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tag:blogger.com,1999:blog-86389501649210868622017-08-23T16:29:51.042-04:00The Flame Broiled DoctorMusings of a doctor burnt to a crispFrank email@example.com:blogger.com,1999:blog-8638950164921086862.post-10001942765289935642017-08-21T15:11:00.000-04:002017-08-21T19:02:10.675-04:00Medicine and the Limits of PoliticsThe obligations on the medical profession do not extend to the ideology or platform of any political party.

It's a big week for the Canadian Medical Association (CMA), holding its 150th General Council meeting in Quebec City. Between the uproar over the government's plan to hike taxes on small corporations (in particular MD corporations), and the somewhat less graspable opposition to the CMA's new strategic plan, there are bound to be some debates that raise the temperature in the room. That's not a bad thing, because apparently the conference room is an icebox.

These sorts of debates within the profession are nothing new. Doctors have argued about money since the time of Hippocrates, and understanding the so-called social determinants of health - that is, how socioeconomic factors like income and housing lead to poor health - is now a core part of the medical school curriculum. What is a more recent development, however, is the expectation that doctors be "health advocates" for their patients and the communities they serve.

It's hard to argue the rationale. Those of us working in health care, particularly when we work with marginalized populations, know all too well the need to speak on behalf of those who lack the means to speak for themselves. And apart from elected politicians, there aren't many people in a community that can match an MD's capacity to have his or her voice heard, in local or even national media.

That said, when a doctor's role as advocate extends to ever-broader patient populations and ever-broader areas of public policy, and terms like "social accountability" are bandied about with ever-increasing nonchalance, the profession inches ever-closer to being not independent, valued professionals, but a collection of glorified public servants in service of a political ideology, or, worse still, a particular political party.

I've witnessed it personally, when a room full of doctors and nurses erupted in applause at a politician's plea to put "the right party in power". That same party, since that election, has forged ahead with a half-baked plan to restructure primary care without stakeholder input; has refused to hold accountable the people that made a shambles of home care; has made the College of Physicians a de facto arm of the government; has taken no significant steps to ease pressure on overcrowded hospitals; and has wasted war chests of money on one file after another.

The point is that while doctors have obligations to their patients, and to a lesser extent their communities, those obligations should not and do not extend to all aspects of public policy. There is no part of the MD job description, and no part of the definition of "professionalism" that includes devotion to a particular tax structure, environmental scheme, or article of foreign policy. Simply because a doctor is obliged to advocate for secure housing, he or she is not obliged to support taxation of "privileged" professionals to pay for it. Nothing in any code of ethics makes self-interest on its own an act of transgression. To the benefit of nobody, this conflict is playing out right now, with back-and-forth moralizing on the tax issue, and personal attacks rearing their ugly heads once more on social media.

There is a danger in ascribing a moral dimension to areas of public policy that don't directly affect patient care. First and foremost, it plays to the agenda of one political party over another, regardless of which end of the political spectrum the party professes to champion. It has the whiff of hubris, of making one doctor superior to another for reasons having nothing to do with knowledge, experience, or clinical skill. Worst of all, however, it will lead to a political "litmus test" that could affect a doctor's candidacy for professional committees, job prospects, or even entry into the profession. Unless they interfere directly in patient care - and this is where Colleges are responsible for drawing up boundaries - political leanings should not affect one's ability to thrive in medicine.

So this is my plea, to friends, colleagues I've met in person, and those I have yet to or might never meet: take a deep breath, and ask if the fight is really about patient care or not. If the answer is 'yes', keep it civil, and listen to one another. If the answer is 'not really' or 'no', remember that smart, caring, curious, and dedicated people are welcome in the profession of medicine, regardless of where they fill in the X at the ballot box.
Frank Warshhttps://firstname.lastname@example.com:blogger.com,1999:blog-8638950164921086862.post-55207649203466287202017-08-09T14:32:00.000-04:002017-08-09T14:32:22.364-04:00The Venn Diagram Of DOOM!It's all my fault. Now look at the mess we're in.

Being a doctor is no cakewalk. It's bloody, it's smelly, the training can be murder, and the administrative headaches are driving otherwise dedicated MDs into depression, burnout, and an increasing desire to leave the profession for good.

Canadian docs have been especially hard hit in recent times. Their professional autonomy and standing as a self-regulating profession have been stripped away. They're struggling to to provide service in remote communities because of completely inadequate resources. Just when things are looking up at the provincial level, it seems the OMA has fallen into chaos once more. Worse still, the federal government has threatened to make incorporation a waste of time and money, upending many doctors' financial planning strategies and leaving their ability to keep their clinic doors open in doubt. Then factor in embarrassing coverage in the press - me and my big mouth - being a Canadian doctor is about as far from okay as it gets nowadays.

Doctors aren't taking these issues lightly, of course. In the name of #TaxFairness (go and look it up on Twitter, it's a thing), the profession is doing everything it can to keep the feds' tax grab from going ahead, from social media campaigns, to op-eds and blog posts, to old-fashioned meetings with their local Members of Parliament.

Still, there's only so far a profession can be pushed, and the straw that broke the camel's back was the unkindest cut of all, a stunning betrayal by the doctors' very own national representative body, the Canadian Medical Association (CMA):

Yes, it's that scourge of the public sector, a vaguely worded diagrammatic outline of strategic objectives, some including the word 'patient' no less!

In these troubled times, is it really appropriate for a (powerless) national medical association to shift its focus beyond the profession itself? There's a limit to how far someone can be pushed, right?

So the MD community is pushing back, or at least pushing back without sitting in on the tedious meetings where these sort of toothless decisions and statements are put together. Some docs, understandably, have cancelled their membership in the CMA in protest. Others have directly confronted the CMA leadership online. And others, after getting extraordinarily worked up this past (three-day, summer) weekend, collaborated to put together this online petition:

Sign the Petition

We, the undersigned, believe that the CMA should re-focus its strategy to defend and advocate for physicians so that physicians can then defend and advocate for excellence in patient care.
It took a few tries to get the wording just right, to get its point across whilst remaining politically correct. In fact, the petition remains true to the oldest traditions of medicine, by printing the words enshrined in the oldest surviving text of the Hippocratic Oath. What says "politically correct support of doctors" more than swearing an oath in the name of pagan deities, implied opposition to (now legally protected) medical assistance in dying, and explicit opposition to abortion?

Since enthusiasm for the petition was explosive over the weekend, there will almost certainly be enough e-signatures to bring the issue to the fore when the CMA Council meets in the coming days. Whether the petition or even the resignations come to anything is anybody's guess. The Big Kahunas of medical associations will be the first to acknowledge that major shifts in strategy and culture take time and energy to get right, and even more time and energy to make people happy.

Will there ever come a day when the drama ends, when doctors can ply their trade, earn a living, and be able to focus on their jobs instead of political nonsense? If there's only one thing we can take away from the never-ending twists and turns, it's that you never can tell.

Frank Warshhttps://firstname.lastname@example.com:blogger.com,1999:blog-8638950164921086862.post-18597473107515886922017-08-01T16:33:00.001-04:002017-08-01T16:54:25.610-04:00Hard As A RockGreat Moments in Medical Discipline. I did not make this story up.

I've made no secret of my feelings on the College of Physicians, particularly in Ontario. The College's communication style is draconian, its goalposts for what constitutes professionalism are ever in motion, and its "mission creep" has metastasized into areas that don't directly relate to the practice of medicine, namely finance and billings.

In some respects, though, I almost pity the College. Apart from being stripped of its independence from the government, its mandate to investigate any and all complaints often puts the College in an unenviable place. Case in point: the Ontario College has been forced to initiate forty(!) investigations into professional misconduct on social media, all at the behest of one crusading complainant. That's an awful lot of work, with little clear benefit to the public at large, for an institution that's intended to protect patients from predatory behavior and incompetence. As I said, you almost have to feel sorry for the College. Almost.

But just when you think you're ready to see the College as doing its damnedest in a lose-lose situation, along comes a story like this, from the Medical Post in March 2017, proving once and for all that the College is waaaaaay too preoccupied with sex for its own good:

The College of Physicians and Surgeons of Ontario has found a [medical specialist] guilty of sexually assaulting four patients...

In response to the set of accusations, [the doctor] not only denied that he would ever deliberately push his genitalia against a patient, but said that it was physically impossible for him to do so—even by accident. He argued that a "panniculus" or "fat apron" (the college's words) that hung over his pants would have gotten in the way.

According to the decision, [a College-appointed expert] examined [the accused] both before and after the defendant was injected with a chemical cocktail to induce an erection. [The accused] also performed a mock examination on [the expert] on a table nearly the same height as the one in [the accused's] office. (bold added for emphasis and, well, fun)

"[The expert] concluded that it would not have been possible for [the accused] to have rubbed his genitalia, flaccid or erect, against the patient," the decision reads. However, [the expert] "did note in his hand-written notes, 'if he were tall, maybe penis would touch knee.' "

When [a second expert] examined [the accused] there were also two college investigators in attendance. [The second expert] found that he could feel [the accused's] penis at three different table heights (the defendant had apparently lost 12 pounds since the previous exam but [the second expert] didn't feel this would have made a difference). The college witnesses also testified that the panniculus made contact with the penis but did not cover it.

However important it is to rid the medical world of sexual predators - and I don't think there are much lower forms of life on the planet - you have to wonder what in God's name the Powers That Be at the College were thinking by letting this spectacle go forward. Did we learn nothing from OJ?

Except of course, this time we aren't talking about a pair of gloves, but rather the reach and extent of a fat man's penis, chemically treated to its maximum size, as measured by independent medical experts with College investigators as witnesses.

Those of us still trying to practice medicine have every reason to dread the College's (largely unchecked) power over our careers. The rest of you lucky souls, however, should be doing a double-take (and really, having a laugh) at a situation so manifestly absurd, it strains the bounds of sanity that the ends - a finding of professional misconduct - could possibly justify the means.

Still, the College will keep on trucking as it always does, until someone with real influence will have the courage and fortitude to make smart, meaningful reforms, and prevent an embarrassment like this from happening again. But that's a tall order these days...unless we resort to certain forms of, ahem, enhancement.

Frank Warshhttps://firstname.lastname@example.com:blogger.com,1999:blog-8638950164921086862.post-5475500103105056712017-07-31T14:07:00.002-04:002017-07-31T14:07:37.054-04:00Hippocratic Proctology?Way too much medical-political news lately, from the taxation issues in Canada to the fiasco in the U.S. Senate. Thought I'd lighten the mood with some historical fiction. Ever wonder what teaching rounds might have looked like in the time of Hippocrates?

Author's note: the medical content (to the extent that it can be called medical at all), is derived from the Delphi Classics translation of the Hippocratic Corpus.

