All posts by drscottwooder

I'm a journeyman Family Physician in Stoney Creek, ON, Canada @scottwooder

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

OMA Physician Service Agreement-A voting guide

Some people are making it seem like voting at the Ontario Medical Association General Meeting is more complicated than the Normandy Invasion. It’s not you know, it actually very easy.

The usual process of ratifying a tentative Physicians Services Agreement (tPSA) is well established. The tPSA is presented to the OMA Board for consideration. If the Board finds the agreement acceptable they recommend it to the membership for ratification. Live presentations with questions and comments, written documents with legal and economic analysis and of course the actual tPSA are made available so that members can make an informed choice.

The membership then votes in a referendum. Members are always disappointed to learn that the referendum is not binding. It advises OMA Council, a group of 250 physicians elected by their peers, who make the final decision.

But why is the referendum not binding? It turns out that Ontario Corporations cannot delegate decision-making power to the membership. Governing bodies like OMA Council must make final decisions. So we can’t have binding referendums. Ontario law, The Corporation Act does not allow us to.

New legislation, the Ontario Not For Profit Corporation Act, widely known as ONCA, will allow for binding referendums. While passed by the Legislature, ONCA is not yet in force.

For the 2016 tPSA a group of members decided that this process was not good enough. They called for a general meeting, as is their right. Five percent of the members submitted a petition to hold a general meeting to decide the fate of the tPSA. The referendum and the special meeting of Council were cancelled.

Although voting in the non-binding referendum would have been electronic, decisions made by the members at a general meeting can be made in person or by proxy.

The process is governed by legislation. The OMA cannot change that.

Voting in person is straightforward. Show up and vote.

We have two weeks notice as to time, date and location. The meeting is in Toronto. That’s great for people who live in 416 and 905 area codes but for physicians in the rest of the Province, it will pose difficulties. Travel is expensive and coverage of clinical duties may be difficult.

So members may vote by proxy. That is they designate some one who will be present at the meeting to vote for them.

They can trust that the other person will vote in a way that is acceptable to the person giving the proxy or they can direct the person to vote in a specific way.

On the actual OMA proxy form, members may designate Dr Virginia Walley, OMA President, to hold their proxy. The can also tell Dr Walley to vote yes or no to the central question of the meeting. Is the tPSA acceptable, ‘yes’ or ‘no’.

Members may also write in the name of any other person to hold their proxy.  Again they can leave voting judgments to the discretion of the proxy holder or they can direct that person to vote ‘yes’  or ‘no’.

I took advantage of that option even though I plan to attend the meeting. This will save me the trouble of standing in line to cast a paper ballot and I hope that what is sure to be a slow process can be speeded up. This is a personal choice and I expect many people who attend the meeting will just vote.

Filling out the proxy form is easy. There is a 15-digit security code which I cut and pasted into the correct field. I indicated that Dr Wally should hold my proxy but I could have typed in any name, even a non-member. I then ticked off a box indicating that I wanted Dr Walley to vote ‘yes’. She is now obligated to do so. If I had ticked ‘no’ she would have been obligated to cast my vote that way.

As I submitted my proxy, there was a double check to make sure that I had voted as intended.

I also checked a box asking for a confirmatory e-mail. That e-mail arrived in my inbox within seconds an I was able to double-check my proxy to make sure it was filled in, as I wanted. If there was an error, or if I change my mind, I can change my proxy as often was I wish. I can also show up at the meeting and revoke my proxy so that I can vote in person.

There is a simple sign in, a couple of boxes to check off, a confirmation procedure and a confirmatory e-mail. The whole thing took me less than a minute.

As someone who has purchased airline tickets, books and stocks on-line, it’s not that complicated.

Scott Douglas Wooder, MD

I Vote Yes

The OMA Board of Directors has recommended that it’s members vote ‘yes’ in the upcoming referendum that will ratify a tentative Physician Serviced Agreement. I was one of two Co-Chairs of the OMA Negotiations Committee that brought a tentative agreement to the Board for consideration. I would like to explain why I think that this agreement should be acceptable to OMA members.

In January of 2015 the Government of Ontario made an offer to the physicians of Ontario that was rejected by the OMA Board of Directors. The government imposed unilateral cuts, followed by a second round of cuts later that fall. They also set an arbitrary cap on physician payments and reconciled or clawed back, an amount equal to any overages in the payment. An arbitrary annual growth rate of 1.25% was set for this base budget. That growth rate did not come close to meeting the needs of a growing and aging population. The inevitable result was conflict.

