SpankyMcFarland

Now that QEII has gone we should become a republic but I doubt we can manage it.

In my province we persisted with an archaic health records system long past its sell by date until it underwent a massive cyberattack. Over the decades, security was only one of the ways it became unfit for purpose. The company did not show enormous interest, let’s say, in our suggestions for improvement of the lab module. I suspect they were banking on the fact that it would be huge trouble for us to change to another vendor. https://www.cbc.ca/news/canada/newfoundland-labrador/nl-opposition-meditech-cyberattack-1.6251420 So, speaking strictly for NL, we are not optimally organized on information systems.

Firstly, quoting a crazy person like John Bolton isn’t going to win over too many sceptics. Secondly, how many Iranians has the US and its allies (one in particular comes to mind) killed on Iranian soil in the last forty years?

What percentage of the Iranian population support the regime? Given what we’ve seen in the West of late, I suspect that a non-zero number of undereducated religious nationalists think that way over there.

That Alaskan election seems to have been conducted in an unusually good spirit: Sarah Palin complimented Mary Peltola as 'a real Alaskan chick' in texts after the Democrat beat Palin in a special House election Congresswoman-elect Mary Peltola said she feels 'fraternity and comraderie' with the opponents she defeated and will face again in November. www.businessinsider.com Political opponents do not have to be enemies.

I think it undermines what she’s saying. We’re focusing on the words, not the issue she is addressing.

So it looks like we need armed personnel around all ministers now. That’s where this is going if people can’t control themselves. This gentleman was allowed to get way too close. Needless to say his views on other matters are hardly surprising: https://thetyee.ca/News/2022/08/27/Attack-Freeland-Rage-Farming/

I wouldn’t buy a beer for anybody who did that to any politician. There’s no possibility of civilized discourse if people behave in such a disgraceful way. And no person should be allowed to demonstrate outside any public servant’s house. It’s thuggish ‘we know where you live’ behaviour.

Some sensible proposals, as usual, from Michael Chong: https ://www.thestar.com/politics/federal/2022/08/24/unbelievable-weve-got-to-this-point-canadas-prime-minister-should-have-less-power-mp-says.html

Patients are in no position to be customers but that role could be delegated in the system to, say, GPs if we had capitation across the country. On a more general note, I think a chief nursing officer is one small step in the direction of a more coherent national health care policy. https://www.ctvnews.ca/health/canada-names-new-chief-nursing-officer-reinstating-role-to-advise-on-health-crisis-1.6038568

I think moving to a purely private system in Canada would be too big a change. Australia, for example, has a mixed system. http://www.familydoctorsforontario.ca/wp-content/uploads/The-comparative-performance-of-the-Canadian-and-Australian-Health-Systems.pdf

I think the capitation model can bring some progress esp. in large urban centres where there is the possibility of competition between hospitals. FPs can see where services are being provided well and quickly far better than governments can. They can distinguish concise, accurate reports from waffling and good clinical care too. They would be useful gatekeepers to protect the interests of their patients and ensure money is being spent more efficiently. https://hbr.org/2016/07/the-case-for-capitation One big problem in health care is the huge asymmetry in expertise and power between patient and provider, i.e. buyer and seller. It’s not like purchasing a washing machine. You may have one chance to get your care right and Google doesn’t really help that much. This is why an unrestricted private system is both bad and highly inefficient. Unscrupulous doctors can sell you all sorts of procedures that are unnecessary or even harmful, a perennial problem in the US. Our public system is well worth preserving as the basis of health care here if it can be tweaked.

Sorry, I’ll provide some clarification. Actually, Andrew Coyne does a better job: The crucial distinction to be made is around who pays. At the moment we have loads of examples of publicly funded, privately provided care. Indeed, technically, many physicians run private companies for tax ‘efficiency’ purposes within the publicly funded system. But large corporations have also gotten in on the act which is different, e.g. diagnostic services. Another scenario would be allowing groups of doctors or even hospitals to compete for contracts to provide services within the public system. Imagine if GPs had a bigger say over where health care spending on each of their patients occurs via capitation: https://www.theglobeandmail.com/opinion/article-private-delivery-of-health-care-yes-please-private-funding-no-thanks/ Basically, the premiers have run out of money and they’re looking for ways to stop this monster cost train bearing down upon all of them. In the first instance we should try to shore up our Medicare system. I, for one, would be prepared to pay a substantial monthly fee that goes directly to health care. However, unless there’s some breakthrough in thinking and spending, I think we will soon see a parallel private system for medically necessary services in this country.