"Now this is something you won't normally see on Kos," said Hippocrates, motioning for his students to gather around the patient, lying naked and spread-eagle on a makeshift table of wood planks. "As I've discussed time and again, the diseases we treat derive from an imbalance of humors – phlegm, blood, black bile, yellow bile – brought on by changes in the air, in the water, what we eat and drink, or how much we exercise. Our job as physicians, as practitioners of the Art, is to understand these relationships and correct the imbalance – apply cold to the hot, moisture to the dry, and so on.<o:p></o:p>

"Today we won't worry about the cause of the patient's condition, because we already know it. This morning's lesson will be one from the surgical realm. We are going to go over the proper treatment of a fistula. It's a channel that develops between diseased skin around the anus into the rectum. Has anyone seen a fistula before?" The five students shrugged in silence. "Okay. Has anyone seen saddle sore before?" Silence again. "Hmm. Well, I suppose it's been decades since the war with the Achaemenids, so you just haven't been exposed to battlefield medicine. <o:p></o:p>

"Rowers and cavalrymen are by far the most likely to develop fistulae. The long hours on horseback or at sea cause a large volume of blood to pool around the anus, stretching and weakening the surrounding flesh – saddle sore, as a horseman might say. Nikomachos here is a rigger on a merchant ship that began its journey in Corcyra, in the Ionian Sea to the northwest of the mainland. The Mbatis wind wasn't enough to propel the ship, so Nikomachos went from rigger to oarsman for a long stretch of the voyage. All that sitting and rowing weakened his anal flesh. <o:p></o:p>

"Once the flesh is weak and fragile, it only takes a slight injury – a fall, a sliver of wood – to create a pustule in the area. If your patient describes a pustule around the anus, or if you see one on exam, cut it open right away to let it drain. The last thing you want is the pustule to burst into the rectum and form a fistula. Unfortunately for Nikomachos, he didn't notice the problem until too late. The fistula expanded to the point that he noticed the fetid smell from contamination with flatus and feces."<o:p></o:p>

And smell fetid it did, even in the open-air colonnade with a mid-morning breeze. Hippocrates had made a habit of mouth-breathing as much as possible around the sick, but his students had yet to discover the best ways of avoiding foul odors. One youth looked absolutely peaked, another ashen and on the brink of passing out. Hippocrates signaled the most senior student to take the poor juniors aside to regain their composure. "Gods! Is that what minotaur shit would smell like?!?" moaned the more alert of the two.<o:p></o:p>

Hippocrates held up a garlic bulb. "The first step in the care of a fistula is measurement of its depth." He stuffed the garlic in the opening by the patient's anus, pushed it as deep as it would go, then plucked it out and held it up once more. A third student reeled from the blast of fetid air. "You can see by the fecal staining how big of a plug we'll need to help the area heal." He handed the garlic to a temple servant with directions to cut a patch of cotton. "We've already given Nikomachos some medication beforehand. He's had three drinking cups of – can anyone recall the elixir?"<o:p></o:p>

"Powdered fennel root, steeped for three days?" said the senior student.<o:p></o:p>

"Four days," said Hippocrates, "plus some honey. Not unpleasant to the taste, actually. The elixir is to be given on an empty stomach, after you've given a purgative. I don't advise wine for pain relief, despite the patient's discomfort." He accepted the cut cotton cloth from the servant, and continued to demonstrate as he spoke. "You'll need to bleach the area clean with Cimolian chalk. Then moisten your cloth in the juice of a milkweed, and sprinkle it with grounds of roast orchid. Thread the cloth through the fistula until you can feel it on the inside the rectum…"<o:p></o:p>

"Gods, that hurts!" screamed Nikomachus. "How soon can I have wine?!?"<o:p></o:p>

"In due time," said Hippocrates, turning back to his students. "The cloth needs to stay in the fistula for six days. We'll fashion a small pessary from the horn of an offered animal and plug the rectum to keep the cloth in place. Nikomachus, you'll be able to remove the pessary as needed to move your bowels. At the end of the six days, we'll apply alum to the area to help dry it up, and anoint it daily with myrrh until it's fully healed. Any questions?"<o:p></o:p>

Hippocrates took delight in teaching the finer points of proctology. The Art was gaining traction in the Greek world, with physicians increasingly trained to look past deference to the gods. His predecessors and contemporaries were enjoying popularity and wealth as they traveled. Proctology was a superb way to keep his students humble.<o:p></o:p>

Frank Warshhttps://firstname.lastname@example.com:blogger.com,1999:blog-8638950164921086862.post-13984362311124721802017-07-22T10:03:00.002-04:002017-07-22T10:03:50.075-04:00Frustrated, IncorporatedPut me out of my misery.

At the dawn of the millennium, when I finished my medical training and entered independent practice, I was strongly encouraged to incorporate my practice. I'm probably more versed in financial issues than many of my peers - who were using their limited spare time to eat, sleep, and exercise - but the vagaries of tax planning are beyond the scope of my knowledge. An accountant - a tax professional - explained the pros and cons to me, the various ways I might use a corporation for retirement planning, estate planning, my children's education, and so on. None of this was shady. There was no way to funnel money to my pet, no labyrinth of phony bank accounts reducing my tax liability to zero, and the only thing I've ever left in Switzerland was in the restroom of the Zurich airport while waiting for a connecting flight.

None of it was exploiting loopholes that billionaires seem to magically get away with...just sound financial planning any business owner is supposed to make use of.

(As an aside, I'm not sure if there's a dime to be saved in the end by incorporating, as the accountant's bill "magically" goes up by an order of magnitude to prepare a tax return on a corporation, but I digress.)

Apparently, following the advice of a professional when it comes to money is now an act of exploitation, as the federal government is poised to do away with the benefits of incorporation, labeling them "loopholes to avoid tax". So, whatever optimism might flow from a rejuvenated doctor-government relationship at the provincial level, the feds, 'twould seem, taketh away. This is a particular sting for Ontario's doctors, as they negotiated the right to incorporate in lieu of a fee hike back in the early 2000s.

I've never been one to complain about my income, and will face a firing squad of my colleagues to say that at times I've felt I was overpaid. But the issue of professional incorporation isn't about income so much as its soundness as a financial planning tool, on the advice of informed professionals. There's nothing about an incorporated professional that's destabilizing to the national economy (as was the case when large businesses were becoming income trusts). This is just a cash grab by a federal government too enamored with its leader for its own good, and too cowardly to raise taxes on the real owners of Canada. You bully who you can, right?

Doctors probably shouldn't panic just yet. Because the issue is federal, and will affect doctors across the country, the Canadian Medical Association is taking the problem seriously. Moreover, doctors are far from the only incorporated professionals who stand to take it on the nose from the proposed changes to the tax code. Many lawyers and accountants - who stand to lose out on both their own savings and revenue from incorporated doctors - will oppose the federal government's proposal as well.

That said, average Canadians should pay close attention to the outcome of events here. After the cuts, the vilification in the press, the stripping of professional autonomy, a blow to doctors' retirement security might be the proverbial last straw, to say nothing of the acute and unfunded cost of restructuring or dissolving a corporation. Many doctors will take a serious look at their job prospects outside of Canada, and walk away without looking back. That can't be good news for Canada's ailing health care system.

Frank Warshhttps://email@example.com:blogger.com,1999:blog-8638950164921086862.post-70105625082301232402017-07-20T14:53:00.001-04:002017-07-20T20:19:15.359-04:00Arrivederci Twitter Some time away in the beauty and splendor of Italy was come il cacio sui maccheroni.

Even the heat of July, Italy might be the most magnificent place on Earth (its climate is more pleasant than southern Ontario's because there's no insufferable humidity). Rolling hilltop farms in the countryside, mountains rising from the horizon above centuries-old Gothic churches, Renaissance palaces filled floor to ceiling with great works of art, monuments of and to Imperial power...amore a prima vista is a certainty.

And the food! Farm-fresh produce (no Costo-bought Franken-fruit), hearty pasta, tender meats in savory sauces cotto a puntino...a daily feast and an idyllic setting in the company of warm, welcoming hosts. Pancia mia fatti capanna!

Okay, what gives with the travel ad for Italy? Not much, other than to recognize that sometimes you need to step outside of your life to take a look at your life.

I left full-time clinical medicine a year and a half ago out of gas, avere le batterie scariche, burned out, fed up, lost, adrift, overly cynical...pick your label. It was the second time in five years I'd felt real dissatisfaction with medicine, with the caveat that the first time, circumstances were much less within my control. Leaving wasn't an easy decision, nor a happy one, nor one I will ever feel comfortable with...but it was the right one.

I was encouraged to write my thoughts, my feelings, my experiences, to assemble them with the funny and tragic stories I'd amassed over the years. Storytelling and writing are activities I've always enjoyed, and (in my opinion, anyway), there's no better way to discover and disseminate wisdom.

So I wrote my book and started this blog, throwing in a podcast here and there if a good idea came my way. It was all in the name of building a "platform", a "brand", or whatever other label one might affix to the ludicrous importance we place on marketing nowadays. Supposedly, the key to effective marketing nowadays is social media, including the platform I've never really understood the point of, namely Twitter. You gotta do what you gotta do, right? Avere le mani in pasta.

After a year and a half on Twitter, I'm ready to say it's been more trouble than it's worth. Not because I've not made some good connections, I have (even though I've yet to follow up on my Twitter "connections" with apparent sex trade workers, but I digress). But not counting people I've made a point of meeting in person, or at least had a more personal discussion with, Twitter has proven tedious and even toxic to what I enjoy most.

As open and embracing of opinion Twitter purports to be, it's little more than a place where people seek comfort in the like-minded, reduce every conceivable issue to an absurd "left" vs. "right" gang-war, and see every disagreement as a license to degenerate into insults and personal attacks, botte da orbe. I claim no innocence here, and will happily apologize to anyone I might have offended or at least shown disrespect.

But that's the kicker with social media, Twitter especially. 140 characters leaves little room for nuance, little room for substance, little room for clarification, and little room for courtesy, regret, or forgiveness. I'm wordy (and sarcastic and cynical and foul-mouthed and curmudgeonly), and see no justifiable excuse to restrict what (I at least think) might be important to say when 140 characters simply isn't enough.

I have much more to say on the corrosive effect I see social media is having on the medical community as a whole, but that's another piece for another day.

So I'm fading into the background from Twitter, essere uccel di bosco. I'll still tweet my blog posts, and will happily respond to personal messages or Twitter shout-outs. But my days of back-and-forth on the latest medical-political controversy are over for now. Darsi all'ippica. Thanks to my many Twitter followers and non-followers for the discussions, re-tweets, and one-liners. I'll drink a toast when I crack my next bottle of Chianti.

Ciao! Ciao!

(Italian phrases courtesy of Smartling.com)
Frank Warshhttps://firstname.lastname@example.com:blogger.com,1999:blog-8638950164921086862.post-57909810449404949202017-07-05T10:22:00.004-04:002017-07-05T10:23:38.851-04:00Taking A Time OutA brutally busy month of June has left my brain-tank on empty. I'm still easily reached on e-mail, Facebook, and Twitter, but no new blog posts expected in July.

