A Message from Southern Alberta Doctors

The following is a letter delivered late March 29 2021 to Lethbridge Media outlets on behalf of the undersigned physicians:

We are writing to publicly express our concern about the recent increase in COVID-19 cases in Alberta, and specifically Lethbridge and the surrounding area. As of March 27th, we have 508 active cases in the City of Lethbridge, and the numbers have been generally increasing. At the height of the second wave, we never reached or exceeded 300 active cases. It is important to remember that COVID hospitalizations, ICU admissions and deaths always trail increases in cases by 2-3 weeks. ICU demand can stretch even longer due to the prolonged stays required by the seriously ill. Although not widely made known, the Lethbridge ICU was at capacity during the tail end of the second wave, long after case numbers had been dropping for some time. It is a disease that is stubbornly persistent when it hits hard. Alberta has seen a consistent case fatality rate of 1.4%, and a hospitalization rate of 4.4%. A simplified projection suggests that each day we add 50 cases, we can expect to need another 2-3 hospital beds within the next 2 weeks, occupied for 3-10 days depending on severity. Our ICU also needs to cover severely ill patients in surrounding rural areas. As of last report, the south zone currently has the highest per capita rate of COVID hospitalizations in the province, and 10/14 ICU beds occupied by COVID patients.

We are all tired of the pandemic, the restrictions and the overwhelming impact it has had on our lives. Fortunately, with the vaccine rollout progressing the end is in sight, but we are not there yet. We ask the public and government officials to recognize that individuals and the health care system are both still at risk. Southern Alberta has been fortunate thus far to have escaped much of the damage this virus has inflicted elsewhere around the world, and that is in large part thanks to the collective efforts of so many of our citizens who have made safe and smart choices to protect themselves and others. The unprecedented lifestyle upheavals we have experienced over the past year are the reason we have escaped many of the dire projections of the past.

While we are fortunate that many of our most at risk of death seniors are now vaccinated, it is important to remember that the average age of a COVID ICU patient in Alberta is 58. Those with the most severe baseline health and fragility are often not admitted to the ICU as intensive care can be too invasive and taxing for the body to meaningfully recover from. The ICU is primarily a tool to keep alive those who are young and healthy enough to recover from a severe infection once it has run its course. If the ICU is unable to meet demand, those who could otherwise be kept alive are at greater risk. While evidence suggests the vaccines still prevent severe disease from the ever expanding variants of concern, there is still not enough data to know how well they prevent transmission. For that reason, even vaccinated people are currently still required to quarantine and miss work if exposed. This means we are still at risk of hospital staff shortages due to occupational or community exposure to COVID-19. Furthermore, in Alberta, family physicians and many other community (non-hospital) based health care providers still have not been offered vaccination. They continue to work at risk in a community with rising transmission.

We do not wish to instill fear, but do advise ongoing caution, and wise decisions. We join our voices to those of other physicians encouraging the provincial government to do its part to get Alberta over the finish line without an even larger third wave, vaccinate all front-line health care workers, and prepare for the additional health care resources that may be required in the south zone. Regardless of government action, we ask everyone to continue to do their part to protect themselves and others by taking efforts to limit community transmission. If we continue to look for ways to be safe, rather than for loopholes and exceptions, we can protect lives and livelihoods over the next few months. We know COVID-19 is most likely to spread where people are gathered in close proximity, unmasked, indoors for prolonged periods of time. Making efforts to distance, wear a mask (2 or 3 layers are superior to 1), meet outdoors where possible, and limit time together where any of those is not possible will reduce the risk of transmission. Limiting contact with individuals outside of a small cohort will also break community transmission chains.

Thank-you to all of you who have been doing your part this past year to combat COVID-19 and support the health care community. We know it has not been easy. Please keep up the efforts to prevent our community and hospital from being overrun by this virus. The vaccines are safe and are the best path back to normalcy. Please receive whichever one you are offered as soon as you are able. Eligible health care workers have happily received theirs in large numbers, and those not yet eligible are anxious to as well. The end is in sight, but let’s finish it properly and save lives.

With concern,

Dr Tavish Barnes MD FRCPC (Critical Care)- Lethbridge

Dr Parveen Boora MD FRCSC (General Surgery)- Lethbridge

Dr Richard Buck MD CCFP(EM) (Emergency Medicine)- Lethbridge

Dr Susan Byers MD CCFP (Family Medicine)- Lethbridge

Dr Rhona Capisonda MD FRCPC (Pediatrics)- Chinook Pediatric Clinic

Dr Tara Daley MD FRCSC (Obstetrics and Gynecology)- Lethbridge

Dr Ehi Eyayi MD CCFP(EM) (Emergency Medicine)

Dr Kevin Foster MD CCFP(EM) (Emergency Medicine)- Lethbridge

Dr Tony Gomes MD FRCSC (General Surgery)- Lethbridge

Dr Charlotte Haig MD CCFP (Family Medicine)- Lethbridge

Dr Nic Hamilton MD CCFP(EM) (Emergency Medicine)- Lethbridge

Dr Andrea Hargrove MD CCFP (Rural Family Medicine)- Taber

Dr John Holland MD FRCPC (Pediatrics)- Chinook Pediatric Clinic

Dr Cathy Horsman MD CCFP (Family Medicine)- Medicine Hat

Dr Rozemin Kizuk MD CCFP (Family Medicine)- Lethbridge

Dr Peter Kwan MD CCFP(EM) (Emergency Medicine)- Lethbridge

Dr Jay Malach MD FRCSC (Obstetrics and Gynecology)- Lethbridge

Dr Bilal Mir MD CCFP(EM) (Emergency Medicine)- Lethbridge

Dr Victor Onyebukwa MD CCFP (Family Medicine)- Lethbridge

Dr Lee Oviatt MD FRCPC (Respiratory Medicine)- Lethbridge

Dr Paul Parks MD CCFP(EM) (Emergency Medicine)- Medicine Hat

Dr Kristy Penner MD CCFP (Rural Family Medicine)- Crowsnest Pass

Dr Karen Robertson MD CCFP (Family Medicine)- Lethbridge

Dr Vanessa Rogers MD CCFP (Rural Family Medicine)- Crowsnest Pass

Dr Hollis Roth MD CCFP(PC) (Palliative Care)- Lethbridge

Dr Sharon Rowan MD CCFP (Family Medicine)- Lethbridge

Dr Ghazala Saif MD CCFP (Family Medicine)- Lethbridge

Dr Melissa Setiawan MD FRCPC (Anesthesia)- Lethbridge

Dr Parisa Shamsi Shahrabadi MD CCFP (Rural Family Medicine)- Crowsnest Pass

Dr Gregory Smith MD CCFP (Rural Family Medicine)- Raymond

Dr Julie Smith MD CCFP(EM) FCFP (Family Medicine)- Lethbridge

Dr Sean Spence MD FRCPC (Critical Care)- Lethbridge

Dr Adrienne Stedford MD CCFP (EM-PGY3)

Dr Michelle Thibodeau MD CCFP (Family and Hospital Medicine)- Lethbridge

Dr Jessica van der Sloot MD CCFP (Family Medicine)- Lethbridge

Dr Iffat Waheed MD CCFP (Family Medicine)- Lethbridge

Dr Nicoelle Wanner MD CCFP (Family Medicine)- Medicine Hat

Dr Dionne Walsh MD CCFP(PC) (Palliative Care)- Lethbridge

Dr Adam Wiebe MD CCFP (Family and Hospital Medicine)- Lethbridge

Dr Sean Wilde MD CCFP(EM) (Emergency Medicine)- Lethbridge

This Pandemic Sucks and So Does Fighting it. No Conspiracy Necessary.

Here we are about a year into the COVID-19 pandemic, and amidst the deluge of statistics, warnings, changing guidelines, protests, conspiracy theories and the continued disruption of our lives, I don’t think everyone feels like they are “in the same boat” anymore. And why would we? The pandemic experience has been different for everybody, and pleasant for nobody. We have all experienced it through the unique lens of our personal experience, personal belief systems, media preferences, and view of the consequences from wherever we are personally standing. With that in mind, I would like to acknowledge the common ground we still share. Whatever your opinion on lockdowns, masks, protests, freedom, public health, economic policy, vaccinations, government competence and overreach, let’s take a moment to agree that this whole experience sucks, and no one likes it.