The OMA launched a Charter Challenge alleging two things. First that the unilateral cuts were unconstitutional and second that the government should offer physicians a process of binding dispute resolution to address the power imbalance between a group who could not strike or take other effective ‘job action’ and a government who was prepared to act unilaterally. The OMA also asked for the unilateral actions to be reversed and sought damages.

Naturally the relationship between government and Ontario doctors soured. Without consulting with the OMA the government proposed a platform of reform that doctors did not feel met their needs or the needs of their patients.

OMA Council directed the Board to demand binding arbitration from the government.

With this background the OMA Board sought to get back to the negotiations table to negotiate a Physician Services Agreement. They sent a small group of physicians, professional negotiators, lawyers, economists and other support staff to explore options for getting back to the negotiating table. In order to protect the OMA Charter Challenge, these discussions were held in confidence and without prejudice. That is neither party was free to discuss details outside a small circle and neither party could use the discussions as part of their respective court cases.

I was a leading member of the OMA side of this small group process.

Ultimately an agreement to get mediation-arbitration was not possible. But while exploring our differences and commonalities it became apparent that a tentative PSA might be possible.

Our side went back to our Board of Directors and gave detailed updates on a regular basis. We also got directions. That’s how negotiations work. The Board has complete control and directs the people it sends to the table.

Unfortunately we were unable to keep our members informed. To do so would potentially have damaged our Charter case.

The financial aspects of the deal we brought back will disappoint many of our members. There are no fee increases. However the budget growth will increase by 2.5% instead of 1.25%. This rate will support growth for an aging and growing population, estimated by ICES to be 1.9% and allow for some growth in new physicians and new technologies. Our economists are reasonably certain that with the 2.5% budget increases, some small one-time payments and active co-management of the physician service budget we will be able to stay under budget. If we do better than expected there will be an opportunity for investment in physicians services. If we don’t do well and go over budget there is the risk of reconciliation.

In primary care we have negotiated provisions that will allow new graduates, early career family doctors and other physicians with mature practices to enter FHNs and FHOs-capitated practice. Every family medicine in Ontario trains in such an environment and expect to be able to choose these practice models on a voluntary basis.

The OMA and government will jointly negotiate changes to Primary Care Contracts to address access, after-hours care and reporting on human resource issues. In return the parts of Bill 210 that speak to these issues will be removed.

I would much rather negotiate these items together than have the government impose changes.

Our Charter Challenge with respect to binding arbitrations continues. We have achieved very strong language to insure government takes no more unilateral action until our suit about arbitration is settled. External Counsel has written extensively about this so I will not give my own legal analysis on this issue. When the OMA hires some of the foremost constitutional lawyers in the country, I believe that doctors should listen to their advice.

We have dropped our challenge with respect to past unilateral action. Again our lawyers explain the reason for this. My own thinking is that we have traded a maybe for a certainty. A bird in the hand is worth two in the bush.

Finally I support this agreement because it restores a crucial relationship in the health care system. Doctors and government need to talk, they need to plan, they need to trust each other.

I know those kind of relationship cannot be written into a contract. Show me. I’ll be saying that, every doctor in Ontario will be saying that and frankly the government will be saying that.

OMA members are being asked to make a huge leap in accepting this agreement.

The alternative is conflict and chaos and that will hurt our members and that will hurt our patients.

Scott D. Wooder, MD

 

Reply to Dr. Francescutti on Professionalism

Professor Louis Francescutti recently published an editorial on the CMA website that proposed a ‘radical idea’ about medical professionalism. He talked about the need for physicians to take a bigger leadership role in the redesign of a dysfunctional health system.  He wrote that we need to hold each other more accountable.  That doesn’t sound too radical to me.  It sounds like common sense.  I think most physicians would agree with the premise.

The piece garnered a lot of feedback, which in and of itself is a good thing. We should be thinking and talking about professionalism.  We need to be system leaders and only physicians have the expertise to hold other physicians accountable.

I agree with many of his high level thoughts. However, I have very strong objections to how he proposes that those high level principles should get implemented.

I’ll start by saying that I have a professional relationship with Dr. Francescutti. I was a member of the Canadian Medical Association Board of Directors for two years.  During the second of those two years Dr. Francescutti was also a Board member as the President-elect.  I left the CMA Board to serve as President of the Ontario Medical Association.  So during the time that Dr. Francescutti was President of the CMA, I was President of the OMA.  Louis was very supportive of the OMA during his time as CMA President.

I always found him to be thoughtful, respectful and incredibly bright and funny. I deeply admire Dr. Francescutti.