Frank Warshhttps://email@example.com:blogger.com,1999:blog-8638950164921086862.post-33141145627974166302017-06-18T23:23:00.000-04:002017-06-18T23:23:18.253-04:00Hey, A Cross-Post!Healthcare and Humanity, a website with some terrific reader-contributed stories from the healthcare trenches, solicited doctors' "origin stories". I guarantee you mine ain't like the others:

"Realizing that your place in life is to serve as a poster child for bad career counseling is disheartening to say the least, but it's also somewhat liberating."
Spoiler alert - it's got another excerpt from the book. Enjoy!

Why I did (but shouldn't have) become a doctor…

Frank Warshhttps://firstname.lastname@example.com:blogger.com,1999:blog-8638950164921086862.post-41094787504926920492017-06-17T22:38:00.000-04:002017-07-05T10:09:22.763-04:00Speaking For The DeadIf a suicide can't shake the medical training system into action, nothing will.

The motto of the Coroner's Office is, "we speak for the dead to protect the living." Unlike a police investigation into a homicide, say, coroners aren't out to assign legal responsibility or solve a crime. The goal is to identify the system failures that led to a death, and help find a way forward so it doesn't happen again. It's work that seems out of place these days, pressured as we are to make maximally productive use of time. It demands time and careful thought, reflection and patience. The problems can't be explored 140 characters at a time, any more than they can be addressed in a political news cycle. But because the work is on behalf of the dead, it's wholly incorruptible.

With a coroner's eye and heavy heart, I read the devastating story of Dr. Robert Chu, who died by suicide in September 2016, having been twice unsuccessful at landing a residency spot after med school. Those closest to him will spend years wondering what signs they might have overlooked, or what offhand remarks they might have misinterpreted, his family members carrying that burden the rest of their lives. But the personal details never tell the whole story, and Robert's death must be considered with the utmost seriousness by every medical educator and administrator in the country.

And to those who might brush it off as "just another suicide, what makes a doctor so special?", I would only point to the (admittedly crass) fiscal math. Canada invested roughly a half-million dollars - more than a decade's worth of the average family's total tax bill - to make Robert Chu a doctor, and he died before signing a single prescription.

What questions come to mind when reading Robert's story, and the accompanying piece in the Toronto Star about the plight of other unmatched medical graduates, outside of whatever personal factors played a role? Many that give pause for thought, and light the way for decision-makers to act.

In his first go-around at the match, Robert was told he was too broad in choosing his electives, perhaps at the expense of focusing on radiology (the article isn't entirely clear on this). Is an early narrowed focus something we should prize in medical students? What about people who discover a specialty late in medical school, or change their mind because of an excellent mentor?

In his second go-around, Robert's sincere interest in psychiatry was questioned because of his past publications in radiology. How did research credentials suddenly become a detriment, in particular as so many medical students have done undergraduate research that is utterly irrelevant to their future practice? And why wouldn't a program take an applicant at face value? Is it not possible to "grow into" a field of medicine? Not every doctor is a journeyman, but interests change and passions are uncovered as one's experience grows. Who's to say Robert wouldn't have been happy as a psychiatrist, and serving the public with the utmost competence and professionalism?

When Robert wasn't matched, why the stonewalling with regards to feedback his unsuccessful application? If the fear is that such sharing of information could lead to "gaming", isn't it past time to overhaul how applicants are selected? Is there too much emphasis placed on subjective factors? Do residency program directors need to face the possibility that they, too, are susceptible to unconscious biases in their selection processes?

Looking back on my own career, and listening at length to friends and much more experienced colleagues, it's long past time we revisit the current system of having medical students choose their field of practice, with little in the way of wiggle room should they have a change of heart. This has contributed to both the generation-old maligning of general practice, and the present crisis of disinterest in family medicine. The policy response to this is necessarily a radical one, but that doesn't make it less worthy of consideration.

More than 100 graduates of Canadian medical schools will be without anything resembling the prospects of their friends and classmates as of July 1st. Some will have found employment or academic work and ultimately land on their feet, but others will be struggling in circumstances they never foresaw and cannot control. Counselling and "resiliency" training are a perfectly fine band-aid, but nothing approaching a cure for the underlying problem. Now that one graduate has felt desperate enough to see death as the only escape, how long until another promising doctor does the same? Do we as a medical community dare accept it?

"Without a residency position, my degree … is effectively useless. My diligent studies of medical texts, careful practice of interview and examination skills with patients and my student debt in excess of $100,000 on this pursuit have all been for naught"
Dr. Richard Chu's voice fell on deaf ears in life. It's up to all of us to speak for him in death.Frank Warshhttps://firstname.lastname@example.com:blogger.com,1999:blog-8638950164921086862.post-15242267604435006682017-06-13T22:34:00.005-04:002017-06-13T22:35:42.933-04:00A Few Bad Apples?I've been working a locum this month, hence less blogging than normal. But I couldn't avoid sharing my 2 cents on this one.

Anyone with an interest in health care and health policy has probably read the Globe and Mail's recent investigation into private medical clinics in Canada. It's an excellent piece, and coming from the more centrist and staid Globe, might carry more weight with the movers and shakers than an investigation by the Toronto Star, which is often too anti-doctor for its own good. The nuts and bolts of the issue is this:

In Canada, any service paid for by the provincial health insurance (Medicare) plans cannot legally be offered or paid for privately. The only exceptions to the law are seen when the medical service is funded through a third-party insurance plan like Workman's Compensation, or the patient is a non-resident of Canada and therefore not covered under Medicare.

Fees to access a medically necessary service, like a membership fee at a clinic, or charges over and above what Medicare pays the doctor and facility (extra billing) result in dollar-for-dollar clawbacks in transfer payments from the federal government to the provinces. These are the penalty provisions of the Canada Health Act, and every province has its own law outlawing user fees and extra-billing to comply.

The Globe found that private clinics - most of them doctor-owned - and many of the doctors that staff them were committing all sorts of acts in violation of College of Physicians policies, extra-billing laws, user-fee laws...if there were a way to violate the spirit or the letter of the law in pursuit of a buck, the Globe found a clinic guilty of it. To make matters worse, the various regulators have been slow to react (if at all). All the while, patients of modest means have been charged large sums of money for services that should be covered in a timely manner in the public system, without the need to fork over a dime beyond their taxes and hospital parking fees.

There's been the usual chatter and umbrage, in the press and on social media. And make no mistake, what's going on is indefensible. To shake down desperate people for thousands of dollars to jump the queue, then paint yourself as a crusader against wait times, is more than a little galling. Then again, we should be no less upset at regulators that have been asleep at the wheel.

I don't see a point in directing my personal disapproval at these doctors or their facilities. I don't have all the facts, it's not my job, and I'm in no position to cast the proverbial First Stone. Instead I'd like to look deeper than the immediate malfeasance, because this sort of thing will happen again and again, no matter how much regulation is put in place.

The first thing to point out is that the private clinic problem constitutes a tiny number of clinics across Canada, and fewer than 1% of the nation's 80,000-some doctors. It's not to forgive it, but this is not a case of system-wide dysfunction or corruption. These clinics could all be put out of business within a day, and it would be back-page news.

And to those who might paint the entire profession with the same brush, I got news for ya: the rest of us hate this too! There is nothing more annoying to conscientious doctors than more regulation, more oversight, and more paperwork, all on account of a few unscrupulous operators. And when these headlines come at the outset of doctor-government negotiations? How much leverage is lost in an instant?

Ultimately, private clinics - whether you see them as out to gouge people or simply providing a service that's in demand - are a symptom, not a major problem in and of themselves. No, the problem is that the health care "system", to the extent that it can even be called a system, is built atop a rickety and obsolete insurance plan, nothing more, nothing less. It was never intended to be all things to all people, and 60 years of experience has proven that health care does not obey the ordinary laws of supply and demand. That we do as well as we do, running above capacity at all times, is a testament to both the quality of the health care workforce and the robust Canadian economy footing the bill.

There is no singular fix to the problems of health care. In business, there's the old adage of "good, cheap, or on time...you can have two". In health care, we're apparently shooting for: comprehensive, evidence-based, modern, accessible everywhere, accessible every-when, equitable, timely, patient-centered, efficient, affordable, accountable, and sustainable. The logical impossibility would be laughable, if it weren't for so many health professionals burning out from trying their damnedest.

Our policymakers almost never sit down and decide on a singular, meaningful effort at reform, think it through carefully, fund it adequately, and stick to their guns when the hiccups inevitably arise. It's just a never-ending stream of pointless and half-baked initiatives in a thousand different directions, dreamed up by political staffers who can't see past an election cycle, planned by people working in a sclerotic bureaucracy rife with groupthink and rigid hierarchies, and executed by hard-working professionals whose feedback goes completely unheard. Why? Because the scammers give all of us - doctors, nurses, everyone - a bad name, and give the politicians every pretext not to listen.

So where do we go from here? We hope that the conversation doesn't stop at a regulatory crackdown on private clinics. Rather, we should have a careful and nonpartisan national dialogue, on what people should expect of the health system, demand of the health system, and contribute to the health system.

Frank Warshhttps://firstname.lastname@example.com:blogger.com,1999:blog-8638950164921086862.post-59560778010316810492017-06-02T09:28:00.000-04:002017-06-03T10:02:09.101-04:00Bill 87: Self Regulation, RIPThe Ontario government's Protecting Patients Act ends the health professions' self-regulation once and for all. In true Canadian fashion, it also ignores the very advice it asked of its experts.

We've all read headlines about doctors who sexually abuse their patients and somehow remain in practice. Or have their licences suspended for a certain time period, with or without restrictions around seeing patients of a single gender. Or require a chaperone to be present when seeing opposite-gender patients. Or face criminal charges but not professional sanction until after the fact. Or vice versa.

That these situations ever arise is abhorrent. Not so much because the abuse and injustice are indelible stains on the profession, though they are, but rather because in disciplining the doctors - and in almost all reported cases a doctor is the perpetrator - the College of Physicians' discipline system disregards the most important person: the victim. Understandably, the government felt a need to step in an enact important reforms.

Much has been made of Bill 87, also known as the Protecting Patients Act. It's an omnibus piece of health legislation, covering five areas of the health care system that have absolutely nothing to do with one another. Three of them - seniors' centres, nurse practitioner prescriptions, and hospital lab services - are without controversy and aren't worth going into. The fourth - mandating that doctors' offices, rather than parents, report childhood immunizations to public health units - is ultimately a resource issue. It's costly and time-consuming for doctors and their office staff to meet the new reporting requirements, so the complaints about the law were predictable and understandable.

It's the sexual abuse provisions in the law that lie at the heart of the matter, however, and the Ontario government appears to be taking the issue seriously. Those provisions include: expanding the list of offences that result in mandatory loss of licence; removing gender-specific licence restrictions; strengthening what and how the College website reports on doctors' offences; offering resources for victim counselling; and others. Moreover, the government is giving itself the authority to make appointments to College standing committees, such as the Executive, Investigations, and Discipline. And for reasons unbeknownst to anyone, the government has also given itself the authority to obtain a health professional's personal health information. Nowhere is a justification for this part of the law provided - not in the preamble, not in the transcripts of the legislature debates, not in committee - nowhere (and yes, I'm enough of a masochist to have read through them).

