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

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A Cold Family Day Weekend

Some good friends of mine have encouraged me to join their club. They shoot skeet on weekends.  The season is November to April, so it is the mirror image of the golf season.  I would be kept out of trouble 12 months a year.  Tomorrow I’m booked in with these fellows for 9 o’clock.

My problem is that the forecast is for -22 degrees C. And there is that evil little afterthought, “feels like 30 below”.  The wind will be howling out of the northwest at 40 KPH.  For a novice shooter like me, the wind might as well be 400 KPH.  Those little clay pigeons will be dancing so fast that the only way I’ll hit one is if it gets blown into the path of a bad shot.

I should cancel.

Here is the problem. I don’t want to blink first.  I know they don’t want to go either but none of us wants to be the ‘wimp’ who backs out because of a little cold weather and wind.

I know where my reluctance comes from. Older brothers and a family culture of not complaining about minor things like frostbite.  My grandmother was born in a one room cabin between Huntsville and North Bay.  No electricity, no running water.  I can’t go out in the woods for a couple of hours? Unthinkable.  My latte may not be perfect and my iPhone may not get good reception.  Wow, some list of hardships.

So I’ll bundle up and go without complaint trying to prove that my generation is as tough as my pioneer ancestors.

That latte better be hot.

 

Scott D Wooder, MD

My Personal Angst Around Physician Assisted Death

Canadians, outside of Quebec, are in a no man’s land around Assisted Dying.  In Quebec the law and regulations seem clear.  In fact earlier this month at least one Assisted Death took place.

The rest of us are scrambling to keep up.

In Ontario the College of Physicians and Surgeons are busy making policy around this issue. Thank God someone is.

I believe that the Provincial Government is also looking at this. The Parliament of Canada has until June 6 to make law.

I have a quirky sense of humour. I find the June 6 deadline to be fitting.  It’s the anniversary of the invasion of Normandy in 1944. D-Day takes on a whole new meaning.

Soon this will stop being an interesting political mess and will start to be a real issue for me and my practice in Stoney Creek.

I support the principle of assisted death. I have some concerns and questions as I’m sure everyone does.

Physician Assisted suicide occurs when a physician provides the knowledge, means and support for a person to end their own life. In other jurisdictions a prescription is handed to a person who goes home and takes it from there.

Euthanasia requires someone, not necessarily a physician, to actively end someone’s life. A number of drugs are usually administered intravenously and the person dies.  Does this require the presence of a physician?  Not really, but that seems to be the accepted reality in Canada.  People talk about physician assisted death, but why couldn’t it be a nurse or other health professional?

I’m also concerned about the need for a competent adult to make a decision. This seems to make it impossible for people to give advance direction about assisted death.  This means that people who acquire certain disabilities that render them incompetent will be forced to live in intractable pain while the rest of us have other options.  Not only is this unfair but it seems inconsistent with the notions of equity that the Supreme Court has championed over the years.  Look for more court cases to sort out that mess.

Which brings me down to my own tiny practice in Stoney Creek. Sooner or later it all boils down to ‘all politics is local’.

I do support assisted dying. The question for me is how I will participate.  How will I help my patients who request this service?

I strongly support a woman’s right to decide her own destiny and that includes her right to have access to abortion services. I don’t do abortions, but I make an effective referral.  What about assisted death?  At this point I don’t have enough information.

If a patient wants to die at home and wants to have an injection, what will be my role? I can tell you right now that I have not started an iv in almost 3 decades.  It’s not that hard a thing to do on a young healthy person but on someone who has been ill for months and who may be dehydrated it can be difficult.   I have no confidence in my current skills.  And that is surely one of the things that can go wrong in euthanasia.  Loss of iv access may make the death experience unnecessarily painful-the very thing that a person is hoping to avoid.

I’ve read all the horror stories about executions in US prisons that have gone wrong. What if something like that happens to one of my patients?  What backup can I expect?

Clearly I need a skills update if I am going to participate actively in my own patients’ homes.

But I live near a city with teaching hospitals, a medical school and fantastic community services. I may not have to get personally involved.  I may have the ability to make an effective referral.

As always, my colleagues who practice in the north or in rural or remote settings will face a bigger challenge. For them, they are the not part of the thin line of health providers.  They are often the only  providers.  Options for referral or other help which may be available to me, might not be available to them.

The usual fall back of a referral to another city would be meaningless for people who want to die in their own homes. I worry about my colleagues and their patients.

I have a lot of questions and very few answers about assisted dying. I’m glad we are having the conversation now.  But in five months we need answers.

Personally I want to do what I can to make things better. Right now I don’t know how.

Scott D Wooder, MD

Primary Care Access-What it means in my office

My professional life changed forever in 1989.  I left my solo fee-for-service practice and joined two colleagues in a group practice where the payment model was capitation.  I joined a Health Service Organization (HSO).

At the time, there were very few physicians practicing in capitated models. There were only about 150 physicians in Ontario practicing in HSOs.  We had the beginning of a primary care team.  In our office we had RNs working to scope, mental health councillors and a visiting psychiatrist.