Think of all the things you miss from late 2019- the changes that make you sad or angry, the things you can’t do and are missing, the people you can’t see because of safety, restrictions, or because they are gone. The losses of income, opportunity and experience are real. Kids are missing out on milestones in their lives, and friends and families are isolated from one another like never before in most of our lifetimes. I feel confident in saying that the person on the other side of the political aisle, the confrontation at the grocery store, or the stranger in the online debate is almost certainly missing the exact same things. Human beings do not thrive in isolation, families cannot succeed in continual economic turmoil, and communities cannot experience normalcy when an invisible deadly threat can strike us or a loved one from a friend or stranger without warning. I think we deserve to give ourselves and those around us a healthy helping of empathy and understanding.

This does not mean we need to accept misinformation, or irresponsible and selfish behavior. It also does not demand a blind and unquestioning acceptance of every decree of government or health authorities. It does ask us to start our questions and our discussions from a place of mutual understanding and respect for the experience and perspective of another. If you do not own a small business that is failing and are at risk of losing your house, then recognize you may not be as intimately aware of the crushing economic consequences of shutdowns as someone who is. If you have not lost one or more loved ones to a sudden and unexpected death with little chance to say goodbye, consider that you might not be able to appreciate the danger and personal anguish of the pandemic as much as someone who has. If you do not work in a hospital or care facility where you see and care for some of the many people suffering and dying from severe Covid-19 infections, your internet-informed musings questioning the reality of the pandemic probably make your entire opinion irrelevant to someone who does. If you have the financial security to enable you to self isolate when sick or exposed without risking loosing your job or the ability to feed your family, then you might not appreciate the terrible choice facing those who risk the possibility of loosing everything when filling out a “fit for work” form when they might not be.

We like our world to be good versus evil, obvious wrong versus obvious right; Luke Skywalker vs the Empire. But real world scenarios are seldom that straightforward, and this pandemic is a perfect example. We (as individuals and as a society) often do not have complete information when making decisions. Especially when it comes to rapidly developing and implementing policies to combat a new and fast spreading infectious disease. Even the experts do not have perfect information, and have been learning as they go. You have heard changing and sometimes conflicting recommendations from health experts through the course of the pandemic. This is because scientific recommendations evolve as new and better information becomes available. When we start off knowing little and learn quickly, what looks to be the best approach is going to change often and quickly. When it comes to scientific advancement, this is in fact “The Way.” And it works. As one example, continuous study and changes in medical practice based on new data in several areas of care have increased the odds of survival in hospitalized COVID-19 patients since the early days of the pandemic. The modern world is awash in information, and no one can be an expert in everything; but as in all complex fields of work and study, the experts still know a lot more than the rest of us do, and we need that expertise. Did you know that the genetic sequence of the COVID-19 causing virus was entirely decoded as early as January 2020? Or that the first prototype mRNA vaccine was developed in a single week-end in that same month? We owe the unprecedented pace of development of current vaccines in part to the experts who were already trying to solve the end game of this pandemic before most people in the world had even heard the word “coronavirus.”

But of course, eventually everyone did hear about the coronavirus, and soon enough could hear about little else. And it goes on. Everyone’s life in one way or another has been turned upside down by something invisible that can only be studied by biological and statistical methods that most people know nothing about, or have only heard about on an episode of CSI. People do not like to lose control of their own lives, especially without understanding why. If the answers were complicated and slow to be found for the experts, is it any wonder people have reached for simple explanations that are easy to understand? There has been an explosion in online commentary on the nuances of PCR cycle counts, infection case definitions, antibody testing, false positives, comorbid diseases, R-values, aerosolization, and a host of other biological and medical terminology that many of these commentators are unlikely to have ever discussed or even hear of before 2020. A few months of online curiosity cannot replace the years of academic background needed to appropriately synthesize and use this information to make and evaluate complex decisions. However, it is often enough to provide a semblance of understanding that feels sturdy enough to support a scaffold of suppositions and inferences that allow someone to explain to themselves what might “really” be happening. In this way one can regain some of that lost sense of control by feeling they can see through the apparent chaos around them, and anchor to an explanation that fits the paradigm of their core belief systems. Often these paradigms cannot fully explain the current reality without the addition of outside interference by someone who is secretly in control, perhaps with sinister motivations that can explain the apparently irrational or overblown responses to the problem. Such ideas often lead to significant suspicion of political or scientific authority figures, or even full blown conspiracy theories.

I do not intend to directly address or challenge every doubt or conspiracy theory, but rather to provide some simple descriptions of some of the unique features of the virus behind the COIVD-19 pandemic. By understanding what makes this virus different than other ones we routinely face, it is much easier to understand why different health organizations and governments around the world have been pushed towards the similar policies and restrictions that have defined our 2020 and early 2021 experience. They are a direct reaction to the nature of this pandemic, and do not require the addition of sinister or conspiratorial motivations to understand how we got here. My intent is not to defend or critique the details of what governments and public health authorities have or have not done, because it has been far from perfect, and is of course colored by political motivations. In fact, I echo the sentiments in this very long article suggesting that if governments were less paternalistic (or conversely dismissive) about COVID restrictions, and more openly communicative about the specific challenges we face and our options to respond, we may have achieved greater cooperative action, and less of the confusion and chaos that has been a breeding ground for suspicion and protest. Understanding the reality of this viruses behavior can better equip us to have the necessary discussion about how to best continue to live with it in the coming months. It is perfectly acceptable and important to discuss the unfortunate trade-offs between public safety, individual freedom and economic security we continue to be faced with, and where it is best to draw the lines. However, this conversation cannot possibly bear fruit unless we understand and accept the same facts, and do not allow them to be overshadowed by fanciful or fearful imaginings of the ulterior motivations we falsely ascribe to others, or wishful thinking about the reality of the virus itself. To use a related medical analogy, you can’t have an open and trusting conversation with your surgeon about treating your life threatening illness if you secretly worry he or she stands to personally benefit from your death and is trying to trick you into making the wrong decision.

As a disclaimer, I am not a virologist or an epidemiologist. I am an emergency department physician with a decent background scientific education and certainly an above average “hobby” interest in immunology and virology, but without credentials in those fields. I have paid close attention to the pandemic, including learning from many better educated in the field. I have treated patients who have suffered and died from COVID-19, and I have also sat around in an empty ER that people were afraid to come to when in retrospect there was little to no COVID-19 circulating in my community. I have tried to pay attention to how the pandemic and it’s societal disruptions have affected those around me, and have thought a lot about why people have come to some vastly different but equally passionate opinions about it and how we have either done too much, or too little to respond. I have become convinced that although opinions will always differ, appreciating the harsh reality of the virus, and acknowledging both the harms of infection and the efforts to limit its spread can open much more productive discussion and solutions.

THE FACE OF THE ENEMY

SARS-CoV-2 (the official name of the virus causing COVID-19 infection) is somewhat of a perfect storm to disrupt modern life. There are a couple of simple reasons for that.

1- It is significantly more deadly than our usually circulating and easily spread viruses. Yes, it absolutely has a higher mortality than the seasonal flu and similar respiratory viruses. I’m not here to convince you of that if you don’t believe it, but there are many good sources to do so with facts instead of media hype (see below for a small sampling). When it enters a particularly vulnerable population, it can cause very high mortality in that group.

2- Infections are mild in most people (about 80%), and completely asymptomatic in some (probably 15-20%). The fact that it is so mild in so many people is what makes it so insidious and has brought us where we are. It is absolutely true that most people who contract COVID will be just fine. This can still be true even with a higher overall mortality. If airplanes had a flawed design by which 1 or 2 out of every 100 passengers died of altitude sickness, most air travelers might still be fine, but the risk of death when flying would still be dramatically higher than it is otherwise.