Other bloggers and op-ed contributors have critiqued these parts of the law, so I won't rehash the arguments. I have two points to make that I haven't seen addressed elsewhere, however.

First, the government convened an independent panel of experts to provide a thorough analysis and set of recommendations to solve the problem of patient sexual abuse. The report is worth a read to anyone. It's comprehensive, patient-focused, and extremely thoughtful. The panel called for a new body to investigate sexual-abuse complaints on an expedited basis, earlier and mandatory involvement of law enforcement, and an abundance of resources to get victims the help they need and correct the imbalance of power between perpetrators and victims.

As is so often the case with Canadian governments, however, precious few of the recommendations made it into the law. It means many hours of careful thought and hard work have gone to waste, and the new law is guaranteed not to solve the problems, or at least address them only superficially. For an issue as important as this (and God knows the transcripts prove that politicians of all stripes can recite the phrase "zero tolerance" ad nauseum), it's a disgrace for the government to willfully disregard the needs of victims. The law allows for rapid online shaming of alleged perpetrators, but not rapid access to legal counsel for victims. Who benefits here? How is justice served? And what's the point of convening a panel only to ignore their advice?

These shortcomings of the law, though, can be corrected in the future. What can't be corrected, however, is the decision by the government to give itself the right to make College committee appointments, including the Executive that runs the show when the Council isn't meeting. Make no mistake, this makes the College of Physicians a de facto arm of the provincial government. The province tried it before, using the College to conduct audits of billings, but that was about money. This is a wholesale abrogation of medicine as a self-regulating profession. The chastened College is now little more than an administrative registrar, with its strings to be forever pulled by politicians. If anyone thinks a different party in charge will undo that, and willingly return power to an independent College, they are mistaken.

All of us - health professionals, patients, policymakers - would do well to reflect on how it is that we arrived at this moment, when the bounds of professionalism will be defined by political whim, rather than thoughtful consensus.

Was it that the College investigation-and-discipline process around sexual abuse was flawed by design? That it put too much emphasis on disciplining the perpetrator, opening the door to aggressive (and therefore lengthy) legal defense, and not enough emphasis on aid to the victims? Or was the disciplinary process not harsh enough, placing too much emphasis on a "fair" process to satisfy public sentiment?

It might be that no amount of regulation could ever prevent sexual abuse of patients. For most of the 2500 years doctors regulated themselves, women were little more than men's property at the best of times. Short of outright rape, sexual assault of any kind wouldn't have been considered a crime from the time of Hippocrates right down to the 20th century, and it's only in very recent years that victims have had legal protections as witnesses to crimes they themselves have suffered. Like the law, maybe an effective self-regulating College was too little, too late to make timely justice and compassion a reality.

Maybe it's impossible for careful deliberation around policy to keep up with a hyper-connected, hyper-litigious, and hyper-politicized world. The wisest of rules take time to get right, but political reality has made the timelines too tight, and we were bound to end up where we are.

I've long been a harsh, even disrespecting critic of the College of Physicians in Ontario. I've found its manner to be overly draconian, its processes too slow and bureaucratic, and its obsession with sex to border on comical. But I have to believe that the doctors, volunteers, and staffers doing the work only ever did what they believed was best for the people of Ontario, and the standing of a profession that's as old as democracy. That the College is now stripped of its independence, and subject to the needs of political expediency, should give us pause for thought and lament. The shelter from political winds is dismantled for good, and nobody can predict what lies ahead.Frank Warshhttps://email@example.com:blogger.com,1999:blog-8638950164921086862.post-58765111491480542152017-05-23T16:56:00.002-04:002017-05-23T16:56:58.865-04:00A Dangerous Idea: A "General" Medical LicenceBecause I can't afford to attend the Family Medicine Forum on a Coroner/househusband/author's salary.

The Family Medicine Forum (FMF) is the largest academic Family Medicine conference in Canada. Each November, thousands of doctors, residents, medical students, teachers, and researchers descend upon one of Canada's major cities - the conference location rotates - to network, socialize, catch up with colleagues and learn. It can also be a real hoot, allowing one to mix-and-match ordinary refresher sessions with offbeat stuff in Medical Humanities and so on.

One of the more fun sessions at FMF is the annual "Dangerous Ideas Soapbox". The Soapbox is a chance for conference attendees to stand in front of a crowd and pitch a radical idea to a willing audience. The idea can be just about anything pertaining to Family Practice. The audience votes on its favorite idea, and, well, something happens. Slowly. Or doesn't.

Since signing off on blog posts and dead bodies isn't terribly lucrative, I won't be making it to FMF this year. But, since my thoughts on the uncertain future of Family Medicine have been fodder for lively Twitter debate, I'm going to go one step further, and present my very own Dangerous Idea:

A new, "general" category of licence to practice medicine.

A bit of history: once upon a time, Canadian doctors were eligible after independent licensure after a rotating year of internship. A doctor could go on for a second year of Family Medicine residency and obtain certification from the College of Family Physicians (CFPC), enter a specialty residency, or go out and practice independently.

In the mid-1980s, the profession had a heated internal debate over how much and what sort of training was needed to practice medicine independently. The conclusion was: two years, with a curriculum and exam administered by the CFPC. By the early 90s, all provinces had phased out the one-year path to practice, though not without causing genuine tumult in the transition.

The "new order" meant that a doctor's chosen field of practice was selected while still in medical school. There was a bit of wiggle room to switch programs while in residency, but once a doctor had been out in practice, re-entry into a specialty could only happen with some sort of return-of-service agreement, if at all. For all this new setup would do to empower the CFPC and bring a (hopefully) renewed vigor to Family Medicine, even the task force foresaw problems down the road:

It requires little imagination to extrapolate the present trend to a day when family physicians find themselves withdrawn into their offices, beleaguered on the one hand by well-trained specialists willing to expand from consulting into specialized primary care and on the other hand by growing numbers of nonmedical counsellors increasingly successful at convincing the public that medical training is superfluous to providers of social advice. We believe this will be a sad day for patients; it will be a disaster for family physicians.
Specialists didn't move into primary care, but Nurse Practitioners and other health professionals have been flexing their muscles for some time now. When you couple that with what the task force didn't foresee - namely, family doctors not practicing family medicine - it would be hard to interpret the falling interest in Family Medicine as anything but the start of a return to the dark days of the late 90s and early 2000s, when up to 3/4 of medical students said no thanks.

Shifting the culture in medicine, or re-examining who should get into med school, will take years-to-generations, if it's even possible. Still, we have chronic shortages in rural areas, and a new phenomenon of specialists unable to find work. It's too little, too late for the current job hunters, but there is a way to help both these problems, and in all likelihood improve the attractiveness of Family Medicine: a new "general" category of medical licence, earned after a mandatory two years of residency, that still allows doctors to enter the residency match for specialties or sit the CFPC exam.

A new (or restored, if you prefer) general licence doesn't mean a doctor should be allowed to practice Family Medicine independently without sitting the CFPC exam. Such a doctor, could, however, cover brief locums, staff a university or sexual health clinic, work as a hospitalist, work with nursing homes, and so on. This kind of work should be paid at a discount, or on a return-of-service basis, as an incentive for someone enjoying general practice to become a full-fledged Family Doctor. Regardless of pay, a general independent licence would give much needed flexibility to recent grads that aren't sure what they want to do, let young doctors take parental leave without the stresses of getting their own practices covered, and help put out rural staffing fires. And it's a guarantee that experience in general practice will raise the beleaguered profile of Family Doctors in the eyes of their specialist colleagues.

A general licence option might even improve upon the popularity of Family Medicine, as new doctors would have time to get a feel for what they do and don't like, without the pressure of having to limit their options while still in medical school. Moreover, such a regime could help recruitment in fields that medical students often dismiss - Public Health, Psychiatry, Pathology - but older docs might take a second look at once they've been working a few years.

I'm not blind to the obvious criticism: where do the patients and taxpayers get a say in this? This is a doctor-centric solution that ignores the real needs of communities. What does it do to a community when young doctors come and go as they please? What about the long-term doctor-patient relationship in Family Medicine?

To which I respond: what's the alternative? The majority of young and future doctors either aren't interested in the job, or at a minimum aren't interested in the commitment. Until you can change the culture and practice patterns of doctors naturally - which might not happen at all - the alternative is forcing doctors' hands: "you will work within these models where you're needed, or you will not work".

Is that really what Canadians want in their doctors? A limited sense of autonomy and control, in the name of serving some public (or is it political?) purpose that flies in the face of the absolute excellence we demand from would-be doctors? The system as currently designed puts the financial risks of practice in the hands of the doctor. You're going to tell a young doctor where and how to practice and make her pay the overhead? How easy will it be to get people into Family Medicine under those conditions? And what happens when one town or province stops forcing the issue in the name of recruitment, or offers incentives such as free rent?

The general category of licence: a dangerous idea whose time has come.

Frank Warshhttps://firstname.lastname@example.com:blogger.com,1999:blog-8638950164921086862.post-75452367578104200002017-05-21T09:41:00.000-04:002017-05-21T09:41:11.446-04:00Does Family Medicine Have a Future? Part IVDon't prescribe the solution until you understand the problem.

As I noted in my last post, Family Medicine is in deep trouble in Canada. Though more medical students are choosing careers in Family Medicine than was the case a decade ago, the trend is heading back downwards. Worse still, training in Family Medicine does not necessarily mean a student will end up as a full-service Family Doctor. Some 30% (if not more) graduating residents either restrict their practices or focus on "subspecialties" of Family Medicine: Emergency Medicine, Palliative Care, Chronic Pain, and so on.

Most worrisome, however, is that the most basic approach to policy problems - economics - doesn't appear to have worked. Governments across Canada made massive investments in reforming Primary Care from the mid-2000s onward, the rate of unemployment in competitive specialties is ballooning, yet Family Medicine remains an undesired career for the majority of Canada's med students. If it's not money or job prospects driving the disinterest, what is it?

It's impossible to believe that there's a single causal factor here. The situation has persisted for decades, thorough years of funding cuts and years of largess, years of incentives and years of restrictions, years of discount tuition and years of exorbitant tuition, and seismic shifts in the demographics and work patterns of the physician workforce. Since doctors, policymakers, and the public are in agreement that there's cause for concern, it's no time for best guesses and remedial half-measures.

As I see it, there are two fundamental questions that need to be answered:

1. Why don't medical students choose Family Medicine?
2. Why don't trainees choosing Family Medicine ultimately practice Family Medicine?

The first question is ultimately one for the medical schools. Is there something about the way Family Medicine is taught that leads to disinterest? It there enough exposure, or over-exposure? Is the career counseling in med school (or in undergraduate schools) both adequate and accurate? Does that counseling cover both the real job demands and realistic job prospects? Is there something about how and which students are accepted to med school that contributes to the problem?