I’m a medical consumer too so why should I complain if my health care options improve? And that’s an ‘if’ we have to watch out for. As I see it, there are two basic options: 1. Private delivery of publicly funded care. Really just an extension of what we have already. 2. Private delivery of privately funded care. I think this is coming in many parts of the country. The provincial health care budgets cannot go up any further so people are going to have to pay out of their pockets. I wouldn’t have been keen on this ten years ago but I’m afraid I see little option now in my part of the world. There are many pitfalls with this - my relatives have experienced them in the UK. For example, if you let one surgeon run both the private and the public list, then extortion can easily occur where people are forced to pay for timely care on the private list. We should watch out for that but I think it’s coming anyway.

Doug Ford met the Maritime premiers on the health care crisis: https://www.thestar.com/politics/provincial/2022/08/22/status-quo-is-just-not-working-doug-ford-rallies-maritime-premiers-in-push-to-change-how-health-care-is-delivered.html There is agreement that something has to change, but what? More private delivery of publicly funded care or, dare I say it, more outright private care? I think the latter is coming.

In the current environment, I have serious concerns about my province moving to a rigorous national standard on all matters licensing. Given the highly uneven playing field in Canada with regard to pay, conditions and the allure of the big city, I can’t see how we will compete with the likes of Ontario under this new regime. One set of national standards would be good in a genuinely unitary state but in our fractured country it will lead to even more brain drain. It’s like a heavyweight telling a bantamweight to fight fair. There’s only one possible outcome.

I think one of the problems I have with the way we assess FMGs is that it doesn’t fully reflect the modern world, esp. with doctors who have been qualified for a decade or two. We live in an age where knowledge becomes obsolete faster than ever and is no longer restricted in its distribution. I can listen to better lectures online any day of the week than I ever heard in medical school or in my residency. Judging the experienced doctor more on their individual skills and knowledge is expensive and inconvenient but I think it’s worth the trouble. Just my opinion.

1. Title by me? One thing I hope we can agree on is that I did not start this thread. The title is not mine. 2. If what I wrote was interpreted as arguing for no regulations or lax regulations on FMGs entering Canada then I didn’t do a good job. I would never argue for that. Most FMGs would welcome a more stringent and more expensive process that delivered a swifter decision one way or the other with less paperwork. If they already live in Canada and some minor deficiency is noted, e.g. a surgeon didn’t get enough training in their internship fifteen years ago in something that is considered vital now, then it should be possible to do a few weeks of training in Canada to sort that out. At the moment it often isn’t. 3. We are a developed country which should be able to provide access to timely medical care to everybody. How exactly that is done is up to Canadians and their governments. We’ve been through some of the options, which will probably be needed in combination, and they all come with their own costs and benefits. One of those options is more FMGs - which we can accept or reject. However, the basic principle that everybody should get basic care in this country should be non-negotiable. We can’t admit defeat on that and in the next breath have the gall to claim we have universal medical care and look down our noses at the Americans.

My own personal risk analysis is simple. I know the foreign institution where my doctor trained and I know I’m far better off with a doctor than without a doctor. For the country, it’s a far more difficult thing to figure out. What I would contend is that, one way or another, every Canadian deserves timely access to medical expertise. As the article on Fogo mentions, we have health hubs here for those without FPs that you have to phone into to get an appointment. Needless to say all the spots go rapidly in the morning once the lines are open and you can bet your bottom dollar that those most in need often aren’t nimble enough to get those spots. Even a Neanderthal like myself can see that technology could help with this particular problem. We run golf clubs better than this, for crying out loud!

