Ontario’s doctors want immediate solutions to health care

The Ontario Medical Association is calling on the provincial government to put money in the upcoming budget to find and keep more doctors, address wait times and improve palliative care. The OMA has a comprehensive plan for fixing the health-care system over the next few years, Prescription for Ontario: Doctors’ 5-Point Plan for Better Health Care. While working on those bigger issues, the OMA has proposed three short-term solutions it recommends the government include in its 2023-24 budget. We hear from the OMA President and a panel of expert physicians.

Transcript

Copy Transcript Copied

(Background music begins)

Georgia Balogiannis: In this podcast the Ontario Medical Association looks at current issues of interest in health care. Spotlight on Health gives you all the straight talk. We're Ontario's doctors and your health matters to us. I'm Georgia Balogiannis for the Ontario Medical Association. 

(Background music swells and fades)

Balogiannis: In this episode the OMA president and a panel of physicians discuss urgent healthcare needs, and the immediate solutions they’d like to see represented in the upcoming provincial budget.

(Background music swells and fades)

Balogiannis: Dr. Rose Zacharias is the president of the Ontario Medical Association, which represents the interests of more than 43,000 Ontario doctors.

(Background music swells and fades)

Dr. Rose Zacharias: The COVID-19 pandemic tested Ontario’s healthcare system in unprecedented ways, highlighting the cracks that existed before the virus arrived here in early 2020. Our system is in dire need of immediate solutions. Too many Ontarians don't have a family doctor, so they have trouble accessing the rest of the healthcare system. 

Waits for specialists are long, so patients can't get diagnostic tests or surgeries when they need them. Hospitals don't have enough beds to treat acute care patients, because too many of those beds are occupied by people who have nowhere else to recover. 

Emergency departments are seeing large numbers of patients turning up sicker. I've been an emergency department physician for 20 years. Never did I think we would see the day that emergency department doors would close because of over-capacity. But that has indeed been the case. Physicians and other health care workers are suffering from burnout, mostly due to administrative burden.

(Background music swells and fades)

Dr. Zacharias: There are 3 things that we can do right now to increase capacity in the healthcare system and improve patient access to care. The OMA is urging the government to include these things in its 2023/2024 budget.

Our first solution is to find and keep more doctors. We need to license more doctors to address the doctor shortage and keep the ones we have by reducing the administrative burden. We support the government plan to introduce a practice-ready assessment program for physicians who graduated from medical school and practiced abroad, but we want to move quickly and increase the number of doctors being assessed.

We also need robust data about our physician workforce, so we can plan wisely for future needs. This planning, this modeling and planning, is so important.

Alleviating the administrative burden must also be an urgent priority. At least 1,000,000 Ontarians don't have a family doctor, and that number is expected to grow as a large number of physicians approach retirement age and others retire early or scale back their practices because of burnout. 

Family doctors provide comprehensive cradle-to-grave preventative and primary care, and they're the gateway to the rest of the healthcare system, including access to specialists, diagnostics, and treatment. Yet many consider the current situation to be a crisis.

(Background music swells and fades)

Dr. Zacharias: We need to address the underlying issues and bring joy back to medicine. The second solution addresses wait times. We need to create a centralized waitlist and referral system for surgeries and procedures. This would allow patients with the greatest need to go to the front of the waitlist. Wait times were too long, even before the pandemic, with some well above the government's own guidelines. 

Sick patients don't have time to wait for diagnostic tests, surgeries, or treatments. Many are frustrated. Many are in pain and unable to work, and their condition may be deteriorating. Some may be depressed or anxious and unable to cope. Their lives are literally on hold. 

Our third solution is about moving more care out of hospitals and into the community. The average cost of one day in an acute care bed in Ontario is twice the cost of a hospice care bed, and more than 10 times as much as it costs to care for that same patient in their home. We're calling for the creation of 500 new hospice beds. 

We're also recommending all long-term care homes in Ontario be equipped with the ability to do certain basic diagnostic tests and treatment, like blood work and urine tests, or the ability to administer intravenous medication and fluids. This could prevent unnecessary transfers to hospital. We have submitted our detailed proposal to the Ontario government and we hope to see our recommendations reflected when it tables the provincial budget before the end of March.

(Background music swells and fades)

Balogiannis: Dr. Chandi Chandrasena is the chief medical officer of Ontario MD, which provides Ontario doctors with the training and support they need, to improve patient access to care and patient outcomes.

(Background music swells and fades)

Dr. Chandi Chandrasena: Ontario MD has done a lot of work in examining the role of technology and how we deliver health care. But I'm always really careful to say that technology in itself doesn't cause burn out. What causes burn out is when the technology is not integrated into the workflow or it's not developed with that end user in mind or it doesn't integrate seamlessly with other technology.