The second question will be the more difficult to answer, and the answers might very well differ from one jurisdiction to another. Is it the economics of practice in some jurisdictions, but not necessarily in others? Is it the administrative demands, that again might differ from place to place? Is it family or cost of living considerations? Is it the complexity of care that's a turnoff? Is the work too challenging or not challenging enough? Lack of support services?

Getting to the bottom of this will require serious time and energy, with the urgency and intensity of a judicial inquiry. Electronic surveys will simply not cut it, even with a good sample size. Medical students, Family Medicine residents, and practicing doctors need to be interviewed in-depth and in a semi-structured manner - the same questions need to be asked of everyone, but leeway is needed to explore issues as they're uncovered. These interviews need to be done by a body like the College of Family Physicians (CFPC) or Canadian Medical Association, that has no direct authority over someone's career. A resident is far more likely to tell her program director what she perceives the program director wants to hear, than to deliver the unvarnished truth.

Once the work is done, then comes the hard part. The CFPC and medical schools need to face and accept the themes coming out of this endeavor, and act upon them. If med students are ill informed about the realities of practice, they need more comprehensive career counseling to set the record straight. If med students don't believe Family Medicine is challenging enough, they need new and diverse experiences (get them out of the city!) If residents don't feel comfortable dealing with complex patients, the curriculum will need a tweak.

There is one uncomfortable truth, however, that the CFPC (and to some extent, the Canadian public) must prepare itself for: it's quite possible that the ideal of how Family Medicine "should" be practiced does not appeal to, and is irreconcilable with, the majority of current and future doctors' personalities, desires, and expectations. Again, we are in a situation where economics has not fixed things. Money's been poured into primary care, but medical students are still opting for specialties, even those with lousy job prospects. There is a policy shift that can address this part of the problem, and help with chronic staffing problems in small communities, but that's a topic for another post.

Here's where I probably burn my bridges. I speak only for myself, but it's time to acknowledge that the "ideal" of comprehensive Family Medicine and the (romantic) Patient's Medical Home belies the complexity and intensity of modern medicine. There aren't enough hours in the day for doctors to be caring medical experts on the one hand, and team-based, prevention-focused, data-driven, guideline-obedient drones on the other. That policymakers see no problem in Nurse Practitioners assuming much of the workload would seem to reinforce that notion.

The idea of the "perfect" Family Doctor is just that - an idea. It's words on the page composed by a committee, not a living, sentient medical professional. It's long past time to examine the intense realities of the job, listen to the people toiling away in the job, acknowledge the rationale of those rejecting the job, and act.

Frank Warshhttps://firstname.lastname@example.com:blogger.com,1999:blog-8638950164921086862.post-38543036330001078452017-05-18T22:47:00.003-04:002017-05-18T23:04:54.742-04:00Does Family Medicine Have a Future? Part IIII over-tweeted on this topic today, and was advised to write a blog post (as penance?).

Almost a year ago, I composed some thoughts about the long-term trends in Family Medicine, including a not-so-urgent call for the discipline to reinvent itself. Shortly thereafter, most of the oxygen in my brain was taken up by a revision of the book, then the fiasco over the tentative doctors' deal in Ontario, so the distant rumblings about Family Medicine fell by the wayside. To make a long story short, Family Medicine is staring down a crossroads, just as it was when I was a medical student (roughly 20 years ago). Unfortunately, the problem is almost certainly worse than The Powers That Be think it is.

The problem, to be blunt, is a rejection of "classical" (i.e. comprehensive) Family Medicine by an overwhelming majority of Canada's medical graduates. I attach no judgement to that statement, it's just the only plausible interpretation of the evidence. Some graphs courtesy of the Canadian Residency Matching Service (CaRMS) to illustrate:

For the past two years, the proportion of medical students choosing Family Medicine as their top field of practice has fallen from its peak in 2015, now hovering somewhere around one-third. The generally accepted target for policymakers is a 50-50 split between Family Doctors and specialists. Of course, many more doctors will end up in Family Medicine, as there are only so many spots for competitive specialties, people switch programs, and so on. But a doctor unhappy in his or her career right out of the gate is a disaster waiting to happen, trust me. Still, is three years of data enough to draw such a conclusion? Let's delve a little further back in time:

Interest in Family Medicine as a first-choice career bottomed out in 2003, at 25% of graduating medical students. Things rapidly improved for more than a decade, peaking at 38% in 2015. Perhaps the minor drop over the past few years is a blip, then, and not a cause for concern?

Wrong, and for two major reasons. First is the problem of what these doctors are doing once in practice. About 10% of Family Medicine residents will go on to pursue a third year of Emergency Medicine training. These doctors routinely become full-time Emergency Medicine specialists, or split their time between the ER and urgent care/walk-in clinics. On top of that, some 30% of Family Medicine residents plan to restrict their practices after graduation, many becoming de facto specialists in Hospital Medicine, Sports Medicine, Psychotherapy, Palliative Care, and so on. Finally, doctors' hours are nowhere near what they once were, men and women alike. It takes roughly two recent graduates to carry the same workload as a retirement-age Family Doctor, possibly more when you factor in how sick and complex the patients often are these days. This is a human resource catastrophe in the making, particularly in rural areas that have struggled to recruit doctors for decades.

The second problem is that we might be misinterpreting the decade-long growth beginning in 2004 in Family Medicine as a return to the normal state of affairs in medicine. I'd argue that it's the growth in interest that was the anomaly, not the drop of the past two years. What makes me so convinced?

The growth in Family Medicine as a career choice coincides almost perfectly with the 2004 Federal-Provincial health accord, the so-called "Fix For A Generation" that saw billions upon billions of dollars rain down on the provinces for health care. During this time, massive investments were made in Primary Care Reform, shifting Family Doctors out of solo practice and into groups and multidisciplinary teams. Family Doctors saw a major increase in income without a concomitant growth in workload, matching if not surpassing some of the less lucrative specialties. With shared after-hours coverage, the mythical work-life balance was no longer a myth, especially for doctors with young families.

2015, of course, marked the end of generous federal transfers. Awash in red ink from the post-financial crisis recession (and for the Prairies, the collapse in the price of oil), provincial governments began tightening the purse strings, exemplified by the repeated unilateral cuts in Ontario. Worse than the financial hit, though, are the obnoxious new restrictions and demands placed on Family Doctors across the country of late. From bureaucratic micromanagement, to endless hoops to jump through for changing one's scope of practice, to political incursion on professional autonomy...Family Medicine might simply not be worth the headaches and the pitfalls.

Physician leaders and policymakers should be under no illusion that this analysis is complete, but nor is it necessarily incorrect. The numbers don't lie - this is a job that at the best of times, only a third of medical students are truly passionate about. It's time to stop navel-gazing and championing a vision of medical practice that is being soundly rejected by most of Canada's future medical workforce. Financial incentives clearly help, but they don't bring things anywhere near where everyone wants them to be.

It's not the price, it's the product.

Next time: some radical(ish) thoughts on what the Family Medicine "establishment" can do to change course.

Frank Warshhttps://firstname.lastname@example.com:blogger.com,1999:blog-8638950164921086862.post-4511781612726989742017-05-15T14:00:00.001-04:002017-05-15T14:44:37.867-04:00How Does This Matter?Time away from the daily grind of practice has given me time to reflect. The results of that reflection are disquieting.

People are surprised when I tell them I enjoy working as a Coroner. My stock answer when asked why is normally a wisecrack: the patients don't talk back; I can't make the patient any sicker; and so on. The real reason I enjoy it - apart from some interesting cases - is that a death is, ironically, one of the few occasions in life when people no longer fret over what no longer matters. Taking just a moment to hit the proverbial pause button, to ponder the significance (or seeming insignificance) of a life, is calming. It fosters pensive reflection and "mindfulness", at least as I've come to understand it.

A doctor in my community died by suicide recently. It wasn't reported in the news, and I had only a passing familiarity with the deceased. I am, however, quite close with some of the late doctor's colleagues, and they have been uniformly devastated. Worse still, they've had no chance as a team to grieve. The need to pick up the pace, to shoulder the load of their dead co-worker, to serve the needs of the system, has overrun the real human needs of the people that make the system work. An insatiable beast now devours its own.

I'm reasonably active on social media. I'll happily engage in debate on any topic from alternate payment plans to zoonotic infections. But amidst all the debates, YouTube videos, blog posts, op-eds, workshops, consultant reports, tweets, counter-tweets, tweets in all-caps (e-shouting?), shockingly absent from the discussion is a simple question: how does this matter?

A computer virus - a few lines of digital code - has put the entire planet on high alert. Nowhere is this more evident than in health care, as experts and technicians are parachuting in droves to loosen the cybershackles that threaten to paralyze every wired-in hospital on Earth. Why? Have doctors and nurses lost the ability to provide care? Is the cumulative expertise of countless professionals now less valuable than the inanimate objects they punch data into? A doctor or nurse - a smart, dedicated, compassionate professional - commits suicide, and the administration sweeps it under the rug. But a computer system malfunction constitutes an all-hands-on-deck crisis? How does this matter?

This video contains a plethora of buzzwords we hear all the time: transparency; accountability; integration; governance, and so on. It's one of many that have popped up all over YouTube, slick productions that those "in the know" are supposed to be immediately grasp will make health care - a messy, human-to-human endeavor - miraculously function the way it "should". Nowhere in the torrent of jargon is anything but passing reference to the poor, the elderly, or the disabled...by far the biggest users of health care. Regardless of who holds the baton of governance, how does this matter?

At the highest levels, governments and bureaucrats squabble over responsibility, fight for control of what can't be controlled, place ever-increasing demands on workers struggling with ever-increasing rates of burnout. To the unemployed man addicted to opioids, or the frantic young woman who grew up with abuse, how does this matter?

It would be nice to think that somebody, somewhere, sometime, in a position with influence but devoid of self-interest, would take this idea to heart, would stop creating solutions where no problem lies, stop debating minutiae when no lives are at stake, and stop trying to perfect what can't be perfected. But nothing I've seen - not from government, not from administrators, not even from most health professionals - gives me reason for optimism.

Sometime in a day or two, or the next day, or the next, my phone will go off and I'll have another dead body to examine, to determine a cause of death. I'll have that momentary pause, that instance of silence between the tweets and the clicks, to think on the idea or debate of the day. I'll look down at the dead, asking how does it matter? The answer will be: it does not.Frank Warshhttps://email@example.com:blogger.com,1999:blog-8638950164921086862.post-45917493705422092612017-05-08T13:46:00.001-04:002017-05-08T13:46:39.718-04:00A New Day For The OMA!Don't you dare be sour! Clap and feel the power!

It's tempting to declare the general meeting of the Ontario Medical Association Council this past weekend an exciting one. That was certainly the vibe on Twitter, provided you could look past the meeting's interminable length, during which not even half of the motions on the floor made it to a vote (but I digress). Still, even as someone who didn't attend and only followed online, it's hard to escape the festive energy coming out of the event.