One of the things that naturally evolved in our office was an early form of Advance Access.  With multiple team members, the ability to ‘see’ people in non-traditional ways and the luxury of seeing fewer people for longer appointments, I was able to see most people on the exact day they wanted to be seen.

My practice has evolved and I have freely stolen from the way other people practice.  I went to a primary care conference in Texas several years ago and learned that primary care physicians at Kaiser were using e-mail, the phone and other providers to provide care in up to 50% of their patient encounters.

My goal is to see patients on the day they call, the next day or the day they want to be seen.  I am almost always succesful.

 

The first question many of my colleagues will ask why is this important.  They rightly point out that many requests for appointments are not urgent and could wait a few days or a few weeks.  That is all true, but so what?  The patient is not going away and they need to be seen sometime, so why not at their convenience?  It costs me very little and is very important to them.

I also think that my office is much more efficient, my staff is happier and I have much less wasted time.  My receptionist walks into work very morning knowing that we have a spot available for every one who wants to be seen.  She doesn’t have to hunt for the next available appointment and negotiate with patients about availability.  Patients are happy because they know that when they are sick or their parents or children are sick they will be seen.  Not as add-ons or squeeze-ins, they get a regular appointment.  Every day a patient says to me, “thanks for getting me in today”. I just smile, I am oblivious to what is happening in the front office and I don’t know that the appointment was just booked.

I get very few no-shows.  Nobody calls at 10, gets an appointment for 2 and doesn’t show up.  And when patients come they usually have one complaint.  I do not have a one complaint per visit policy and I don’t need one.  I rarely have a patient come in and tell me about the cold or back pain they had 3 weeks ago.  It’s gone now but they didn’t want to cancel.  That doesn’t happen.

The second question is how do I do it?

Because I’ve been doing this for years, I never have to catch up.  It’s like having a clean garage.  I have to spend a few minutes each week keeping it clean but never have to do the major clean up thing.  OK, this part about the garage is not true, but the analogy holds.

I make use of the phone-a lot.  As I review lab results and consultations, I delegate calling the patient with the results to the right person.  Normal results are dealt with by a clerk, slightly abnormal results that need explanation or action are dealt with by a nurse and I call people for significant things.  Might as well call the patient now because if they call first it’s 3 or 4 calls to sort things out.

I book phone appointments.  People are given a specific time and date and I call them at their preferred number.  Most people are waiting by the phone and if i call a few minutes early, they are already waiting.  Even short office visits take about 15 minutes.  If someone, leaves work, drives to my office, finds parking and then waits 15 minutes to see me, they want to get their money worth.  My average call is 3-5 minutes and it is almost always terminated by the patient.  “Gotta go Doc”.  Talking to me on the phone for 300 seconds can be quite a chore.

One of my priorities in the next 12 months is to add e-mail as a tool for patient communication.

Most of my phone appointments are follow ups.  I start someone on an anti-depressant and want to make sure there were no side effects, or I review an U/S before the someone is sent to see a surgeon for gall bladder surgery.  There seems little point in bringing someone into my office to get a message that could be given over the phone.  It is more efficient for the patient and more efficient for me.

My payment model makes all of this possible.  I get a few dollars for a follow-up appointment if it’s done face to face and nothing for a call but the efficiencies are so obvious to me that I’m more than happy to make the call.

And of course I could not do any of this without a fantastic primary care nurse working with me to share the load.  I rarely do immunizations, PAP smears or preventative care reviews.  The nurse does that.  We also share responsibility for well baby care, pre-natal care and all of those crazy forms that everyone wants filled out today or yesterday.

Another thing we stole from kaiser was dealing with unscheduled issues anytime they come up.  A 35 year old woman shows up with a rash and someone notices that her last PAP was over 3 years ago.  We don’t give her an appointment to come in for a PAP, we offer to do it on the spot.  Some women want to defer, but most sigh and agree.  That is a major saving of time for both us and the patient.

I used to do a presentation on behalf of the OMA about advance access.  It met with mixed reactions.  But I have had some fantastic feedback over the years and physicians and practices that try it have been successful and happy.  A friend of mine from Etobicoke, who has been a skeptic about primary care reform tried it and told me that his practice has significantly improved.  That conversation with Dr William Russell was very comforting to me.

I’ve only scratched the surface on the benefits and the challenges of improving primary care access for a practice.  It helps patients plan their lives, frees up clerical staff time and relieves them of an onerous chore and improves the quality of life and likely the income of the physicians who move forward on this.

I’ve only talked about primary care offices.  I see little reason that many of these same principles couldn’t be adapted to specialty care too.  I won’t make the mistake of telling specialists how to practice.  I tried that once with my wife and got an earful.

It probably helps the rest of the health care system as well and that is why the Ministry of Health and Health Quality Ontario should put some resources into helping practices improve access.  Issuing a fiat that primary care access must improve won’t work, but working with the OMA to develop an action plan might.

Our current problems with government won’t last forever and we need to start planning for a return to a normal relationship.

Scott D Wooder, MD

Blessed Are the Peace Makers……

I’ve done something that not a lot of doctors have done.  I’ve negotiated two $11 Billion dollar contracts.