3- COVID-19 is more transmissible than similar respiratory viruses. This means that with normal human day to day behavior, a single infected individual will infect more people than they would with a simple cold or influenza virus. On average, one case of influenza in the general public will infect 1.3 new people. A SARS-CoV-2 case probably leads to 2- 3.5 additional cases (in the absence of infection control measures). This infections per case rate is loosely what is meant when you hear reference to an R-value, although the term and its variations have not always been properly applied in public usage. If you have a hard time visualizing that, draw it out on paper. One person infects 2. Then they each infect 2. Draw that happening 4 times. Then do it again if each person infects 3 others and see how those totals compare after 4 cycles. At each step that gap grows greater and greater. This is exponential spread. On a population scale, this is why fractional increases in seemingly low infection attack rates (R values of 1.5 vs 1.9 for example) can translate into such enormous population effects, and why personal behavior patterns and public health measures that can reduce the current R value can have such a significant effect.

4- COVID-19 has a long incubation period and significant period of asymptomatic infectivity. It is a stealth virus. It commonly takes 5-10, and even up to 14 days to develop symptoms after being infected. And there is a period of time (probably 2 days) before you feel sick (if you ever do) when you can spread it unknowingly to others. In the absence of very intentional and careful surveillance, this allows it to silently spread very extensively in a community for 2-4 weeks (or perhaps longer) before we start to see a significant number of people actually becoming very unwell. Once it is detected in the form of a rise in very sick people coming to hospital and action is taken to stop the spread, it takes 2 weeks just to see how bad it was when you started, and 2 more weeks to see the results of your attempts to slow it. That can be a long time to have no room in the ICU.

5- Those who do get unwell with COVID-19 tend to be sick for a long time. There are two manifestations of this. First is the long ICU stays and long time requiring a ventilator. Time needing mechanical ventilation for this infection is notoriously longer than in other respiratory illnesses, with a median of 2 weeks on a ventilator in several studies. This makes the virus a disproportionately heavy burden on health care systems. That means compared to another disease with a similar hospitalization rate, COIVD puts more pressure on the system because those coming into hospital need to stay there longer. Secondly is the COVID “long hauler” syndrome. Still little understood, this describes the significant number of survivors who are left with some level of functional disability lasting for a prolonged period of time, with some still suffering indefinitely since their infection. We still don’t know how long these symptoms might last. About 10% of those infected experience some form of prolonged illness. It occurs in people of all ages, and even in those who only had mild symptoms during their initial infection. Due to a propensity to increase the risk of blood clots, COVID infections also cause a disproportionate rise in life or ability threatening strokes, heart attacks, pulmonary emboli and other viral inflammatory complications. Lives can be ruined even in survivors.

THE BATTLE

That’s it really. It’s those 5 features of the virus introduced into a naïve population (meaning one without any pre-existing immunity), combined with modern global travel patterns and the structure of our health care systems that can explain almost all the unique challenges of this pandemic. In the absence of testing and interventions to control it’s spread, it has followed the same pattern in many places. It enters a population silently, and begins rapidly spreading through asymptomatic or mildly unwell individuals. That 1 – 2 week cycle between infection and illness can be repeated several times without much notice, as most people are not getting very sick, and those who are going to eventually be very sick do not become so right away. By the time the trend of increasing illness gets onto the public health radar, there is already a high level of community spread, and many more people who are on the cusp of severe illness. This was the hallmark of early pandemic experiences at hospitals in places like China, Italy, Spain and New York that raised the alarm for health care workers around the world. And it was health care workers speaking out first. Days to weeks before COVID-19 began to dominate headlines, it was filling my med-Twitter feed with posts by concerned caregivers throughout the world. The warning was stark: first you don’t see it at all, then you see a trickle of mildly ill people, then you are crushed by a wave of the severely ill that keeps on coming. At this point, even if you implement strict public health measures, it takes another 4 weeks before your actions today will start to lessen that crush of sick people that is just starting to come in. This is how health systems have become overwhelmed. The crush is reliably followed a few weeks later by overwhelming demand for morgue space, and other body transportation and storage services.

Let’s look more closely at what we mean by an overwhelmed health care system- or more correctly, an overwhelmed critical care system. It might be surprising to know how few extra very sick patients it takes in a given hospital to overwhelm its resources. Many are running on the edge (or just over) capacity in any given normal influenza season. Intensive care is exactly that- intense; it requires a lot of people and resources. It’s much more than just a bed and a ventilator- it’s all the doctors, nurses, respiratory therapists and other health care team members needed to care for the patient. There is a good deal of specialized training required to know how to do this. You can’t just throw any doctor or nurse in the ICU and expect they are going to be able to provide the best care. Overflow can be dealt with to some extent, but only for so long. Staff become burned out, or exposed and infected themselves. The COVID-19 death toll among health care workers is sobering. People have often been brought in from elsewhere- which can only happen when there are places with people to spare of course. COVID patients may begin to overflow into other units and critically ill people may stay in the ER longer than they should. All these resources turned towards pandemic patients need to come from somewhere. This blocks critical care beds and staff from the usual, routine needs that are still there: trauma, heart attacks, strokes, sepsis, overdoses, recovery from critical surgery, and all other forms of critical care are affected in an overwhelmed system. It can become impossible to provide the normal standard of care for a host of medical problems. Not to mention the difficulties presented by all the PPE staff must wear and work in. If you think it’s hard to order coffee through a mask and plexiglass shield, try working a multidisciplinary cardiac arrest wearing a mask, face-shield, a gown made out of a rubber shower curtain and still maintain good communication with people inside and outside a sealed room. All these factors increase the risk of substandard care and can inflate both the COVID death rate, and the rates of death or lasting harm from every other medical need requiring critical care.

This is the situation that health care providers, public health officials and concerned governments around the world have been trying hard to avoid for the past year. Success has varied from place to place, and time to time, but it has been widely agreed that it is unacceptable to allow health care systems to become so vastly overwhelmed that the death rate from otherwise survivable COVID soars, and that anyone needing hospital care for any reason becomes at risk of not being able to get it. This is the rallying cry to “flatten the curve;” it is to smooth out how many people become infected in a given amount of time so the system can cope. If it seems like it’s taking a long time and repeated interventions to flatten, that’s rather the point. If it seems like you are making a lot of sacrifices for an overall death toll in your area that is sad but not terrifying, that is also the point. The alternatives are to try to completely eliminate it (with the most extreme public health measures, as has been largely achieved in places such as New Zealand and several Asian countries), or to let it “flame out” as quickly as possible, permitting the system to be overwhelmed for a time in the hope of achieving early herd immunity. Both these approaches take a view of getting over the pain more quickly; one the pain of a lockdown, the other the pain of the virus. The hope in each case is to limit the overall damage, albeit with a vastly different perspective on what is more important to protect. Jurisdictions that have opted for the fast flame method have generally reversed course after finding the cost and difficulty to be too high (Great Britain, Sweden), and seeing that it really hasn’t ended the problem any quicker. There is a lot of experiential evidence suggesting countries that pursued the elimination strategy successfully have suffered the fewest infections, least economic damage and shortest disruption to normal life. They are currently living with the lowest levels of pandemic restriction in day to day life.

This is a good time to point out that when we talk about interventions to protect the health care system, we are really only talking about a subset of infected people who are the problem: those who are sick enough to need the hospital, but strong enough that they have a chance to recover with medical care. This does not include the group with the highest risk of death- the elderly and the very infirm. Keeping someone alive through a devastating illness is not a trivial matter. It means taking over a number of the body’s failing organ systems, sustaining life and providing the body with time and resources to help it overcome an infection and heal enough to resume it’s own life sustaining functions. If the body is unable to recover despite this care, there is little further we can do for it. This is why the very elderly and those with very poor baseline health are often not even offered life support/ICU care. In some people this care is futile, as the body is not going to be able to recover from a severe illness, regardless of the care we provide. That’s when medical care becomes focused on end of life comfort. Everyone has seen the statistics showing those 80 and over are at highest risk of death from COVID. Yet in this US study (as one example) the median age of COVID ICU patients was 64, with only 22% of them aged 75 or older. This means a very large percentage of covid deaths are among those who were never treated in an ICU because such care would have been futile, or against their desires for a focus on comfort and dignity near the end of life. Covid ICU patients are for the most part those who are somewhere between middle age and recently retired; people who may have a comorbidity (most commonly diabetes, hypertension and obesity), but were otherwise living normal, functional lives. These are the “salvageable” potential COVID deaths that require an intact medical system to save.