And with good reason. After the internecine battles over the rejected fee agreement with the province, and the "palace coup" that led to the wholesale resignation of OMA Executive, Ontario's doctors have appointed their new leaders. The lucky(?) folks in question are the new President, Dr. Shawn Whatley, and President-Elect Dr. Nadia Alam. If ever there were two doctors more tapped into the zeitgeist of medical politics, you'd be hard pressed to find them.

Dr. Whatley is a prolific physician-blogger (with, like, 100 times my audience, so spread the word!), who I've sparred with on more than one occasion, if you can call sarcastic tweets 'sparring'. He's been a player in the OMA for a number of years, and resigned from the OMA Board over the mishandling of negotiations and the tentative deal in 2016.

His chosen successor, Dr. Alam, was the public face of resistance to government cutbacks on physician services. She's been a fixture on Huffington Post's Canadian website, has appeared on TVO's The Agenda, and has endured personal criticism in the opinion pages of the Toronto Star.

More to the point, the two enjoy enormous popularity, at least among politically active doctors in Ontario. They'll have the full confidence of an energized, emboldened OMA Council, and will presumably move quickly to address the perceived deficiencies in governance on the part of the "old guard".

The bigger question is whether an engaged membership and renewed leadership can effect results beyond reform of the OMA itself. The doctors have yet to see anything tangible from the rejection of the 2016 offer, and there's still no framework for arbitration in place. Without secure and sufficient funding to run their practices, what do the doctors have to show for all the infighting?

There's bound to be ill will. The number of current and future doctors that openly favored collaboration over confrontation with government numbered in the hundreds, the growing drumbeat for job action is almost guaranteed to result in more discord, and let's never forget how nasty and distasteful such discord between doctors can get. There's no such thing as a free lunch, but doctors are better off not squandering what they get in a food fight.

(Confession: I have no explanation for that last metaphor. I just felt an urge to include a picture of the lunchbox.)

Nevertheless, it behooves Ontario's doctors to give their new leadership the time and support to hammer out a new governance structure for the OMA, and to take a chance on a sharper approach to negotiations with government. It doesn't mean anyone can expect a return to the bountiful days of the mid-2000s. But getting the government to take its obligations to the crises in medicine seriously - hospital crowding, patient complexity, burnout, among others - is something the new OMA leaders strongly support. All of Ontario's doctors should too.

Frank Warshhttps://email@example.com:blogger.com,1999:blog-8638950164921086862.post-2773561130538077372017-04-29T20:29:00.002-04:002017-04-29T20:29:08.425-04:00Cancer: The Problem Is PrevalenceSuccess is taking its toll.

By most measures, we do a magnificent job as a society with cancer. Over the past 30-plus years, the overwhelming majority of new cases of cancer - what we call incidence - has been a side effect of population growth and population aging. We could do better with lifestyle choices, smoking being the obvious habit we'd do well as a society to kick. Still, we should tip our hat to the fact that the incidence of breast, colon, and prostate cancers have been falling every year. Awareness and screening are doing their job.

Moreover, we're getting very good at treating it, not that cancer is a monolithic disease. Death from cancer, adjusted for age, has been falling on average for 20 years now. Death rates from prostate, colon, and breast cancers have been dropping by 2-3 percent a year for at least a decade. The majority of people with anything less than metastatic cancer (spread through the body) live at least three years, and the numbers have improved dramatically over the last few decades. So what's the problem?

The problem is that while resources, human and otherwise, have kept pace with the incidence of cancer, they haven't kept pace with its prevalence, the number of people living with the disease. In contrast to what we see with many other conditions like diabetes or heart disease, cancer patients can't be referred back to primary care (family doctor or nurse practitioner) with instructions for long-term management unless they've been cured. And if the patient's cancer is metastatic, only the cancer care system can provide appropriate management.

Consider the following: chemotherapy requires hospital or quasi-hospital infrastructure; the treatment agents, and familiarity with their effects and toxicities, are not encountered in most medical training programs; the evidence base is in constant flux; and treating the patient often involves the entire family, in particular as end-of-life care approaches. Cancer care blends the long-term and intimate doctor-patient relationship seen in family practice with the highly specific knowledge base of a medical sub-specialty. There are few doctors that have the unique combination of intellectual and emotional skills needed to thrive in the field, and fewer still that have the passion to pursue it.

We're seeing an explosion in the prevalence of cancer i.e. the number of people surviving with the disease. In the past 20 years, the proportion of people alive with breast and colon cancer has risen by roughly 45%. For lung cancer that figure is 31%, and the number for prostate cancer is well over 100% - more than double the number of people alive with the disease.

What do all these numbers mean? It means the doctors providing care for cancer patients and their families have been pushed past the edge. The Cancer Centre in London, Ontario (now my home) has seen doctors suffer life-threatening health crises in the past few years. Some doctors urgently needed time away for mental health, one of whom did not return to work. The rest are reaching advanced stages of burnout. There is no reason to suspect the situation is different anywhere else in the country.

Money won't solve anything. You could bump the pay of every oncologist in the country by $100,000 per annum, and it wouldn't change the emotional or time demands of the job. A sympathetic administration is always nice, and God knows the computer system doesn't help, but no amount of money and micromanagement will make the situation any better until a basic fact is acknowledged: if we want people to live longer and better lives with cancer, forget about the skyrocketing direct costs of treatment (though we need money for that too). No, we're going to need highly trained, skilled, dedicated professionals...and the ones providing that care now need all the help they can get. Yes, we train some family doctors to do the work, and could always train more. But that's a classic example of robbing Peter to pay Paul, stretching the pool of family doctors beyond where they are now, unless we decide to kill off family medicine as a profession...and for the record, I think that's a terrible idea.

There will always be debate about sustainability in health care, and there will always be trade-offs among public policy priorities. However, if we want our cancer patients to live longer, live better, and yes, die better, the people on the front lines working themselves to exhaustion towards that end need our help. And they need that help today.
Frank Warshhttps://firstname.lastname@example.com:blogger.com,1999:blog-8638950164921086862.post-56800927644332547912017-04-26T11:28:00.000-04:002017-04-26T11:28:29.499-04:00U.S. Politics is Professional WrestlingBlogging has been slow because of tax time and start of work on a new book, but I've seen too much in the media not to share this piece from my personal Facebook page. Yes it's off topic, but it's all in good fun.

I can only conclude it's serendipity. The most influential newspaper in the U.S. is catching on to a theory I've held since before the 2000 election, and on a day I'd planned to craft a rant about: that the best way to think of U.S. politics is to compare it with WWE (formerly WWF) pro wrestling.

How Wrestling Explains Alex Jones and Donald Trump

This piece in the Times misses the mark entirely, trying to make Trump and Alex Jones understandable by buying into kayfabe. That is, to understand why some people think the world of these real-world cartoon characters is to understand the same emotional process that makes fans of pro wrestling suspend their disbelief. Horseshit.

I've got an easier way to think about it: U.S. politics is professional wrestling, minus the physicality. The politicians and media personalities play obvious parallel roles to popular Sports Entertainment figures and conventions. Need proof?

Watch a debate between "political strategists" (i.e. hacks) on CNN, then listen to the commentary on an old Saturday Night's Main Event broadcast on YouTube. As with the on-air banter between Jesse "The Body" Ventura and Vince McMahon, CNN debates pit a mean-spirited, lying spin doctor (the Republican) against a flustered and hapless babyface who seems miserably unprepared for a fight (the Democrat). Even if the wrestling was awful - and in the 1980s, it usually was - the verbal back-and-forth provided more than enough entertainment. It's why mindless bullshit like Crossfire never stays off the air very long.

As for late-night comics or talk radio/Fox news shows, they're like the regular promo segments some wrestlers earned by virtue of their exceptional mic skills. Bill Maher's show is a political Piper's Pit. Bill O'Reilly had a virtual Snake Pit before Jake "The Snake" Roberts turned babyface (given his recent sexual harassment woes, perhaps Brother Love is a better comparison).

As for Info Wars? If the ever-incoherent Ultimate Warrior weren't already dead, I'd swear without the face paint and steroids he was Alex Jones.

But the comparisons don't stop with the media. So much of U.S. politics is pure theatrics, you can draw easy parallels between the politicians and famous pro wrestlers. Bill Clinton is like Hulk Hogan: can still charm a crowd like the best of them, but wears out his welcome quickly and is decades past his prime.

Barack Obama? The Rock (for God's sake, he even used the catchphrase "Do you smell what Barack is cooking" on an episode of Raw): boundless charisma, thrust into the top spot before he was seasoned, with an added factor of cool.

Which brings me to Donald Trump, the only politician (though I use that term loosely) to see a change in his pro wrestling counterpart. In the primaries, he was clearly "The Million Dollar Man" Ted DiBiase: obnoxiously rich, endlessly arrogant, and doling out insults like the dollar bills DiBiase would taunt and bully the audience with. (You can't help but wonder if Trump himself wasn't the inspiration for the character.)

Since the election, however, Trump has become 100% the Honky Tonk Man: bumbling, ineffectual, seen as an unworthy lame duck from the word go, and almost universally despised.

These comparisons demand almost no mental effort to make, so confident I am in the validity of this theory. Like Mick Foley says on the cover of his second book, sometimes the real world is faker than wrestling.

Frank Warshhttps://email@example.com:blogger.com,1999:blog-8638950164921086862.post-2849247130178967492017-04-17T18:52:00.000-04:002017-04-19T10:03:43.722-04:00Data is the New Cowbell...or is it a smokescreen for inaction by policymakers?

Unless you've been living under a rock for twenty years, you're probably familiar with the "More Cowbell" skit from Saturday Night Live, originally aired in 2000. Mocking the recording sessions for Blue Oyster Cult's Don't Fear the Reaper, Christopher Walken (playing the band's producer) feels that the album's title track demands an ever-more-prominent cowbell, played masterfully by a flabby Will Ferrell. The skit has reached legendary status, in some corners even called the greatest SNL skit of all time. I'm not sure I would go that far, but it's certainly among the all-time greats.

It's hard to put a finger on what's made the sketch so beloved. Christopher Walken is outstanding as always, delivering even the most idiotic lines like they're ripped from Shakespearean tragedy. The other cast members nail the cliched look and mannerisms of 70s rock stars. And more than any comic save the late Chris Farley, Will Ferrell is unafraid to make himself look like a complete ass for laughs, his belly jiggling outside a shirt several sizes too small. Then again, it could just be the immortal meme of More Cowbell.

In health care, it would appear that we have our very own flavor of cowbell, namely data. Yes, we gotta have More Data: safety data; quality improvement data; waitlist data; usage data; efficacy data; payment data; and so on and so forth, up to and including the all-important meta-data. If we're to believe the High Priests of TED Talks, data shall set us free, solve all of our problems, and make sure not a dime of taxpayer money is wasted. Is there anything more data can't do?

