federal Government and small business owners and self-employed professionals.

The government’s position is a published list of tax changes. Small business’ position is that no changes should be made. This is a situation that seems doomed to failure. There is no overlapping solution possible. The Government can force through their changes, if they are willing to pay the political price.

What would an interest based approach look like?

It should start with a fresh process. There should be broad and fulsome consultation with all Canadians.

Let’s assume that government wants a fairer tax system that requires ‘wealthy’ people to pay a fair share of taxes. Let’s assume that small business wants to be able to plan for the future, provide for parental leave, illness and retirement. Let’s assume that farmers and other small businesses want to be able to pass on their assets to the next generation. These and other things are each party’s interests. And of course Canadians who are not self employed professionals or small business owners have their own interests of a vibrant economy and access to good, reliable employment.

How can the government get out of their current dilemma? They could capitulate and say no changes are needed. That has happened before. More rationally they should be willing to work with the small business community to find another way forward.

It would make a lot of sense to pause and hold public and private discussions with everyone, including government, small business owners and other tax-payers, to come up with an interest based solution.

Sometimes we all have to put a little water in our wine.

 

Scott D Wooder, MD

Brexit, the Donald and the tPSA

There is a common thread that ties together the United Kingdom’s vote to leave the European Union, the American Presidential election, which surprised many folks and the overwhelming decision by Ontario’s doctors to reject a proposed Physician Service Agreement between the Ontario Medical Association and the Government of Ontario.

The tie that binds all three results together is not the superficial similarity of a majority voting contrary to the wishes of the establishment. That would be a wonderfully simple view of the world that would let the OMA leadership (including me) off the hook. “We couldn’t expect anything different, look around that world and see people reject authority”. We need to look deeper or the OMA will not learn and will be doomed to repeat the same old mistakes.

The common element between the three elections is that people who proposed positive actions defeated people who warned that voting for the other side would send us all to hell in a handbasket.

People voted for hopeful change

I don’t have a deep understanding of the twists and turns of the Brexit campaigns. The Economist, June 20 2016, has laid out a summary of the main arguments for the Leave and the Stay campaigns. The Leave side made strong positive arguments. Immigration, complex regulations made in foreign capitals, jobs and the economy would all improve if the UK left the EU. It doesn’t matter for the purpose of my argument if those assertions are true or false, the point is that they speak of a positive result. The Stay side’s best arguments were that leaving would lead to a ruined economy. There is no mention of the positive things that would accrue to the UK if they stayed. There were no positive arguments.

A similar thing occurred in the American election. Mr Trump talked positively about policy. Again, forgetting for a moment the practicality of the policies, he spoke about building a wall, bringing jobs back home and re-building the Military. If Trump was elected foreign powers would fear and respect the United States of America. Make America Great Again.

Ms Clinton’s main arguments were all about Mr Trump’s unsuitablity. He was a buffoon. His perceived misogyny, racism and intolerance of foreigners were all she talked about. “A man who can be provoked on Twitter should not be given the Nuclear Codes.” It’s a good line, but it’s not enough.

I know she had dense volumes of policy papers—somewhere, but that’s not the message she got out. She talked negative. She got crushed in the Electoral College.

Anyone who thinks that her win in the popular vote is significant doesn’t understand power. “Winning isn’t everything, it’s the only thing.”-Red Sanders UCLA

What happened to the OMA during the recent vote on the tentative PSA? I’m afraid that the OMA leadership lost their way.

There were plenty of problems with the content of the agreement, there were plenty of problems with the negotiations process and there were plenty of problems with the ratification process, but the vote was won and lost during the 6 week ‘campaign’.

The OMA forgot to articulate the positive changes that would result from a ratified PSA. We should have focused on primary care enhancements, relativity, fee modernization, which would have including lowering some overvalued fees and increasing some undervalued fees. We should have talked about the leadership opportunities for physicians in health care transformation. We should have focused on our patients.

Instead we talked about the dire consequences of the status quo. “If we don’t agree to this contract we will be worse off.” It’s not a catchy slogan and worse it’s not a good reason to support something.

I’ve gone back and re-read an essay I posted on this site called “I Vote Yes”. I Vote Yes  It does lay out positive reasons for voting in favour of the proposed deal. Later on, I changed my tone and spoke about the bad things that would happen if we turned down the tentative deal. I originally said that we needed to talk, that we needed to trust and that our patient’s need a relationship between doctors and government. Somehow, somewhere I switched my message to a darker place.

The No side did much better. Turn this down and we can negotiate something better. It almost didn’t matter what the ‘better’ meant.   The fewer details the better.

No sold hope, Yes sold fear. Guess who won?

I’m not naive enough to think that the results would have been different with a different message. The margin of victory was too large for me to think that. But the Yes side had no chance with such a negative message.

Next time a decision is sent to OMA members, the OMA should forget about using fear of the alternative as a reason for Doctors to support something. Tell them the facts and let them make up their own minds.

Scott Douglas Wooder, MD

 

Addendum

I almost didn’t publish this piece. I’m not trying to criticise others, I’m trying to learn through self reflection. I publish it because I personally made major errors in the tPSA process that I hope I can learn from.