Faced with this specter in the early stages of the pandemic, with incomplete information on how the virus spread, how high its true mortality rate was, and a limited ability to test for it, the best course of action was an abrupt and complete as possible shut down of much of society. Initially this was to buy time to develop tests, study the best treatments, ramp up production of PPE and medical supplies, implement pandemic capacity plans, and figure out how far the virus had already spread. When you have a pathogen that can spread so insidiously, with carriers unaware and a long incubation period, the only way to fight it initially is to change people’s behavior to deny it the opportunity to spread. In fact, until vaccination is widely achieved, this still remains the best way, which is why it has been so difficult to find a way to move beyond that heavy handed approach. Hence the cycles of quarantine/lockdown- both terms used rather nebulously over the past year to refer by most to the various rules, restrictions and recommendations designed to (or at least intended to) limit the amount of person to person contact through which the virus spreads. People are prone to argue whether or not lockdowns “work,” by which presumably they mean work in limiting the spread of COVID. How effective any single intervention is, and its trade off cost is a very valid discussion. However, the underlying intention behind such interventions is a sound principle that does work; anything that reduces how many, how often and how long people are gathered in close enough contact to share a respiratory virus with people outside their household IS going to slow, and could ultimately stop the spread of the virus. Further data over the course of the pandemic has confirmed that the highest risk “super-spreader” scenarios are large groups of people, indoors, unmasked and in close physical proximity for extended periods of time, as is reflected in the current CDC prevention guidelines. To the extent we limit or stop that from happening, we will slow the spread of COVID.

In fact, we have seen astounding evidence at how effective this is in other circulating diseases. You have no doubt heard the incredulous reports that there is little to no influenza (the flu) circulating this year. (And yes, we’re still testing for it. No the flu won’t make a COVID swab positive, any more than having tuberculosis would give you a positive syphilis test). It’s not the only thing that is AWOL this year. Pediatric bronchiolitis, croup, even asthma exacerbations are all staples in the ER every winter, triggered by respiratory infections. Where I work, they are almost non-existent this winter and I have seen similar observations by physicians in many places. How many colds have you had in the past year? Contrary to conspiracy claims, this is not because we are arbitrarily relabeling everything as COVID. It is because these conditions are all caused by infectious respiratory viruses, and we are in the midst of a worldwide campaign to stop an even more infectious respiratory virus. Reduced travel within and between countries, limited social gatherings, compulsive hand sanitizing and mask wearing are all having the exact effect one would predict- stopping the spread of respiratory infections. In the case of influenza, it may well have been largely stopped in the Asian and southern hemisphere nations where we usually get our new annual strains from- areas that are generally doing a better job than North America at COVID control. In fact, in my opinion seeing how well COVID has still spread as much as it has in the face of current measures that have nearly eliminated the flu and other respiratory infections is an even greater indication of just how contagious it is. If we had done nothing, it would surely have hit us so much harder.

Accepting that reducing personal contact does reduce transmission, we can then rationally discuss what measures work better than others to achieve this, what the costs of such measures are in dollars, freedom and mental health, and who pays the price for either decision. Certainly the hodgepodge of variable rules, restrictions and exemptions experienced in any of a number of jurisdictions during the pandemic highlight that there is not always a lot of evidence based decision making going on, but rather a lot of best guesses, influenced heavily by individual opinions, financial limitations, and local political persuasions or lobbying. While the rationale behind the lockdown approach is valid, the devil is most certainly in the details. Any intervention is also only as good as the public’s compliance to it, which has certainly waned as the pandemic stretches on, leading to further discussions on the merits and ethics of education, enforcement, and the diminishing returns of repeated “shut-downs,” where a possibly less effective result is being paid for by a potentially diminishing pool of voluntarily compliant individuals. There is a cost to moving in either direction, and it is often paid by different people in each case. This is a classic demonstration of how interconnected we are. No man (or woman) is an island, and our choices in these matters always affect others around us.

The costs of pandemic control measures to individuals, businesses and society continue to be abundantly clear. Limits on personal mobility, isolation from friends and family, loss of opportunity in education, sports and recreation, mental stress, loss of jobs, collapse of small businesses, bankruptcy, domestic violence, delays in routine health care and elective surgeries, delayed cancer diagnoses- the fallout from these and more will be with us for years. The longer the pandemic drags on, the more it is going to “suck” because of all these things. Much of this is unavoidable. Even if we assumed that no mandated public health restrictions were imposed, much of the economic and isolation consequences of the pandemic would still be with us. When people are aware of an existential threat to their own health, and that of loved ones, they change their behavior to limit risk. When a community is in outbreak, many people will chose to stay home, and businesses that rely on mobility and mingling will suffer. These are self preservation and economic choices; both immediate income and future earning potential can be decimated by serious disease in a home- to say nothing of medical costs where insurance is inadequate. It is a false dichotomy to assume that in setting a pandemic policy we chose either health OR the economy. Likewise, a full focus on protecting everyone from infection will still have inadvertent health consequences as surgeries are delayed and medical appointments put off. There is no policy of pure health or pure economic protection- only compromises and priorities. There is evidence to support that the harsher short term economic and public restrictions of a viral elimination strategy actually do the least overall economic damage. If viral spread is successfully stopped and nearly eliminated early on, life can return to normal much sooner- albeit with significant surveillance effort to prevent a re-entry. The alternative, which most of the world is living with, is repeated cycles of opening and closing as cases and hospitalizations cycle, with no return to normalcy in between. Whether these closures are driven by government policy, or people’s natural behavior in the face of local flare-ups, the effect is often similar. And given the long incubation period, each part of the cycle drags on for weeks. Off and on half measures to live with this “slow burn” of cases leads naturally to the longest period of societal disruption and living with an ever present small to moderate risk of infection. Whether there is more suffering from prolonged restrictions, or more suffering from viral infections and deaths varies from place to place and is perhaps a matter of personal perspective.

SEEING IS BELIEVING

A prevailing theory in understanding the anti-vaccination movement is that vaccines are a victim of their own success. In a world where very few people have personally seen the effects of polio, tetanus, or even measles encephalitis, it becomes increasingly more difficult to remind people that these diseases exist, and that they are terrible. People become complacent, and question the need for vaccination. I suspect we are seeing a similar effect from the tenuous control we have achieved in much of the world over COVID. While the overall death toll still remains distressingly high, the fact that we have prevented the near simultaneous overwhelming of most of the world’s medical facilities that was feared in the early months means that most people’s entire experience of the pandemic has been the disruption of their lives from the policies and restrictions put in place to control it. They may see low local death tolls- a consequence of successful transmission suppression- and wonder what’s so bad about this virus. Combine that with how well we have isolated the sick, and the very common experience of having “mild COVID,” and it is not surprising to see doubt creep up about how necessary this all is. Certainly millions of families worldwide have personally experienced the tragedy of an early death of a love one, but maybe the very isolation that keeps us safe also prevent us from sharing with one another more intimately the reality of death from COVID. If you have not had someone close to you be very sick, or if you do not work in a facility that cares for them, then you will have little first hand knowledge of what is so bad about COVID. We live in a world where there are many voices trying to convince us someone is fooling us about any given issue. When it is so hard to see the damage for yourself, many people may find such claims about the pandemic to be a seductive path back to normalcy.