I'd never argue that collecting data is without merit. Post-market surveillance of medication safety is essential to making sure bad drugs are taken off the shelves. Every health care provider and facility should strive to ask itself if and how it can do better. But there are trade-offs to everything, and the present obsession with data in health care is having unintended negative consequences. It's well past time we took a more critical look at the purpose and costs of all this data collection, rather than analyzing the results ad nauseum without taking action.

The first problem is that gathering all this data generally demands the use of electronic medical/health records (EMR or EHR). Suffice it to say that the promised cost, time, and error reductions of EMRs haven't been borne out by the evidence, and doctors anecdotally would seem to agree. EMRs run the risk of eroding clinician-patient interaction, are prone to technical failures, and are a time-sucking pain to boot. Is it any wonder why doctors will half-jokingly describe themselves as very expensive data entry clerks, spending from double to triple the time on a computer as with patients? How does all that administrative time not put good patient care in jeopardy?

More importantly, is all this data we're collecting being used in good faith? I'm not talking about an individual clinic deciding that a quality improvement initiative isn't worth the bother after all. Rather, is the demand for ever More Data really just a stalling tactic? How many hospitals have had a capital project or new initiative turned down because the numbers weren't to the government's liking? It's hard not to see the push for data as a play for time, when hospitals are having to stuff meeting rooms and storage(!) rooms with patients, only to be brushed off by government officials that fret over what hour of the day to take a patient census, or even question the severity of the problem.

Or worse still, perhaps More Data is being demanded with a more galling purpose in mind: privatization. Nobody would be surprised to learn that U.S. based pharmaceutical companies have a keen interest in EMR data - what better way to find the doctors that are or are not prescribing enough of their product? But what about Canada, where the Ontario government is looking to market all that juicy data to help balance its budget? Is that what all those hours of data entry are for: to enable the power brokers and policy makers to be complicit in the deterioration of patient care, in the name of making a buck or saving political hides?

I've argued before that we've invested too much faith in the benefits of electronic records, and have paid too little attention to the price of that faith. Now we have a second-order reason to question our passion for information technology, and the supposed utopia of ever More Data: just what (and who) are collecting all this data for?
Frank Warshhttps://firstname.lastname@example.com:blogger.com,1999:blog-8638950164921086862.post-54842670047608099552017-04-10T13:38:00.000-04:002017-04-11T10:20:10.378-04:00A Theory of Relativity, Part IIIWhen doctors' work can't easily be compared, and how the government fits into the picture.

In the last post, I went over what could be thought of as the first principles of addressing doctor pay relativity. I'd like to thank readers of this website and the Medical Post for some thought-provoking questions and counter-arguments. The only way these issues can ever get hashed out is through open and vigorous debate, which can't be done in tweets, and certainly can't be done when there's a negotiated offer on the table, or when a medical the association is being sued by its own membership.

Apart from the "technical problem" of doctor pay, i.e. translating what a doctor's typical income should be into a fee-for-service schedule, there are three (really two, as I'll explain) unresolved issues:

1. How can we compare the work of unrelated medical specialties?

2. How do we leave room for incentives and disincentives in such a scheme?

3. Where does the government, and by extension, the taxpayer footing the bill, fit into the picture?

As I noted last time, the work that translates a doctor's time and effort into a comparable unit has to already been done, or at the very least provides a solid starting point to work from.

The formula is by no means perfect, and given the number of years passed, the profession probably needs to re-survey members. But the logic is sound. What was missing was a check against the actual work the doctor does: the basic scheme - (TIME x INTENSITY) + OVERHEAD - mapped onto that specialty's average workload.

That's fine for comparing one Family Doctor to another, or a Thoracic Surgeon to a Colo-rectal Surgeon, but what about comparing a Family Doctor to an Ophthalmologist? Or a Psychiatrist to a Radiologist?

If doctors are forthright about the relative intensity of their jobs, there shouldn't really be a problem. A Forensic Pathologist's hour of moderately challenging casework should pay the same after expenses as a Plastic Surgeon's. The respective hours worked and volume of cases will account for the differences in net pay. If the difference is still excessive, one of them is underpaid relative to the other.

Things naturally get tricky when we deal with doctors who have trained for different lengths of time, the obvious example being Family Doctors (2-3 years of residency) as compared with Royal College specialists (at least 5 years, plus 1-2 years of fellowship training). There might never be a satisfactory solution here, and in some jurisdictions it's led to the medical associations breaking up along GP/specialist lines. At the risk of great personal harm, I propose a starting point for long-term negotiated solution:

When comparing specialties to arrive at an equitable per-"time x intensity" net pay, start with years of post-secondary education and training as a multiplier.

A typical Family Doctor (traditionally) has a four-year Bachelor's degree, four years of med school, plus two years of residency, for a total of 10 years. With a five year residency, a typical community specialist will have 13 years of post-secondary education and training, yielding a multiplier of 1.3. Which means that if a Family Doctor earns, say, a net pay of $100,000, a specialist working the same hours, at the same intensity, should net $130,000. Again, this is net pay, with overhead, liability insurance, and professional expenses factored in. And again, this takes difficulty and intensity of work into account.

Is this "fair"? You can't know until you work through the math and compare the result with what doctors are currently earning relative to one another. While it seems at first glance like a Family Doctor's work is being discounted significantly, maybe even excessively, a doctor's long-term financial plan can't be disregarded. A three year head start on consultant-level earnings can make a major long-term difference in terms of paying down student debt and getting an earlier start on retirement savings. Does that make a GP's lifelong earnings a wash with a specialist's? Likely not. Then again, specialty residencies can be far more intense than Family Medicine training, particularly after internship. The Royal College exams also take an enormous toll on a doctor and his or her family, bordering on traumatic depending on the specialty. Family Doctors have a challenging road to full certification, but it's not as awful as the one taken by specialists. In any case, I only proposed a 1.3 x multiplier as a logical starting point. Doctors negotiating in good faith should be able to reach consensus from there.

Finally, we come to the issues of incentives/disincentives, and the proper place in the relativity discussion for government. I consider these to be connected, based on another "fundamental principle" for the relativity discussion:

Doctors should decide among themselves what their time is worth relative to one another. The price of that time is to be negotiated with government.

Right now, the divide-and-conquer strategy of governments (not only in Ontario, but in jurisdictions anywhere) is to say, "We will only pay $a for cataract surgery, but will be willing to hike the pay of a Geriatrician consult from $b to $c. Talk among yourselves whether to take it or leave it."

Under a relativity agreement, the response is, "No. A doctor's time is a doctor's time, once costs, training, and stress are factored in. The profession is united and stands behind the work put into arriving at this formula. You don't want Family Doctors making an easy buck, seeing nothing but runny noses all day? Go ahead and de-list the service, but expect to pay more for what the doctor sees in its place. You want more opioid counseling? Let's talk about a new service code. More rural doctors? We'll help you develop cash incentives."

The aim of a relativity agreement isn't necessarily to win more money for doctors. It's certainly not to impose a communist-style single wage level for all doctors. Rather, it's to do away with money as a crass motivator for doctors to choose one specialty over another or alter their practice patterns inappropriately. What I've raised in this series isn't intended as a be-all-and-end-all solution, but rather a way to prompt doctors - that have been badly divided and maligned for some time - to seek solutions in good faith, for the sake of professional harmony, and the stability of the broader health care system as well.
Frank Warshhttps://email@example.com:blogger.com,1999:blog-8638950164921086862.post-57189985389485233612017-04-04T22:34:00.001-04:002017-04-05T07:07:00.483-04:00A Theory of Relativity, Part IIFirst principles to address doctor income relativity.

The last post touched on some of the major problems with deciding how much doctors should be earning relative to one another. As a brief recap, the major barriers, apart from tribal squabbles, are:

1. Exclusion of overhead considerations in the fee schedule
2. The need to translate policy (government priorities, practice incentives) into the fee schedule
3. Determining who makes the decisions

Though it's been in the dustbin for 15 years now, the Ontario Medical Association once convened the (clumsily named) Resource Based Relative Value Schedule Commission to try and fix the issue in the past, using a pretty rigorous survey of individual specialty sections, and comparisons with the U.S. and Australia. The final document is worth a read if that sort of thing interests you, if nothing else because the algorithm the Commission developed was a good one.

Naturally, this begs the question of why the new fee schedule was never implemented. As it was well before my time, I can only speculate as to the real-time politics at play. Still, there is one thing that springs to mind: while it created a viable formula for determining what each medical service - a house call, a colonoscopy, or a heart transplant - is worth relative to other services, the report left out the reality of what doctors might actually do most days in practice.

For example, the algorithm determined that a repeat liver transplant was the most time/skill intensive medical service, deserving of the highest overall fee. No argument, but how often will a surgeon perform a repeat liver transplant? And is there room in the formula for government/public health priorities? For negotiated incentives and "win-wins", as opposed to unilateral action and laying the ground for "gaming" the billing schedule? Possibly. As I see it, though, there must be agreement around a few core principles if this exercise can end in success.

Doctors with roughly the same training, doing roughly the same intensity of work, for roughly the same amount of time, should earn roughly the same net income.

This can't be stressed enough. If doctors as a community can't agree on this as a fundamental principle - that doctors who train and work as hard as one another should earn the same pay after expenses - a medical association is not capable of representing its entire membership, and might as well be broken up.

In practical terms, it means that reaching a more equitable fee schedule involves not just the "forward" assignment of fees using an algorithm such as that developed by the Commission, but a "backwards" check against the net incomes of the typical doctors in that specialty. An example will help illustrate what I'm getting at.

Imagine a community hospital with a Respirologist and Gastroenterologist on staff. They have the same office hours, take the same share of call and hospital consults, book the same amount of vacation, and have the same number of scope days (bronchoscopy and gastroscopy/colonoscopy, respectively). Whatever math is used to determine the appropriate fees for their respective services - consults, scopes, and so on - I hope everyone doctor can agree that their net incomes should be the same within a reasonable variance (say 10-15% in a given year).

If the figures don't roughly match for a typical practitioner in each specialty, that's a signal of a lingering problem: either one specialty really does work harder than the other; some codes need further adjustment in one specialty; or, less likely, something in the fee schedule is creating a questionable incentive i.e. something about the fee schedule is susceptible to gaming. While taking advantage of quirks in the fee schedule to maximize income makes sense in the short run, it should be discouraged. It gives the bargaining adversary (i.e. government) free ammunition, both in the fight for public opinion, and for divide-and-conquer negotiating tactics.

Doctors must agree to the process, and accept the results of a relativity initiative, before entering negotiations with the government over the revised fee schedule.

As was the case with the first principle, consensus needs to be reached within the medical community, with a priori commitment to the results, before engaging with government. It's either a true medical association, or a collection of tribes with the association as a little more than a government-sanctioned mouthpiece. There will necessarily be winners and losers, but strength will only come from a unified voice. If the government wants to make investments in certain areas over others? Not if it breaks a hard-reached internal consensus. Government wants to cut fees for one specialty and reallocate the money like Robin Hood? Not gonna happen, because doctors have agreed this is what their work is worth.

The revised fee schedule must be opened for periodic review.