I was very disappointed to hear how contemptuous he is of Provincial and Territorial Medical Associations (PTMAs) including, presumably the OMA. The PTMAs “all say the right things (the patient comes first) but a quick reality check tells us otherwise”.  I served on the Board of the OMA for a dozen years and I firmly believe that we always considered first the well-being of our patients.  Dr. Francescutti offers no proof for his opinion so I will waste no time in providing proof of my rebuttal.

Dr. Francescutti’s suggestion that physicians all be in “salaried positions on one-year contracts that can be renewed if they continue to meet performance standards” is troublesome from my point of view. The suggestion is apparently inspired by the Cleveland Clinic, which Dr. Francescutti visited while CMA President.

That model may work very well in the United States. Physicians there who lose their positions can move across the street or across the state and practice in another setting.  Here in Canada where there is a single payer, being thrown out by one’s peers would effectively end a physician’s career.  There are no other options.  It is actually illegal in Ontario to practice outside of Medicare.

Can you imagine someone losing their ability to practice medicine because their peers thought they ordered too many ultrasounds?

And there is more to it than that. An academic ED physician might be able to pack up his practice over-night but for a community based family physician like me the costs would be enormous.  I have a five year lease.  If I’m shut down by my peers in year two, I’m on the hook for over three years rent with no hope of return.  I have employees who have worked for me for 25 years.  Can you imagine the severance I would have to pay?  I have no pension, no benefits and at age 56, I can’t afford to retire.  I guess Dr. Francescutti’s plan suggests that after 30 years as a physician, I should have no job security.  And yet this plan is supposed to improve my morale and increase my sense of engagement.

And what about the administrative nightmare of doing quarterly reviews on 70 thousand physicians. That’s 280 thousand peer reviews a year.  At $500 per review, that’s $140 Million per year.  I checked the arithmetic twice on that one.

It would also tie up 560 physicians working full-time for 50 weeks a year, assuming they could do 2 peer reviews per day. I don’t think we can spare the manpower.  But maybe I could get a job lie that.  At least I’d have some security.

“We, as physicians, need to stand up and accept responsibility for what is going on in our dysfunctional health care systems across Canada. If we won’t fix the problems, who will?”

It’s a great question. It’s a great premise.

But can’t we do all that without beating up our colleagues? Can’t we find constructive and realistic implementation plans that help our patients without destroying ourselves?

Scott D Wooder, MD.

Dr Elizabeth Bagshaw-She would look great on a Canadian Banknote

Earlier this year, Prime Minister Trudeau announced that Canada would likely feature a woman on a new Canadian Bank note.

Elizabeth Bagshaw
Elizabeth Bagshaw (1881-1982) Medical director of the first birth control clinic in Canada.

Since the only woman to serve as prime minister served for a very brief time, this has led to a search for a woman who was not an elected politician.  I’ve seen many names put forth and they all seem to be deeply admirable people and we would likely all be proud to have them honoured in this way.

I’d like to put another name forward.  Dr. Elizabeth Bagshaw.

It’s impossible to practice medicine in Hamilton and not to have heard of Dr. Bagshaw.  I was part of a team from the Hamilton Academy of Medicine who nominated her, successfully, for the Canadian Medical Hall of Fame.  During that time I got to know her story well.

Dr. Bagshaw was born on a family farm in rural Ontario.  She was a driven person and became one of the first female doctors in Canada.

She competed her medical degree and did post-graduate training in Toronto.  She moved to Hamilton and started practice in 1906.  She continued to practice for 70 years and finally retired at age 95.  She had a very active obstetrical practice and delivered thousands and thousands of babies.  For three consecutive years in the 1920s she delivered more babies than any other doctor in Hamilton.

All of that is very impressive but it is her advocacy work for women and their families that is her legacy.

In the 1930s she started Canada’s first birth control clinic. She served as medical director of that clinic for 30 years.

During that entire 30 year period it was illegal to counsel women about birth control.  Dr. Bagshaw deliberately defied the law to improve the lives of women and their families.  Where can we find such medical heroes now?

Dr. Bagshaw always put the needs of her patients first.  One could spend years trying to better summarize the code of ethics of a physician and not come up with a better summary of duty than that brief sentence.

Dr. Bagshaw would be an inspiration to young girls and boys today.  She would teach us all about our own humanity.  She is an inspiration to at least one grumpy, middle-aged  family doctor in Hamilton today.

Dr. Elizabeth Bagshaw would look great on a new Canadian bank note.

Scott D Woooder, MD