A part of this perception is certainly the striking regional variability that has been seen with “spikes” of covid. Parts of a country or even city can have much higher case loads than another, and the strain on the local health system can come at different times. This is likely a result of decreased movement between regions, but with the propensity for COVID to spread rapidly within a susceptible, localized population. If the virus gains a foothold in a care facility, a close knit neighborhood with poor distancing practices, or a homeless shelter with a large transient population, there can be a significant local spike in cases and hospitalizations. Super spreader events like weddings, funerals or house parties can make a noticeable difference to local health facility needs a few weeks down the road. Governmental restrictions or recommendations tend to be much broader than these local outbreaks, meaning you may be living under restrictions tailored for communities nowhere near yours. It’s also important to remember that an overwhelmed ICU can still exist in an otherwise underutilized hospital and primary care system. When critical care is overwhelmed, elective surgeries get cancelled, visitors are restricted and anyone who doesn’t need to be in the hospital is kept out. People self restrict their movements, so medical clinics may be empty, and ERs avoided except in the most extreme need. Remember not everyone in health care can provide critical care- those that do can be over-run with sick patients while the rest of us find we have much less to do than normal. If you are not in the ICU, the hospital can seem a surprisingly empty place at such times. It’s not going to look like a scene from an outbreak movie, or from Lombardy Italy in early 2020 unless things are seriously out of control. That’s the scenario we are trying to avoid.

The average person is not going to see the side of the pandemic that critical care providers, or nursing home staff are going to see. And that’s on purpose- the fewer people exposed to the environment of heavy COVID viral loads, the better. Likewise it is fair to say those in health care and political decision making are sheltered from the most severe economic impacts compared to those who are losing their jobs or businesses. I will mention that is not universally the case- as surgeries are put off, clinic visits reduced, and even routine ER visits tumble, there is probably an overall loss of income that has been experienced by most of the health care community this year, at least where I am from. Yet, that is not the same as businesses that can no longer open, or employees who’s service based skills are no longer in demand. There is also the important consideration of those working low income labor jobs who do not have the economic luxury of staying home, even when sick. Working conditions often come with their added risks too. There is a reason there have been so many large outbreaks linked to meat packing plants. No plan for the sick or exposed to take a mandatory leave of absence is going to work if the financial support to make that possible is not provided. It is important for all of us to consider the perspective of those experiencing a very different pandemic than we are.

IS THERE A BETTER WAY?

That’s what everyone wants to know, and I don’t have the knowledge or qualifications to give the answer. There are a lot of popular and attractive ideas out there. Some give simple, painless sounding (or at least less painful) solutions that they insist are better. As in all complex problems, I fear many simple solutions are too simple, and gloss over some of the realities of this pandemic. We can look at them too through the lens of understanding the unique properties of SARS-CoV-2.

One popular approach advocated in the Great Barrington Declaration and similar proposals is to simply protect the vulnerable, get on with our lives, and wait for herd immunity to take hold, presumably after everyone young and healthy has been infected and recovered. It’s a nice idea, but if you try to develop a specific policy based on that, while keeping in mind the insidious and stealthy nature of the virus, it loses its simplicity. Who are the vulnerable? The elderly for one- do we simply lock them away with no outside contact? No visitors, no leaving home? Are we not already essentially doing almost that and still seeing regular stories of terrible outbreaks and death in senior facilities? And this is while we still have all these other rules and restrictions on for the general public. Where do they go for medical care? Who takes care of them in their facility? Do we also make caregivers live in the facility with no outside contact? What about their families? How often do we test everyone? The tests are imperfect, and false negatives are the most common error. What do we do when a case slips through? What about those not in a senior facility already? Do we build massive complexes to house them in? Are they allowed to stay at home or with their families? If they do, are their families allowed to work or leave? Maybe you don’t want to impose rules, so everyone “voluntarily” decides how they are going to protect their relatives. How can they do that when anyone they meet could potentially pass on the virus without warning, and they themselves could be unknowingly infectious for the next week or two? It’s a false choice- there is no real action they can take to protect their loved ones without completely isolating themselves from society. Who else is on the at risk list? There’s the immunocompromised (including cancer patients and those on immunosuppressive drugs for many different chronic diseases). People with high blood pressure, diabetes, obesity. Pre-existing respiratory conditions. There is no firm line between high risk and low risk- there is a spectrum and it is very hazy at points. What policy do you make that is going to realistically allow those at high risk to stay safe while letting everyone else carry on with life as normal? There isn’t one- you can’t do it. Even the blanket shut-downs many of us have been living under (which are entirely un-necessary according to the Barrington philosophy) are not enough to adequately do this.

The entire question of whether or not herd immunity can be achieved through natural infection is another issue. I won’t delve into it, but there is mounting evidence that natural infections may not provide the complete long term immunity that would be needed for this to work, at least not for enough people. We also know this virus mutates easily. Every new host is another opportunity for mutation, and any new mutation could be the unlucky one that raises mortality, increases infectivity, and evades the old immune response. There’s a very good chance if you let if “burn through” the population that the virus that comes out on the other side will be different enough to start the whole infection cycle over again. This is the same phenomenon by which we have new flu variants every year. Furthermore, with uncontrolled community spread (even somehow sparing the elderly and infirm) there would also not likely be a way to prevent prolonged overburdening of the health care system, which as described above will increase all cause mortality. Remember, the ICU system is there to support mostly the middle age to retirement age group who are the infection deaths potentially preventable through good medical care. There would be a large sacrifice in this age group too with this approach (and certainly some even younger too). Alberta Health Services put out a very fair and comprehensive discussion of some of the limitations of the Great Barrington Declaration.

So what about elimination? It has been done very well in several nations where people are living a mostly normal life today. Can other countries, states or provinces go for COVID zero? Perhaps. I don’t think there is any theoretical reason it could not be done, and the evidence certainly suggests that it is the least painful and quickest path out. There is an argument to advocate for it in Canada, in light of the new variants beginning to spread more widely. If you are not an island there are certainly more travel complexities to address, but I think the biggest barrier is public buy in. It won’t happen if most of the public is not entirely on board with the true, real and significant lockdown that would be required to get there. Even with the promise of “normalcy” afterwards. Even if a western government was willing to impose such a program against the will of a part of the populous, it would not be enforceable. Maybe at the beginning of the pandemic there would have been more appetite for it. If we knew how long it would drag on, I think there might have been in many places. But here in the west we have generally been given political messages of overly-optimistic reassurance with too early reductions in restrictions, and inadequate travel rules to keep new cases out, and existing ones from spreading. A more realistic comparison to the multi-year phases experienced in all prior pandemics may have made the prospect more attractive. I would support the attempt, but I don’t see it happening now, especially with vaccinations beginning (even though that too will take a long time to significant herd immunity).

THE WAY OUT

Clearly there is no quick and easy path out of the pandemic. Whether we double down in squeezing it out, or give up and let it run rampant, there is pain in either direction. There is hope in the excellent clinical data and evolving real world experience with all the major current vaccines undergoing distribution. Mass vaccination is I think the best way out, but it will take time and public buy in. If you are frustrated by wearing masks, not seeing family, and an inability to work or travel, this is certainly the fastest way back to normal. Get vaccinated when you are able to. It is safe and effective. Most frontline healthcare workers where I live have already gladly received it. The longest, and most painful path is to deny the virus is a threat and help keep it burning right on the edge of overwhelming the critical care system by refusing to follow the basic health guidelines that have been given. They only work if they are followed, and if they don’t then we either enforce more painful restrictions until they do, or give up and surrender to the virus. There is at least now an endpoint on the horizon.

As I’ve said before, there is a valid discussion to have about what interventions, rules and public health measures are most useful, and which have a greater cost (economic, personal or otherwise) than they are worth. If we are to continue on the path of the slow burn until herd immunity by vaccination, then we must continue to be diligent and cooperative, and accept that things will not return to normal until that point. If we acknowledge both the reality and the risk of the virus, as well as the cost of the measures we take to control it, we are better able to make wise decisions. There continue to be challenges ahead, particularly with new, more infectious variants staring us in the face. We will also continue to learn more about the virus, and the success (or not) of different containment measures. We should be willing to alter our course based on new information, and that information- as well as its limitations- should be freely shared with the public.