It's in everybody's long-term interests to make doctors' fees reflect the ever-changing realities of medical practice, new evidence, and shifts in public health needs. Moreover, changes in what doctors are paid for and how much will always leave the door open for the wrong kinds of incentives. Professional cohesion must come before short-sighted financial gain, and the good faith of the taxpayer must be respected. Thinking practically, every 8 years seems like a reasonable time frame, given the slow lead time for changes in practice to gain traction.

Can doctors put aside (admittedly decades-old) squabbles and get on the same page? Time will tell.

Next time: relativity between non-comparable specialtiesFrank Warshhttps://firstname.lastname@example.com:blogger.com,1999:blog-8638950164921086862.post-89046775325186364032017-04-01T09:26:00.001-04:002017-04-03T12:35:42.124-04:00A Theory of Relativity, Part IA look at one of the most contentious issues in all of health care.

In my early days of practice, working ER shifts in Atlantic Canada, it was easy to tell which doctors would be around for a consult by the cars parked in the staff lot. The Family Docs all drove Subarus, the Internists drove European sports sedans, and the Radiologist rode around in a $90,000 sports coupe. These docs all got along for the most part, but most communities aren't so lucky, and medical associations are notorious for internal battles between specialties over income. For all the finger-pointing and name-calling, this, in a nutshell, is what policymakers and pundits are getting it when they raise the issue of relativity: how much should one doctor be paid relative to another?

Why is doctors' relative pay such a sticky issue? Outside of the obvious - every doctor believing his or her work is underfunded and/or underappreciated, and income affects how medical students choose a specialty - there are a few wrinkles to the problem that aren't as easily fixed as you might think.

Gross vs. Net Income

First off, and this can't be stressed enough, the public is by and large misinformed about the economics of medical practice. Disclosing the incomes of salaried doctors on a "sunshine list" is one thing, but publishing doctors' gross billings - generally for the purpose of scoring political points - ignores overhead costs (rent, staff, equipment) and volume of work, that can vary widely and wildly within and between specialties.

I'm going to illustrate this, using some not-unrealistic but somewhat arbitrary numbers. Let's say a doctor bills the provincial insurance plan $250,000 in a year. Sounds pretty good, right? From that amount, though, the doctor must pay for: renting office space; utilities; medical and office equipment (exam tables, scales, computers, phones); salary for a receptionist and/or nurse; medical and office supplies (needles, bandages, paper); business insurance; and other expenses such as bookkeeper's and/or accountant's fees. Beyond that, the doctor also has to cover a variety of professional expenses: malpractice insurance; licensing; medical association dues; and conferences (including travel and hotel costs).

If it's a family doctor, upwards of 40% of that $250k can end up going to these overhead costs. Apart from salaries, which is dependent on how many hours a week the office is open, most of those overhead costs are fixed. He or she must pay for rent and licensing and insurance and dues, whether the number of patients seen in a day is 5 or 50. The net income is still nothing to scoff at, but to say that doctor makes $250k is incredibly misleading.

In contrast, a psychiatrist might take in significantly less in gross billings, say $200k. However, the psychiatrist almost certainly has lower overhead costs - space demands are much less (one room plus a waiting area), and no nurse or medical supplies need be on hand. Professional expenses are the same if not more, as specialists usually pay more for malpractice insurance and conferences. But the overall amount paid for overhead will be significantly less, say 25% for the purpose of illustration. In terms of net income, the psychiatrist is probably a little better off than the family doctor. But if the papers and the politicians only concern themselves with gross billings, who's more likely to face scorn? (Really neither at that level of billings, but I hope you get my point.)

So when you see a doctor with $1 million or more in billings - which is a lot, don't get me wrong - is that truly reflective of the doctor's net income (and therefore take-home pay)? What if that doctor's specialty has substantial equipment costs, like Gastroenterology? Higher rent because of specialized construction needs, like the lead lining in the walls of an X-ray suite? The point isn't to bemoan the pay in some specialties, it's to point out that gross billings rarely reflect a doctor's income accurately. Moreover, what happens when doctor-government negotiations don't go smoothly, and public opinion is looked to as a mediating factor?

The Billing System Problem

The second major headache when it comes to relativity is that doctors are traditionally paid by the government insurance plan on a fee-for-service basis. That's certainly changed a great deal in the past two decades, notably in teaching centers and family practice. Still, alternate funding schemes haven't solved the relativity problem per se, so much as they've changed the incentive structures - not necessarily for the better - and provided more predictable incomes in some fields of practice.

For better or for worse, fee-for-service medicine is the "legacy" payment system we're stuck with in health care, in particular for specialists. Therefore, any attempt to change how much doctors earn relative to one another must necessarily be translated to a change in the fee schedule. Even if the respective medical association and government come to an agreement on what, for example, a Pediatrician should earn as compared with a Cardiologist, determining how that balance should be reached is no small feat. Again, an example helps to illustrate this.

Let's say the government wants to increase the pay of Geriatricians as an incentive to get more trainees into the field. For the sake of argument, let's further assume there's consensus that a Geriatrician should earn roughly the same per hour as a community Neurologist, and right now Geriatricians earn 10% less. How should the money be allocated? Should the fee for consultations be increased? Follow-up visits? Should a new billing code be created for coordinating management of the patient with Home Care providers?

What happens when you go through this process for procedure-intensive specialties, like Otolaryngology or Ophthalmology? How do you determine which procedures to increase or decrease fees for? Will that significantly change how doctors in that specialty practice, creating unintended incentives to favor some procedures over others? What effect will that have on wait times for certain surgeries? It's not hard to see how the complexity of the issue can balloon beyond anyone's ability to control.

Who's the Boss?

Perhaps the biggest conundrum with the problem of relativity is the question of who should decide how much one doctor earns as compared with another, independent of what the comparative earnings should be. Is it the political party in power, acting as the agent of the general population? Is it the Ministry/civil service, acting as the executive arm of the government? Is it the profession itself, deciding by whatever internal mechanism it deems appropriate? If so, would the medical association employ an empirically derived formula? Or would the outcome flow from an exercise of power by some factions over others?

None of these answers is clear. The ready response, an appeal to basic economics, fails miserably. Health care simply does not obey the normal rules of supply and demand, which is a major reason it's funded through a socially subsidized insurance plan rather than left to market forces. Those most in need of health care are generally least able to afford it, and the public's demand for health care has been proven everywhere to be more or less insatiable.

Nevertheless, and as argued above, relative inequity in how doctors are paid creates major problems for the health care system. It can warp the choice of specialty for doctors in training, leaving some fields chronically understaffed. It's led medical associations to become little more than alliances of infighting tribes, rather than the single unified voices put forward by proper unions. However, there are better ways to address the problem than unilateral fee-slashing by governments.

Next time: guiding principles to address relativityFrank Warshhttps://email@example.com:blogger.com,1999:blog-8638950164921086862.post-60163938494931307092017-03-27T19:55:00.000-04:002017-03-27T20:13:07.801-04:00The Flame Broiled Doctor, Ep. 7: Needle Me ThisRecovered from the man-cold and sewing a pig costume for a Grade 8 play. This one is about vaccine refusal, as requested by Twitter!

Music credits:

"Slow Burn"
Kevin MacLeod (incompetech.com)
Licensed under Creative Commons: By Attribution 3.0
http://creativecommons.org/licenses/by/3.0/Frank Warshhttps://email@example.com:blogger.com,1999:blog-8638950164921086862.post-84645927499159979642017-03-13T15:11:00.001-04:002017-03-13T15:11:43.566-04:00A Man-Cold, ManPodcast episode on vaccine hesitation/refusal was supposed to be recorded and uploaded today, but I doubt anyone wants to hear me blow my nose in high-def audio. Should be ready to go in a day or two.

Frank Warshhttps://firstname.lastname@example.com:blogger.com,1999:blog-8638950164921086862.post-25804785644965137172017-03-06T23:43:00.000-05:002017-03-06T23:43:46.871-05:00"Meaningful Job Action"? The OMA Should Let It GoDoctors seem frozen over what job action might look like.

Was it just this past summer when Ontario's doctors were in the midst of a Civil War? Forced to whittle away precious time on social media, tweeting, counter-tweeting, and name-calling over the tentative deal with the province? Because some days, it feels like it happened years ago.

But as they say, the past is prologue. It's a brand new year, and with its elections wrapping up literally hours after this post is published, a brand new OMA is getting set for renewed negotiations with the province, this time with binding arbitration (apparently) on the table. For the first time in forever, there might finally be labor peace between Ontario and its doctors.

Nevertheless, the OMA hasn't been sitting on its laurels. In preparation for negotiations, they assembled a major working group around job action, to build on their online forum and member engagement. A casual glance at the OMA Twitter feed would seem to indicate some serious noggin-knockin' went on, a focused effort to come up with a comprehensive, at-the-ready plan of action should negotiations with the province break down again.

What can we glean from the OMA tweets? Well, the parameters are in place for doctors' job action, and they are underwhelming to say the least:

Let's see...job action can't get anyone in trouble with the College, can't affect quality or safety, can't affect trainees, can't interfere with emergency care, can't be unfair to one group of doctors over others, and must have active support and participation from the membership. I'm a little unclear on two things:

1) What conceivable actions - satisfying the above criteria - could possibly be enough of a nuisance to get the public to force the government back to the table (which is the entire point of job action)? After the doctors rejected two offers in 2016?

2) Would that be support from the members that have been pilloried in the press for threatening and bullying fellow doctors, the members that ousted the OMA leadership, or the members that continue to threaten the OMA with legal action over the makeup of the negotiations team?

There's an argument to be made that the plan for job action is more of a "fixer-upper opportunity" than a sure-fire way to get results. Perhaps a rock-solid plan is just around the corner after a few more consultations, a few more planning sessions, and a few more...magic trolls?

With all due respect to the beleaguered OMA, the idea of effective job action is a dud. Full-on strikes failed miserably in the past, and the only thing milquetoast half-measures will do is irk a minority of patients and confuse many more. And if the irked patients in question are irked enough to consider calling the press? Every news outlet in the country will haul out the embarrassing archival footage of past strikes faster than you can say, 'Duke of Weselton'.

Ontario's doctors have almost ZERO solidarity these days, and buy-in on job action - even halfhearted job action - will be nowhere near enough to affect public opinion and pressure the government. The doctors attempting job action will look at best weak and ineffectual, at worst...much, much worse.

For the sake of everyone's sanity, the incoming OMA leadership needs to settle the worst of the tribal infighting. It needs to assemble the toughest negotiations team possible, and give them a firm mandate for a fresh round of talks with the province. And it needs to send the idea of job action where it belongs...in the dustbin. Just let it go.

Awesomely awesome update: For the first time in my (admittedly brief) career as a blogger, I had someone call me out for my comments on both Twitter and YouTube! I always love a lively debate, and DAMN did this vlogger ever throw down the gauntlet (if you don't have time want to watch the video, I'd invite you to read my responses in the comments section).Frank Warshhttps://firstname.lastname@example.com