It’s Not Easy to Hunt in Ontario, and That Makes Me Happy.

I grew up in a house where hunting and fishing were a part of our lives. With five kids, a mortgage and one income, wild game helped out with the food budget.

My paternal grandfather was born in rural Ontario. He came from a big family. His wife, my grandmother, came from a tiny community in Northern Ontario. She was the oldest of 16 children. In a time and place where there was no electricity, no transportation and no jobs, families lived off the land. Nothing went to waste.

By the time my father was born, at the beginning of the Great Depression, the family had moved to Toronto. It was a tough time and they depended on a successful fall hunt to have meat for the winter.

We used to laugh because my father would save the water he used to wash his hands for “the next guy”. I don’t think he ever lived in a house without running water, but both of his parents grew up in houses where water was pumped by hand. Those old cultural habits die very hard. Nothing was wasted, even water.

The first thing I learned about firearms was safety. My father kept a .32 special, a 22 and a shotgun in the basement. They were locked up but we all knew where the key was kept. Same with the ammunition. I never touched his firearms and neither did any of my brothers. It was a deep taboo in our family to touch firearms without an invitation from the owner.

Now I have a gun safe and the combination is private. It’s better that way.

We had toy guns as youngsters.  I’m not sure why. We were not allowed to point them at anyone. Children would be severely scolded for pretending to shoot another person.

To this day, if I walk into a sporting good store and see someone waiving an empty firearm around, I leave the store at once. I don’t think that the firearm is loaded, but how do I know for sure?

I hunted as a boy. I remember one time going out in the bush with an uncle to hunt rabbits. My father’s cousin had a beagle and we heard it all day long. But we never saw the dog and we never saw a rabbit.

My uncle did not waste the trip though. He handed me his shotgun and invited me to shoot a sapling from a yard away. I shot and the 4-inch sapling was shorn right off. “Imagine that tree was one of your brothers”. Lesson learned.

Although I’ve always fished, I stopped hunting as a teen. School, sports and later medical school, my new family and my practice were all much more important. And I didn’t need the meat.

I started shooting skeet about a year ago. It’s fun, it’s done with friends and no one gets hurt. It gets me out of the house in the winter.

But you need a Firearms Licence, commonly called a PAL to acquire and possess a shotgun.

The first step is a firearms safety course. For the general PAL that allows one to acquire non-restricted firearms like a shotgun, the course is all day. The one I attended lasted about 10 hours and had a written exam and a practical exam. They weren’t hard exams, but they demonstrated that before someone bought or possessed a firearm, they knew how to use it safely.

After passing the firearms safety course there is an application for the licence. There are reference checks, questions about spouses, ex-spouses and other conjugal partners. My list was very short. The RCMP then does a final police check.

The whole process takes a couple of months. It’s hard to argue with the emphasis on safety. I don’t want someone owning a semi-automatic rifle who does not know how to use it safely. I also understand why we don’t give guns to people who have had a violent relationship with an ex-conjugal partner.

But even after you get a firearms acquisition and possession licence, you still can’t go and buy a rifle and head off to Crown Land to harvest a deer. The next step is a hunter’s safety course.

Again, it’s an all day course and goes over the rules and regulations of hunting.   It emphasizes safety safety, safety.

There is a large segment on ethical hunting. There is a candid discussion about only harvesting animals that are not required to sustain the population, using and not wasting the animals and respecting the rights of property owners and non-hunters to peacefully enjoy their lives.

After a not insignificant investment in time, effort and money, I can legally buy and possess a firearm and purchase a hunting licence from the Province of Ontario.

The Ministry of Natural Resources sets limits on the number and type of licences issued in each zone of the Province.  Municipalities will limit where and when firearms may be discharged.  I see deer in my backyard in Ancaster nearly everyday if I’m ambitious enough to look out the back window at dawn.  But the City of Hamilton won’t let me shoot them.  It would not be safe.

I will go hunting this fall. I’ll go north.

It’s great to get out in the bush for a few days of peace and I do it with a supportive group of friends. I don’t care if I even see an animal. In many ways I hope that I don’t. But if I do decide to take a deer, it will be done with respect and thankfulness.

The respect will be for the animal and for the heritage I’ve inherited from my family

It takes a while to get a firearms licence and a hunting license. It takes planning and hard work.

I think that’s a good thing for us all.

 

Scott D Wooder, MD

 

 

Clearing the Decks

I just sent the following to the Chair of the Board of the OMA.  It is my letter of resignation.

It will come as no surprise.  It is time to move forward in a new direction.

 

Gail Beck, MD

Chair of the Board of Directors,

Ontario Medical Association

 

Dear Dr Beck

Please accept my resignation as Co-Chair of the Ontario Medical Association Negotiations Committee.

The members have clearly spoken and they have rejected the agreement that was brought forward for them to consider.

We have a difficult road forward but my resignation will make that road much clearer.

I want to thank you and all of your colleagues on the Board and indeed all the members of this Association for the kindness and courtesy that has always been shown to me.

Yours truly,

 

 

Scott Douglas Wooder, MD

cc Dr. Virginia Walley, President

cc Mr. Tom Magyarody, CEO