The COVID-19 pandemic is a major challenge to our society- no secret plots or conspiracies necessary- it’s the nature of the virus. It’s not the first such challenge to humanity, and not the last. I’m not going to claim there are not people who are using this as an opportunity to further their own political agenda, or to profit economically from the suffering of others- these things have always been with us, and in the increasingly hyper-partisan political world of the west, will continue. The media loves sensationalism and will focus on what catches the most attention, as they too always have. But there is still plenty of good and objective reporting behind the hype of headlines and sound bites, and there are plenty of civic and medical leaders trying to find a path forward where there is no clear best answer. Hopefully a little more understanding will motivate people to spend less time looking for hidden agendas, and more time discussing the legitimate and difficult questions of how to live with this reality. How do we balance saving lives with restricting personal liberty? How do we protect health care systems from becoming overwhelmed without causing irreparable economic harm? How can we make it more financially possible for people to isolate when they should? How do we make these decisions when we still have incomplete information about the spread of viral variants and the best ways to contain them? These are not simple questions and are worthy of tough discussion. But when we are distracted by false information, unyielding conspiracy theories, and the need to constantly defend the utility of scientific expertise, then we cannot even have these discussions. Let’s acknowledge that this is hard on everybody, and we are all doing our best. Opinions can and should differ, but we can still do our best to make sure we are using real information to make really important decisions.

Alberta Doctors are off to Battle. Who has our Backs?

The COVID-19 pandemic is undeniably here. Most of Alberta is currently in the calm before the storm. We are doing the right things to prepare our hospitals, our medical staff and our province. Social distancing started early compared to elsewhere. If it is adequately embraced, we will hopefully be spared the worst effects other parts of the world are already experiencing. It is a stressful time for everyone, and we in healthcare are feeling it all day every day.

Yet while we prepare to be part of the front line against the coming storm, our stress is amplified by the persistent need to look over our shoulders. As we’ve been looking to the fight to come, we have little trust or confidence in our political generals, and are still bleeding from wounds they inflicted, and unsure how to deal with the bigger ones still to come. The Alberta government has not relented in their attack on physicians, despite the bluster of unity in political press conferences. You may have read otherwise in the media, and yes, as of this writing, after months of physician outcry, they have relented on one proposed change; delaying the reduction of complex modifiers (despite still claiming they should not be a problem). See this previous post for an understanding of why this will be so bad for primary care. A step in the right direction, but this is only one of many ill conceived changes that are still scheduled to come into effect on April 1, leaving many physicians unclear on how they will manage their businesses beyond that date. This coincides almost exactly with the period when we expect to see our health system beginning to strain under the load of Covid-19 pandemic patients. Physicians are far from the only ones facing significant economic uncertainty right now, but we are the ones being asked to put our own safety on the line for Albertans. Health care workers around the world have a higher infection rate than the general population due to our risk of multiple exposures (see here and here).

I’m busy with plans for how our local ER is going to cope, so I do not have time for details, but in brief these pending changes still include:

  • The loss of clinical stipends to support palliative care, trauma and other critical programs (note AHS has announced it will delay until August some of these cancellations given the pandemic. I suspect this was an AHS rather than direct government initiative and it does not include all stipend losses).
  • Daily “encounter caps” still mean many after hours walk-in clinics will need to close
  • Still undisclosed cuts to in hospital consultation fees that may make hospital work unsustainable for some specialists and rural physicians

More specific concerns as addressed in recent communications to government can be read here.

Even in the midst of pandemic planning, further stress has been put on Alberta physicians through the following developments:

On March 13, the Minister of health gave 1 year notice of termination of the contract with provincial radiologists, with the apparent intention of putting out a tender to have the province’s medical scans in the future read by the lowest bidder. This is a contract that was recently renewed in binding arbitration with a 12% fee cut. The full implications of this are not entirely clear, but one possibility is that the reading of diagnostic tests in Alberta could soon be filled by a cheaper overseas radiology “call center” of sorts. Would you rather have your MRIs, mammograms and CT scans read by Canadian trained and regulated radiologists, or the lowest worldwide bidder? As an ER doctor who relies on those reports to care for you, I know who I would rather have reading them, and who my lawyer would.

Social distancing is beginning to be achieved in health care throughout the country by the roll-out of “virtual care” fee codes. These allow your doctor to be paid when communicating with you through email, phone or video call to minimize face to face contact, and avoid clinic visits for at risk patients during the pandemic. It has been recognized throughout Canada as a key pandemic response. The fees need to be high enough to allow the doctor’s office to use them, and still pay overhead. Premier Kenney is fond of comparing Alberta physician billing to the rest of the country, so let’s do that here:

  • BC: $31 -$35 per visit
  • Manitoba: $38 – $44
  • New Brunswick: $45
  • Quebec: $49
  • Yukon: $51
  • Saskatchewan: $35
  • Ontario: $37 (> 10min), $68 per half hour of counseling

Health minister Shandro proudly re-introduced the old H1N1 pandemic virtual medicine fee, at the same old fashioned rate of $20, regardless of time spent. That’s 30-70% lower than anywhere else in the country. We have a few other pre-existing telephone fees that also pay about $20, but are limited to 14 uses per week. There are many Alberta family doctors on social media who are trying to protect their vulnerable patients during a pandemic by keeping them at home, and are right now operating at a loss to do so. Remember this money is used to pay clinic rent, utilities, staff and equipment.

This is completely unsustainable, especially in a pandemic. There are already clinics in Alberta that have announced or are planning a closure. We (speaking from the soon to be overwhelmed hospital front) need our community physicians to be able to stay in business and keep caring for Albertans! All your chronic diseases and usual day to day health problems are not going to be put on pause as easily as a Florida vacation. If family doctors, palliative care doctors and other specialists cannot provide good, comprehensive primary care – from their patient’s own homes when needed – we will further burden the acute health care system at the worst possible time in our provincial history.

[Update March 23: Today the Alberta government announced some additional temporary virtual medicine codes that are similar to regular office visits fees for both family physicians and specialists. There are a few significant restrictions including that the patient, not the physician must initiate the call, no time modifiers will be paid for longer visits, visits must last a certain minimum number of minutes to be paid, and there is no remuneration for additional administrative time including chart review, charting, prescription or consult letter preparation. They will not be subject to daily caps. This represents a definite improvement, and time will tell how clinics will adapt to survive a potentially prolonged period of “socially-distant” medicine with newly restructured rules governing their income.]

This is an unprecedented time. Everyone is suddenly either out of work or overworked, depending on what they do. Financial times are suddenly stark for many, and are going to get even harder – but is this the time to carry on with draconian and frankly completely uninformed tinkering of the health care system? By politicians who have shown no interest in listening to the experts about how that system works? Nurses have been told their layoffs will be delayed until after the pandemic. I’m sure they are grateful for the message that while they are needed to shield the province from harm they are at least temporarily of more value.

The Alberta government wants to renovate the house of health care. Instead of working with the architects who built that house, and the people who maintain it, they have come in and started unilaterally demolishing the foundation – primary care. We have spoken up loudly about it, insisting we can fix the house together, but that they are going about it the wrong way. They have persisted, and now a hurricane is coming – we are rushing to hold up the walls, leak proof the roof and make room to shelter more people. Meanwhile the government continues to dismantle the structure behind us.

It’s becoming clear that the UCP does not want this pandemic to delay their plan to reshape health care into an as yet unknown image. Have you seen the ads suddenly popping up in your social media feeds for virtual online health care in Alberta? Is that where the health care budget is going now – to these private companies? As I am writing this, Premier Kenney happily announced (on twitter) new partnerships with online health delivery companies to take care of your health needs over the phone or an app. Don’t be fooled – they are paying discount doctors a cheaper rate to do incomplete electronic medicals while a private company is pocketing the difference. Do you think that service will be an adequate replacement for your family doctor? What kind of health care relationship will you develop with this app while your GP who knows your health history and can actually physically examine you is being undercut and going out of business? This is one more thing that looks like it will save money in the short term, but will cost much more in the mid and long term because it destroys the patient’s medical home- the most health and cost effective tool in Alberta’s public health system. This government has proven itself incapable of understanding the basic principles of health care and health economics. They are dangerous.

We no longer have time to continue this asinine fight, but perhaps you are finding yourself with more time than you used to have. Perhaps you can take up the battle to defend our backs while we face the storm.