I've transitioned from paper to EMR — electronic medical record. And over time I've added a number of other digital tools in my clinic. I feel that the delivery of health care has changed with technology in some ways for the better, but it’s also increased that administrative burden. These are the tasks that have fallen on physicians and clinicians, that perhaps in the past could have been delegated to others, or were not necessary.

It could be not having access to your patient's medical information when you need it. It could be the time needed for charting or documentation, or just sorting through the large number of medical reports and tests that are received daily. There are many tasks that can be automated with the right technology and the right workflow but it takes stakeholders working together to make these improvements so that the technology is actually a benefit and not a burden.

Ontario MD has recently worked with the Ministry of Transportation to develop digitized or electronic forms to help streamline this process, so they're always up to date, and they can bypass the facts. But for an E form to be truly useful, it can't just be a digital version of a paper form. 

It has to be developed in a different way. It has to include the end user and it has to be integrated into technology. So more eforms need to be developed but the process has to be perfected to be done properly. So, done properly, technology works well for physicians and their patients.

(Background music swells and fades)

Dr. Chandrasena: Let's talk about access to medical information within a patient circle of care. So, it's that frustrated patient who has to tell that same story over and over again — their medications, their past medical history, well, really everything.

Because their systems aren't integrated, they don't talk to each other.

Oftentimes I might send a patient for another test that was just done. What a waste of time for them. Or the medication. I need to know what's been prescribed so I don’t over-prescribe. So there's a real need for this integration. 

It means that the patient's information is available to whoever is providing the care to that patient at that time. It saves physician time and effort. It reduces that administrative burden. And it really avoids that frustration that patients have when they have to repeat their history and repeat their story many, many times.

(Background music swells and fades)

Dr. Chandrasena: The OMA burnout task force, they developed a white paper called Healing the Healers. It's a system-level solution to physician burnout. In it they discussed five changes at a system level. Two of them are related to the work of Ontario MD, which is around that administrative burden and integration of technology. 

One solution is using a medical scribe. So this is a person who's trained to be present during the appointment to be that note taker to do those tasks. And they've been found to improve efficiency, reduce administrative burden, and reduce burnout.

But what's really exciting is what's coming down the pipeline — artificial intelligence.

The technology is early, but it's being developed. But once perfected, it could automate these administrative tasks and be integrated into our records. 

So imagine a Siri or an Alexa, who's writing the notes. I would much rather listen to my patient and not be distracted by the technology or the administrative tasks or the hours of work I'm going to have when I go home. But this requires funding, training, ongoing support, to adopt these technologies properly and to create that capacity that we so desperately need right now.

(Background music swells and fades)

Balogiannis: Dr. Jim Wright is executive vice president of the OMA's Economics Policy and Research Division. He is a pediatric orthopedic surgeon, who spent much of his career at Toronto's Hospital for Sick Children, where he served as surgeon-in-chief.

(Background music swells and fades)

Dr. Jim Wright: In reducing wait times, we have two solutions. The first, which has received a lot of attention is the idea of moving some of the lower acuity, surgery and procedures into the community. But what I wanted to talk about is the second solution, which is called centralized waitlist. And I want to talk about it from the perspective of a patient.

Pretty much all of us would have a family doctor that looks after our needs on an ongoing basis. But, once in a while, the family doctor needs to refer to a specialist.

Well, that family doctor then has to send a referral note which would go to a specialist and unfortunately the system, because specialists are overburdened, sometimes they can't accept that referral. 

Well then, that comes back to the family doctor who then says, ‘okay, I need to find another person’ and they send another letter. Well, that letter may come back. That's enormously frustrating for the family physician. I'm sure it's frustrating for the specialists. But who it's really frustrating for is the patient, because the first wait is the wait to see the specialist. 

So a centralized referral system as a first step could actually take that referral and it would be their job to find a doctor. It's not this back and forth, back and forth, back and forth. So that should dramatically — what we call wait one or W1 — that should shorten that list, and also minimize the frustration for the physician and reduce burnout, but mainly from the patient's perspective. They need to see that specialist.

(Background music swells and fades)

Dr. Wright: The second way in which the centralized waitlist may be helpful is some of these specialty centers have been set up across the province. So the family physician realizes they need the expertise beyond what they have. Well, some of these centralized can say, ‘well, maybe you're not quite ready to see the surgeon’. So they can triage that and again that helps the family doctor and gets the patient to see the right specialist in the shortest period of time.

The third piece, and this is the most exciting, is that family doctors often don't know who has the shortest waitlist. Wouldn't it be great if the family physician could send that referral, and then the referral could go to that specialist who happens to have a short wait list? We call this W2.

That's the step between ‘you've seen the specialists, and you want to have your procedure’, you want the surgeon or proceduralist who has the shortest time between when they've seen the patient and they actually can do the total knee replacement, or the arthroscopy, or the tubes in the ears for children, whatever it is. 

