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@drsanjeevgoel
From #yuvalnoahharari “science Will replace natural selection with intelligent design as a chief mortar of evolution. Not intelligent design of some God above the clouds, but intelligent design of a cloud – the IBM cloud, the Google cloud.” #biohacking
#timferrisspodcast mentioned #21nocomplainchallenge - started today - using an “I’m Awesome” band my daughter @omiyag3 gave me #biohacker #sparkbiohack #biohackchallenge #biohacksummit #sparkmedicine
The future of healthcare???
Personalized, automated awesome service – this is the future of healthcare??
I thought I'd never go to McDonald's for breakfast. I had sworn to myself and my kids that this is not something we do. But I had to this morning. And came upon the kiosk version here at the McDonald's. The service was awesome they even customized my Egg McMuffin to have only egg whites. Can this be the future of healthcare?? There's no question that healthcare is lagging behind other industries that don't have the same focus on customer satisfaction. No wonder our patients get frustrated with how things operate.
Customer Satisfaction???
We need to be careful that the pendulum towards improved patient experience is not compromising patient care that in an environment of finite resources does require careful and thoughtful decisions so that all patients receive high quality and “appropriate” care.
We are being reminded daily that it is now a patient centred healthcare system.
How many of us wonder seeing a patient who is upset for not being seen more urgently for a sick note that their employer is requesting taking the spot of an elderly patient who has had difficulty accessing the phone system?
With Bill 41 (the most recent incarnation of the Patient’s First agenda) having gone through 2nd reading, this message of patient satisfaction has now become front and centre. But I think to confuse “patients being first” versus “patients experience being first” are two totally different matters.
I don't think anyone can dispute that the purpose of our healthcare system is to serve improve and protect our patient’s health but the real question is how should we achieve this this objective.
Is it through maximizing patient experience? The cursory look at the evidence (2 min google search) does support a wholehearted endorsement that improved patient experience leads to improved patient outcomes.
http://bmjopen.bmj.com/content/3/1/e001570.full
http://www.institute.nhs.uk/patient_experience/guide/making_the_case_for_improving_patient_experience.html
But there is also are dissenting opinions on whether the drive to improve patient experience leads to improved outcomes. The article below describes the focus in the US on improving “customer satisfaction” that doesn’t necessarily correlate with improved patient care - in fact they may not related at all.
http://www.theatlantic.com/health/archive/2015/04/the-problem-with-satisfied-patients/390684/
The post truth culture is here
Everywhere I look around me these days, there appears to be societal upheaval with singular narratives of victimization, fear, anger and lack of trust. I think this is a sign of our new culture - where no one appears to hold the truth anymore. We only need to look at US politics south of the border which tend to foreshadow major new trends in society at large in Canada and around the world.
This past week, a reporter suggested that perhaps Clinton’s secret service agent was carrying a “diazepam” pen. Within 1 day, this allegation got picked up by some major media outfits and was repeated on Sean Hannity’s cable “news” program. Donald Trump also began to question Clinton’s “mental health”. Before long, this unfounded allegation was blitzing the media.
A simple fact check the next day to the secret service by a reporter confirmed that it was indeed a flashlight and NOT a diazepam pen. This was reported by the New York Times and Washington Post immediately but it was too late.
Surprisingly, a sizeable minority of people in the US don’t believe this fact check done by the mainstream “liberal” media and believe that Clinton is using a diazepam pen.
What does this mean when people don’t trust reputable newspapers and sources with their information?
Who holds the truth anymore? and why is this happening?
I believe you are seeing the beginnings of the post-truth culture here in Canada as well. The advent of the internet has opened up a myriad of places for us to find our “news” and interact with others about the news.
Research has shown that the result of having access to such a diverse set of places (sites) to get our information is that we naturally seek information from sources that match our ideological basis. (we like to read from and talk to people who share our views) We are all guilty of it and I’ll be the first to admit it. Instead of leading to a more balanced viewpoint, this leads to a polarization of viewpoints and positions.
Take for example my colleague physicians who challenge the “liberal bias” of mainstream newspapers such as the Toronto Star and Globe and Mail because it clashes with their viewpoints or whose initial reaction to communication put out by the OMA, the MOH, Health Quality Ontario is hostility and condemnation.
The consequences of this polarization are showing up in the current debate between physicians on how to create a sustainable health care system. We need to be mindful of this macro societal trend and how it affects our own biases. The future of our profession depends on it.
Examining our “Oath”
My blog post a few days ago on the upcoming vote on the tentative physicians services agreement has definitely stirred up emotions on both sides of the argument of whether or not to support the agreement. Those in the “NO” side have accused me of being naive, not knowing the true nature of how negotiations work, having outdated thinking, being a socialist and of course all of this shouted out IN CAPS in case I missed their point.
Specifically the idea from the last line of the blog where I suggest that we act/vote so that we can “get down to the urgent work at hand - for our patients.” has drawn out a lot of emotion.
In my opinion, supporting the tentative physician services agreement is in the best interests of our patients. This is a risk that a rejection of the agreement could lead to further unilateral cuts to the system. I think people may argue about the level of that risk. But can one really dispute that this risk of further unilateral cuts (voting NO) is not greater than if we shifted our stance from an adversarial to a partner position with the government (voting YES). Cuts to the system, will impact our patients resulting in longer wait times and decreased access and delaying the opportunity to improve the system.