If you can,

Contact your MLA. There is growing feedback coming to physicians from some back-bench UCP MLAs that they are not happy with their own government’s approach to health care, especially once they understand the facts – that the system is going to suffer and health care is going to cost more. This is not ideological, it is math and basic health economics. We have been encouraged by some to continue our advocacy to THEIR bosses – the Minister of Health, Premier Kenney and whatever small room of yes men is setting provincial policy. Don’t accept willful ignorance or cowardice from your elected MLAs. It is their government, and its power rests in their votes. Their future jobs rest in ours. The UCP recently passed a bill limiting their own member’s ability to debate or comment on some legislation- the Premier does not want his own MLAs to speak up. Demand that they do.

Find your member of the Legislature and their contact information here.

Contact the Premier and the Minister of Health. Tell them you see through the propaganda, and insist that they acknowledge the problems that have been identified by so many physicians. Their response is always the same: “We are holding the line on health care funding.” “Alberta doctors are paid more than anyone else.” These are deflecting answers that ignore the problems in the details of their actions. Do you care what the total budget for your new house will be if the builder refuses to properly pay for the pouring of the foundation? It doesn’t matter how much you spend on the roof tiles, the house is going to collapse.

Premier Jason Kenny contact information

Minister Tyler Shandro contact information

Demand at the least that these changes be put on hold until after the worst of the pandemic is past. Invite them to then take that opportunity to collaborate with doctors and other healthcare providers who can help find the inefficiency and waste in the system, and who will continue to offer sustainable cuts  to  their own income in hard economic times – later, when there is time.

Demand our province raise virtual medicine fees to a level commensurate with other provinces, so clinics can stay open and avoid further layoffs while caring for patients in isolation.

Consider signing this petition, asking the government to see sense and delay the changes.

While you’re at it, please sign this petition, asking provincial and federal governments to please immediately implement a national plan to ramp up production of protective medical equipment. We will need it badly and the entire world is headed into an immediate severe shortage. What a great way to create some jobs in a crisis! Please consider speaking out about this.

If you want to get out of the house, please consider donating blood. It will be sorely needed for many, and is safe to go and do.

Please continue to follow the excellent advice and leadership of Dr. Deena Hinshaw, our chief medical officer of health. Thanks to her, and thanks to the blessedly wise decision of our Premier to follow her advice, Alberta has a chance to be more prepared, further in advance than much of the world. We hope it is enough, and we hope you will have our backs, while we do our best to protect the health of every Albertan.

 

Alberta South Zone Physicians Speak Out

Below is the text of 2 letters put out by Alberta physicians in the south zone in response to upcoming health funding changes implemented by the Alberta government:

 

An open letter from Alberta South Zone emergency physicians

March 3, 2020

Premier Jason Kenney
Health Minister Tyler Shandro
Mr. Nathan Neudorf
Ms. Michaela Glasgo
Mr. Drew Barnes

c.c. Ms. Shannon Phillips

We write to you today as a united voice of southern Alberta Emergency physicians in the cities of Lethbridge and Medicine Hat to add our voices to those of physicians across Alberta in response to the imminent changes coming to our healthcare system. We are deeply concerned that as early as April 2020 our emergency departments will begin to be overwhelmed due to reductions in local primary and specialist care. We also warn that any decision that degrades access to community based primary care medicine will inevitably result in increasing, unsustainable health care expenditures that will rapidly reverse any budget savings anticipated by these measures.

The emergency department has often been called the “canary in the coal mine” for problems in any healthcare system. When patients are unable to obtain or visit a family doctor, they come to the ER for routine care. When referral visits to specialists or for elective surgeries are delayed, patients come to the ER in crisis. When community long term care beds and accessible home care is unavailable, patients who no longer need hospital care have nowhere to go and languish in expensive hospital beds. When hospital beds are full, new patients requiring admission cannot be accommodated and remain in the emergency department. Elective surgeries are cancelled because there is no postoperative recovery space available.

All these factors combine to grind the efficiency of the emergency department to a halt, impairing its ability to accept and treat new patients. Wait times soar, ambulances pile up and become unavailable to respond to new emergencies. These causes of emergency department crowding are well documented and understood by health care professionals. There is abundant evidence that emergency department crowding increases costs to the health care system and has a cost in patient lives. There is also abundant evidence and consensus from health care experts here and around the world that investing in primary care, long term care and home care is the most effective and affordable way to reduce the burden of expensive hospital-based care.

We recognize and applaud this government’s stated intention to increase the availability of community long-term care and await details as to how this will be implemented. Nonetheless, we are concerned that the current government either does not fully understand the above relationship, or does not understand how the unilaterally imposed changes that were vehemently resisted by the Alberta Medical Association will rapidly decrease access to quality community health care, resulting in poorer health for Albertans, and a rapid increase in the utilization of expensive emergency and hospital based care.

Southern Alberta currently enjoys some of the best emergency department wait time indicators in the country. The average wait to see a physician in a south zone regional hospital is about 55 minutes. Our zone has been identified in the past as one of the most cost efficient in the province. This is in large part due to an excellent primary care system that is accessible to patients, and a network of specialists available to provide timely consultation, admission and follow-up for emergency department patients.

Currently, a simple visit to the family doctor costs Alberta Health $38-$56, from which clinics pay their operating expenses and employ their support staff. An equivalent simple visit to the emergency department costs $359 in hospital overhead + $29 in doctor fees. If additional time, complexity, consultation or testing is required, that expense rises significantly. There is a similar disparity in cost to the system between community and hospital care in other areas of medicine. The ER is generally busiest on weekends, holidays and Mondays – all related to times when community care is less readily available. As community care decreases and more people become reliant on the ER for their care, it is easy to see how health costs rapidly rise.

 

The following are specific ways in which we anticipate our emergency departments will be immediately affected by these changes beginning April 1:

  • The reduction and loss of complex care modifiers will make it difficult for family medicine and specialist clinics to remain financially viable unless visit lengths are significantly reduced. Less time translates into poorer care, making it more likely complex patients will experience a health crisis requiring a trip to the ER and/or hospital admission.

 

  • Daily visit caps on community physicians will shorten or eliminate evening walk-in clinics. These patients will come to the ER instead.

 

  • Daily visit caps will disproportionately affect high volume orthopedic, surgery and cast follow-up clinics, meaning more patients will come to the ER as they cannot see their surgeon.

 

  • Yet to be clarified changes to specialist in-hospital visits and the loss of on-call stipends have our consulting specialist colleagues already notifying us of decreased future availability to rapidly see and admit patients in the ER, as they will need to book additional time in clinics to continue covering their overhead expenses. This will dramatically increase the amount of time patients will be held in the ER before moving into the hospital or receiving an urgent procedure.

 

  • Of particular concern is the potential loss of the stipend supporting the Acute Trauma on-call service, which provides general surgeon coverage in hospital to respond to trauma team activations. This 7-year program has decreased adult and pediatric trauma death in Lethbridge by 65%. In 2018 there were 107 major trauma patients treated in Lethbridge, and 63 in Medicine Hat. Time is critical in these instances, and an increase in preventable traumatic deaths is highly likely should it be lost. The status of this program is unclear due to governments’ lack of response to requests for clarification and is expected to be lost on April 1.

 

  • Palliative care is losing the stipend needed to cover the travel cost of home visits to vulnerable and dying patients. Home visits may no longer be possible requiring more palliative patients to be admitted to hospital and preventing us from discharging them back home into palliative care.

 

  • We provide emergency referral care to all community hospitals in southern Alberta. Rural physicians across the province have been speaking up loudly about their impending inability to provide the same level of care under the new framework. We anticipate unplanned intermittent rural ER closures due to a shortage of physician coverage, similar to those experienced elsewhere in Canada. This will mean more visits from rural communities by patients seeking emergency care.

 

  • The elimination of “good faith billing” means that disadvantaged patients with addictions, mental illness or homelessness are likely to face significant barriers to obtaining care in the community, as many of them are unable to produce proof of provincial health insurance.

 

  • Already we are hearing established community physicians and soon to be graduating medical residents making plans to work outside Alberta due to the instability and acrimony of the relationship between physicians and government. The government’s plan to dictate where future doctors will be allowed to practice will drive many graduates from Albertan medical schools to other provinces. There is abundant work elsewhere. This will mean fewer community providers, and higher reliance on the ER.