Here’s the reality of health care on an island near me: On call for an entire year! And when you send somebody to the local hospital, you’re the guy you’re sending the patient to. I’m amazed the doctor stayed so long under such conditions. Another of my bugbears - our health hub ‘system’. https://www.cbc.ca/newsinteractives/features/two-week-stint-on-fogo-island

Hold on. As you know from your own industry, risk is ubiquitous and cannot be fully eliminated. The airline industry has done a far better job than health care on examining every single element in flying planes to see where that risk is and to reduce it. We have only just started to be as rigorous and systematic as you have been. What I am saying is that risk in medicine goes with the territory. If I decide to see my doctor today, the risk starts with me getting in the car and driving to the clinic. When he sees me he may miss something that eventually harms me or he may actually do something that harms me. That’s the bargain we all sign up to when we see a doctor no matter where our doctor comes from. My new GP happens to be foreign trained but I count myself lucky to have anybody in view of the fact that 37% of people in my health region don’t. So is there is a non-zero risk seeing any doctor. In my previous post, I was merely conceding that there are added risks with foreign trained physicians over and above those with our own CMGs (and Canadians who train abroad, a special category of FMGs who have already received much of their education in Canada). One big problem with FMGs is that they have highly variable training and it’s entirely up to Canadians to decide how to manage this extra risk. An extreme position would be to eliminate the risk entirely by banning FMGs. This would have the benefit of removing the possibility of some of the incidents we have seen with FMGs but it would also carry a significant cost. For example, I would lose my doctor. For me the risk of undiagnosed illness would then shoot up. I’m simply not prepared to to spend my days in the ER, wasting the valuable time of ER staff, for chronic medical conditions, nor should I have to do this in a developed country. So I believe some sort of middle course is sensible - FMGs have a role to play in our health care. If we are going to continue to allow FMGs in, I would merely suggest that there should be some shift in emphasis to focus more on current skills, especially with experienced physicians. That’s just my random, internet crazy person opinion.

Sure, that’s a problem. There’s a risk giving any doctor a licence. This applies to home-grown graduates, Canadians who go abroad to train, and outright foreigners. Disturbed and dangerous medical students and trainees slip through the cracks all over the world - indeed, we had two examples of that in Newfoundland some years ago. There’s also a non-zero risk in renewing any doctor’s licence. What about older docs, both Canadian and foreign-trained, an area that is deserving of considerably more scrutiny? Most of us must have heard of doctors who were past their best but still hanging on. With all that said, the risk with foreign doctors is intrinsically much higher than with CMGs. Their range of training is enormously varied, with national standards in some countries virtually non-existent. The only way to eliminate all risk from foreign trained MDs is to exclude them completely from the system. If we allow them in, it’s going to cost a lot of money to assess them properly and some bad apples will still get through. There’s no denying that; there have been some terrible incidents. It’s up to Canadians to decide whether the risk is worth it and how much we should spend to try to bring it down to an acceptable level.

I want to make the process easier, not the standards of clinical skill required. There’s a lot of needless delay and duplication even when applying to one province. What’s needed changes greatly as a doctor matures. A young foreign graduate should be carefully looked at in every aspect and their med school training is important. With an older specialist decades into a career, time has a way of revealing what is up in terms of both character and competence. Have they stayed in just a few jobs, have they published, what’s the general feeling about them in their specialty? These were the guys we were looking for, people ready to lead and put down roots. We have a lot to learn from the airline industry on QA and we’re only starting with Just Culture in medicine.

Here’s a simple scenario for anyone to think about. You’re the new Health Minister in NL and this is your first question: Journalist: 25% of people in Newfoundland and Labrador have no GP. What is your plan to deal with this? I don’t know about other provinces but down here I haven’t seen detailed, granular league tables similar to those CIHI produces for health parameters on how we are doing with recruitment and retention by health region, community size, IMG/FMG, age cohort, gender, specialty etc. that are updated in real time. Trends would be a lot easier to spot then. Instead we limp along until a big loss of doctors somewhere is noticed by some member of the public and the minister has to make reassuring noises. It’s a bit like coastal erosion. Actually, in my health region the figures are even worse: 37% don’t have a GP! I’d like to say this can’t go on but that would ignore where things seem to be headed. Some research in Canada suggests that rural electives by FP residents increase the likelihood of rural recruitment. However, our local experience with this has been disappointing. We’re not succeeding there.

Retention of IMGs isn’t just about pay. There are many other lifestyle factors involved. Here’s an example of a Newfoundland town that’s trying to address one of those key issues: https://www.cbc.ca/news/canada/newfoundland-labrador/gander-mosque-doctors-1.6554703