I didn’t do it by myself of course.  I was part of a team that negotiated those contracts.  But I was the team leader, the Chair of the Negotiations Committee that negotiated those contracts.  Both times it was a lot of work.  There was a lot of stress.  I didn’t eat properly, I didn’t sleep properly.  I didn’t exercise properly.

And the whole time I was negotiating I had to run a family practice with 2,000 rostered patients.  In 2008, I spent almost 150 days in negotiations.  I may be cheating in my count.  On those days when i negotiated from 0800 to 2000, I counted it as a day and a half.  One time the members of my team, including current OMA President Mike Toth sat at the table from 8 in the morning till 3 at night.  We counted that as 4 half days or 2 full days.  Weird math but that’s how we accounted for our time.

And do you know what the toughest part of both sets of negotiations was?  It was saying “YES”.

In 2008 we got a great deal.  Our members were happy with the rate increases.  We addressed, but did not solve relativity.  We made commitments to improve patient care, attach family doctors with unattached patients and Improve community mental health medical services.  The Government seemed happy with the agreement at the time too, but shortly after our agreement, the world underwent an economic meltdown and the Province’s budget went from surplus to deficit.

In 2012 we had to face the Province’s fiscal challenge.  We did that by finding $850 million dollars in evidence based savings that did not have a negative impact on patient care.  We stopped paying for things that cost a lot but that were not improving quality.  For instance we stopped paying for annual physicals for adults 19-64.  We saved some money and improved care.

It sounds counter-intuitive but it can be done by looking at evidence, engaging clinical experts and working together to improve the way we deliver care.

Most people will understand that it was hard to say ‘yes’ to the 2012 agreement.  It was a negative deal for doctors.  But I can tell you that it was just as hard to be the one who said ‘yes’ in 2008.  It’s a lot of pressure to speak for 30 thousand colleagues.

It’s very easy to say no.  in negotiations it’s often the path of least resistance.  Unfortunately if solves nothing.  At the end of the day there is no agreement and no way forward.  There is no way to work together to improve patient care.

I’m sure it’s the same for the Government.  It’s easy to say no for them as well.  In fact it’s very easy because they have the Legislature of Ontario behind them and they can change laws and regulations.  By saying no in October 2015, they get everything they want fiscally.

However, they do not get a healthy, productive relationship with physicians.  Whether they respect physicians like they say they do or whether they regard us a cogs in a vast machine that they control from Queen’s Park they miss the chance to work with fabulous, dedicated and very smart people who only want to be able to care for their patients as well as they can.

At some point people from each side are going to have to realize that we are much stronger together than we ever are apart.

Someone will have to make Peace.

Scott Douglas Wooder, MD

Why I Support Canadian Doctors for Medicare

A couple of weeks ago I started making small monthly contributions to Canadian Doctors for Medicare (CDFM).

I don’t agree with everything that they say and do but on the other hand I can’t think of a single group to which I belong that could meet that standard anyway. I tend to have some funny ideas and I’ve given up looking for Canadian Doctors Who Think Like Scott. If such a group existed, they likely wouldn’t have me as a member anyway. Sorry Groucho.

I support CDFM because they try to help patients just like the ones in my practice.

I work in Stoney Creek. When I first started practice, I had lots of steelworkers and their families in my practice. I had lots of farm families too. But Hamilton and Stoney Creek have changed. The well-paying manufacturing jobs are disappearing and are being replaced by less well-paying service jobs. Fewer people have benefits.

I shudder when a waitress or a truck driver in my practice is diagnosed with diabetes. I know that some of them will not be able to afford the medications that they will need to prevent serious complications.

Canadian Doctors for Medicare stands up for people in that situation.

I also have a personal reason to support CDFM. I grew up in a working class family. My father was a very hard-working tradesman at Bell. He worked 6 days a week and took all of the evening overtime he could get. I knew that when it rained, he would be out all night fixing ‘wets’. My mother stayed home and there were 5 kids in my family.

We were not poor by any stretch of the imagination. We weren’t part of the working poor either. But in the 60’s, before medicare, my parents thought twice before taking one of us to the doctor’s office. And forget about the emergency room. If you were awake and could walk, you didn’t need a doctor.

The arrival of medicare helped my family out enormously.

I was reminded of that this week when an acquaintance of mine, in her late 70s, refused to go to the hospital even though she had severe diarrhea and had nothing to drink for a week. She would not listen to my advice and I was on the verge of picking her up and carrying her to the ED when she finally relented. She was severely dehydrated.

She was given three litres of fluids and sent home. “See I wasted eveyone’s time. I should never have gone to the hospital.”

This was a person who grew up in an era when one didn’t go to see the doctor or go to the hospital until it was too late.

We need medicare because people like my friend should not have to think twice about getting help.

Some people may argue that we can have two parallel systems. A medicare system and a second option outside of medicare. Others will argue that the private system will always be better funded and will rob resources from medicare.

I’m just glad that there is a group out there fighting for my patients.

Scott Douglas Wooder, MD