I don’t think any physician can argue that acting in the best interests of our patients is our primary responsibility - we all pledged to honour the oath we undertook in med school.
Was it just platitudes then or have we lost some of that love of why we are doing this work in the first place? I would argue that the vast majority of us are in the latter category - overwhelmed with the day to day challenges of caring for our patients, dealing with the “system” (ie working for the “MAN”) and getting our kids to soccer practice.
I believe that challenge we all face is taking a few moments to reflect on what brings us joy in our work. For me, it still is the healing interaction with my patient. Vote YES.
The choice that awaits us
As many of you are aware, we are having a binding referendum on Aug 14th at the Allstream Centre to decide whether or not to ratify the tPSA. My personal opinion from talking to colleagues and reading the social media chatter is that we are pretty divided on whether to approve or reject the agreement. It is unclear what direction the members will vote on Aug 14th.
Some of you may have read the article in the globe by Andre Picard on his thoughts of the infighting between doctors and the way some physicians have been opposing the tentative agreement. He has referred to this as “Trumpism” - the idea of blaming and attacking everyone (fire the negotiators, OMA council resign, MOH lying etc) as a strategy to persuade the general membership of the righteousness of their position to reject any agreement.
I believe Mr. Picard has made a valid observation - which has earned him the ire of the many physicians who resent being lumped in with Mr. Trump. I too have alluded to the similarities between the resistance by some physicians to the agreement and the movement to have the UK leave the EU (Brexit).
The root cause I think is a widespread populist anger by physicians…. against who they perceive are “elites” in “positions of power” making unwise decisions about healthcare.
But why are physicians so angry?
In spite of a modest raise in their incomes over the past 15 years, many physicians feel burned out, many are extremely stressed with the volumes of patients, administrative work, and new responsibilities being downloaded to them. Couple this with a health care system that is falling apart at the seams, struggling to maintain the same quality of care that Ontarians are used to. The healthcare budget is growing fast (approx 3.1% per year) faster than the provincial budget. And with an aging population, there doesn’t appear to be any respite in sight. On top of this, physicians are being asked to shoulder (through shared decision making) some of that added system responsibility of using resources wisely and efficiently. No wonder many are angry and upset!
What is the choice?
Physicians can continue to direct their anger towards the MOH and the OMA hoping for a magic fix to the structural issues that are stressing our society. A rejection of today’s tentative agreement will result in “business as usual” with more unilateral cuts as the government struggles to keep the budget intact. Some physicians will hope that it will force the government to come back to the bargaining table with more money (raises with no hard cap). How realistic is this goal based on the reality of today? It will only delay the inevitable conversation that is urgently needed to overhaul the system to ensure it becomes sustainable for our children.
OR
Physicians can take up the challenge and vote to accept the agreement (however imperfect it is), and begin in earnest the conversation, ask the difficult questions and listen to our patients about what they want - a health system that works now and in the future.
I for one am hoping we choose YES on Aug 14th and get down to the urgent work at hand - for our patients.
Sanjeev Goel
Family Physician
Wise Elephant Family Health Team
Visit us on Facebook “Creating Better Health Together” to start the conversation now
So I was sitting with my dad, Ratan Goel after an article had come out in the media about the amount of money that some physicians were billing in the Ontario. In particular the amount of $6 million dollars/year for an opthalmologist as the top biller was highlighted by the news story. My dad, who is an engineer, not from the medical profession and I believe representative of many people in this province who find this amount of income to be difficult to comprehend. Being an engineer, he took a pad and make some quick calculations - based on working this physician taking 2 weeks of vacation per year, 13 stat holidays and working every day except weekends for 10 years straight (without a lunch or washroom break) the grossly billing rate would be $2658/hr. Now of course these are gross figures and do not include the cost of overhead (staff, rent, equipment, insurance etc). But this made it very clear that when numbers only detailing gross income are put out without the corresponding expenses, it sure appears that certain docs are raking it in.
The Hidden Drivers of our HealthCare system
It has become much more clear now. What is the underlying driving force for the changes we are seeing with our healthcare system. Shortage of money due to budgetary constraints - Yes important but why the urgency now? I had the pleasure of seeing the OHRC’s presentation at the OMA council last week. What has become apparent on looking at the data is that physician supply in Ontario (primary care docs and most specialists (except for a few like psychiatry) has dramatically increased and outpaced population growth since the mid 1990′s. Over the past 15 years, physician supply increased by 37% whereas population growth was 19%. This is due to a number of issues but primarily it appears that Ontario has been a net recipient of physicians coming here from outside the province. International Medical Grads (IMGs) form approximately 40% of the new physicians per year that enter the province. Furthermore, the # of CMGs has has also increased over the past 15 years. The result has been that we went from a relatively stable rate of physicians in this province in (550 - 650 people/physician) to a dramatic fall in the past 10 years to about 475 people/physician. Based on the rate of new physicians joining the workforce, the ratio is expected to drop below 400 soon as physician numbers are growing 3x as fast as the population? The question is - is complexity due to the aging of the population growing as fast?
If not, are we prepared to address the “elephant in the room” that these facts present - a relative oversupply (to what Ontario has had over the past 50 years) and the implications, challenges, opportunities and choices that they present to us.