Those are the kinds of things that we want to achieve with the centralized wait list, which is extremely exciting. It's going to require some investment and some coordination, but we believe it can be done, and we think it will substantially improve the access for patients but also reduce some of the frustration for physicians.

(Background music swells and fades)

Balogiannis: Dr. Brian Berger is the physician leader in the department of Continuing Care, Rehabilitation, and Palliative Care at MacKenzie Health, and medical director of Hill House Hospice. He is also the former chair of the OMA's Palliative Medicine section.

(Background music swells and fades)

Dr. Brian Berger: My philosophy is that a society is best judged by how we care for our most vulnerable patients. And I could argue that the most vulnerable patients that we do see are those who are dying. If we can provide support to them in a very compassionate caring basis that says a lot for the care in our society. 

Palliative care really is all about comfort care. So it's the physical, emotional, social, spiritual comfort, and in essence it really shows respect for an end-of-life journey.

Originally palliative care was all about care right at the very end of life, and people may still think of it like that. But more and more, we tend to see patients early in their trajectory, when they have got what appears to be an end-of-life diagnosis, and from very early on we can help them steer through some of these comfort milieus. So we do our best as palliative care practitioners to help them with that.

And what I really see is a major issue is the patients who become more acutely palliative in terms of their end-of-life diagnosis. Things are really deteriorating for them. They're unable to be managed at home for a variety of reasons, and they land up coming to a hospital, and they land up stuck in acute care. That amounts to a cost of around $1,100 a day. 

The question really is, is why are they stuck in acute care? I can share with you, that's not certainly their choice. If people had a choice where they could always be best cared for, many times it will be home. But in order to send people home, you really need good 24/7 coverage for those patients, and much more hands-on care. 

Home care, at the moment, really costs around a $100 a day. What a comparison to $1,000 a day! The thing is that at the moment, and I see it every day, families are expected to carry a lot of the care burden. And it really saddens me sometimes to see and hear from families that they are becoming the nurse or the personal support worker, as opposed to being the wife or the husband, or the partner, or the child, or the grandchild. And how sad is that if they have to be feeling that burden? 

I feel that the more we put into home care support, recognizing the patients’ and families’ needs, we can land up sending many more of those patients that are occupying an acute care bed to home. In our area, patients who are entitled to the absolute maximum of home care, which is 8 hours a day, is really reserved for people in the last week of life. 

Well think about the patients with ALS, with severe end-stage Parkinson's disease, etc. Very, very difficult for them to be cared for in the home framework, because they may not be the last week of life, but their care needs are very high.

(Background music swells and fades)

Dr. Berger: People may say, ‘what about hospices?’ This is a wonderful alternative to being in an acute care bed in a hospital. A hospice is really 24/7 coverage by a nurse and personal support worker, often volunteers, in a beautiful home-like environment. Making the family once again, having to be the family and the nurse, etc., helping with the nursing care. Hospices are great. 

Unfortunately, we in total will probably have around 500 beds in the province. If we work on the ideal which is around 10 hospice beds for 100,000 population, we should have around 1,000 beds to cope with the volume that's needed. And we see that every day. 

Hospices are forced to turn away patients with prognosis maybe a little longer than a week or two or three, etc. And once again those people are stuck in acute care beds. So, by having more hospice beds, you may be able to take people with a little longer end-of-life trajectory, make that comfort that much better, and really help the situation tremendously. 

The other problem with hospices is although hospitals are somewhat close to 100% funded by the ministry, government funding only funds. 50% of hospice costs. Well, that's an enormous burden on hospices to raise money from their communities. Communities that may not have a lot of financial resources are struggling much more to raise funds for their hospices, and one or two have had to close over the last few years. 

If more funding was devoted to hospices, we'd be able to clear out those patients from acute care. Those palliative patients will be getting, I would argue, a better form of care for their situation. And patients waiting in the emergency could go into the right appropriate, acute care bed, where they need that kind of care, instead of being lying in the emergency as well. So I think that's a win-win situation for a lot of people.

Finally, we can also think of patients going into a palliative care unit at a hospital.

It's a wonderful place for people to be at the end. I would argue that that should be supported in each hospital setting as an important place to be. And very finally, long-term care is a good option for people to go back to. But you have to have the right supports in place — enough amount of staff. 

You have to have a philosophy with long-term care, once patients like this — because many are refusing patients, saying that their prognosis is too short, and the patient continues to lie in the acute care bed. So long-term cares are a very good option, but they need a lot of support as well.

(Background music swells)

Balogiannis: This podcast is brought to you by the Ontario Medical Association and is edited and produced by Jodi Crawford Productions. To learn more about the Ontario Medical Association, please visit oma.org.

(Background music fades)