 

 

Alberta has developed its current model of “the medical home” in primary care over two decades of thoughtfully structured changes to all levels of health care funding. World leaders in health economics and comprehensive patient care have helped build a primary care system that is the best in Canada. It is currently used as an example by other provinces to improve their health services and recruit physicians into similar models providing the best value per dollar in health care. To be frank, the currently planned changes on April 1 risk rapidly destroying 20 years of health delivery progress in this province.

We recognize that the fiscal reality of Alberta means savings must be found in all areas of the budget. Physicians have been willing partners, voting to accept decreases in fees in our last round of negotiations, and had again proposed global cuts to their own fees in the recent negotiations terminated by your government. The Alberta Medical Association has repeatedly expressed its willingness to return to the negotiating table to find sustainable decreases in health spending that will not have draconian and devastating effects on the foundation of Albertan’s medical care. If the AMA was “not willing to consider” your proposals this is why; they will immediately harm patients, and they will not save money.

It is not too late to put a hold on these changes and return to the negotiating table to repair this government’s relationship with physicians and find actual savings in health care. We urge a similar cooperative rather than adversarial approach to ongoing negotiations with other public sectors. The experts in each field are the best positioned to identify potential cost savings and avoid the unintended consequences of indiscriminate cuts. Use their knowledge and experience. A financially secure Alberta is in everyone’s best interest.

The elephant in the room right now is the inevitability that health care workers in Alberta may soon be overwhelmed by the response to a coming pandemic. As always, we will rise to the occasion and provide the best care we are able. Please Premier Kenney, Minister Shandro – can we deal with one freight train crashing into our health care system at a time?

 

Thank-you,

Chinook Regional Hospital (Lethbridge) Emergency Physicians:

Dr Stephanie Brass

Dr Richard Buck

Dr Nathan Coxford

Dr Ryan Derman

Dr Chrisjan deWaal

Dr Sharon Fehr

Dr Kevin Foster

Dr Nic Hamilton

Dr Mervyn Hiebert

Dr Ehi Iyayi

Dr Matthew Kriese

Dr Peter Kwan

Dr Magdalena Lisztwan

Dr Duncan Mackey

Dr Kevin Martin

Dr Nicholas McPhail

Dr Adrian Millman

Dr Bilal Mir

Dr Wes Orr

Dr Braden Teitge

Dr Alan Wilde

Dr Sean Wilde

 

Medicine Hat Regional Hospital Emergency Physicians:

Dr Ryan Currah

Dr Hendri Faul

Dr Chris Ghazal

Dr Dan Girgis

Dr Geoffrey Harris

Dr Joe Hawkwood

Dr Ash Jaffer

Dr Jan Joubert

Dr Michael Lee

Dr Tyler van Mulligen

Dr Edwin Orellanna-Jordan

Dr Paul Parks

Dr David Sameshima

Dr Chris Stewart

 

******************************************

From Dr Tony Gomes, Chinook Regional Hospital Department of Surgery

Dear Residents of Southern Alberta: When you are brought to the Chinook ER after a serious accident or an with an urgent surgical problem, we Trauma and GI Surgeons would love to assure you that we will be there waiting to take care of you, but the Alberta Government does not value this (hopefully you do). Her is our letter to our local MLA’s-please take a moment to read it.

Dear Local MLA’s:
I am attaching a letter sent to Alberta Health Services administration last month. We still have not received a reply from AHS, and assume our Acute Surgery/Trauma service will terminate at Chinook regional Hospital as of March 31, as all such programs are being defunded by the current government.

In a nutshell, in 2013 our group of 6 General/Trauma Surgeons saw gaps in Hospital and Trauma care and proposed an in house surgeon to provide better onsite care, improve trauma mortality and move patients through the hospital system more efficiently, avoiding or shortening hospitalizations and completing as much care as possible during the daytime to (avoid nighttime overtime for our support services such as Nursing, and saving money).

This program has been very successful, decreasing the number of patients dying of trauma by over 65%. We have succeeded in saving money , shortening hospital stays and delivering more efficient care. In addition, our rural patients transferred in for surgical opinions and specialized procedures received them within a few hours and were often transferred back to their local rural hospital on the same day.

Unfortunately, all such stipend arrangements end March 31, and combined with other fee changes (the clawback of any physician fees related to hospital visits), will make it impossible for us to keep a surgeon in the hospital during the daytime for emergent issues or rapid trauma care.

We also want you to be aware of the consequences of not having this program after March 31- longer hospitalizations, longer waits in ER for the surgeon who will be working in their office and cannot attend til 5 PM, more night time emergency cases, which all lead to more overtime, more hospital overcrowding and higher costs. In addition, based on our statistics, there will also likely be a higher trauma death rate.

Please support programs like this by supporting your local physicians and contacting your MLA to ask why important and vital programs are being deleted by our present UCP government.

We want to be there waiting for you!

Please Give Me a Reason To Stay

This is a follow-up piece to my last post Incompetence and Consequence: Alberta’s New Framework for Health Care, in which I describe why physicians are so upset over the Alberta Government’s cancellation of their contract with doctors, and why the government’s sudden cuts targeting primary care medicine are so damaging and will actually increase cost to the health system in a very short period of time.

An excellent 3 minute visual summary of the problem can also be viewed here.

Most of this post is not my words but those representing a sample of the hundreds, if not thousands of family physicians, rural physicians and specialists across Alberta who have spent the last 6 days trying to understand the magnitude of the change just thrust upon them, planning and sometimes weeping while they struggle to decide how they can continue practicing medicine in Alberta, and realizing it will be impossible to provide the same quality of care they have previously provided to you, their patients. Despite the government’s mainstream and social media advertising campaign patting themselves on the back for not cutting overall health spending, they continue to stubbornly ignore the devastating impact they are about to have on primary care due to cuts already made and fee changes scheduled to come into effect April 1 2020. This despite numerous warning from physicians of all specialties since their proposals were first released last November. In a complex health care system it is less important how much money you spend, and more important how you spend it. They have chosen to ignore the input from the many experts in health care in this province and to make these decisions on their own. Here are the fruits of this incompetence, after less than one week.

Meet Dr. Tannis Spencer, a doctor running a family practice in Edmonton, and doing extra work during her evenings and weekends in the form of home care visits to palliative patients, and sorely needed detox treatment for addictions. She recently made the difficult decision to start closing her palliative care practice, as it is becoming too financially difficult to maintain all components of her work. This tough decision inspired her to share the following words with fellow physicians, who encouraged her to pass her story on to others. She has invited me to share her words on my blog. Following her story, you will see screen captures I have collected over the last few days of Alberta doctors on social media, publicly sharing their frustrations with their patients and with the Government of Alberta. You can find these and more discussions on twitter at #ABdocsforpatients

*************************************************************************************

“I found a random assignment from grade 5 while cleaning out my basement a couple weekends ago. On the bottom it said, “Future Plans: To see Egypt, become a writer and a doctor.” I can’t believe I wanted to be a doctor as far back as grade 5.
But wait, I also wanted to be a writer. I paused for a long time looking at those words. No one really knows I loved to write novels and short stories, because I never pursued writing after high school. I went straight for medicine, full speed ahead.

Now I barely have time to read a book unless I’m on vacation.

This weekend, I asked myself “Why am I doing this?”

It’s a question that has sadly come up much more often than I care to admit. As I approach the official “5 year post-graduate” mark from Family Medicine residency, it feels like 2020 will be the worst for Alberta doctors.

Maybe I should have been a writer instead.

I am so very tired everyone, and I think I speak for all Family Doctors when I say those words. I think anyone can understand that being on overnight call is exhausting. People might get that working from 9am to 9:30pm with only 30 minutes for lunch and no break for dinner is pretty tiring too. I’ve been working long hours, charting on days off, burning my eyes out on a computer until I needed glasses and then being unable to stop for at least 14 days at a time before I take a day off – it’s physically demanding.

Emotionally, I am drained too. People don’t go to the doctor to say “Hey doc, everything is fine, just wanted to check my blood pressure”. They come in with “Doctor, I felt a lump in my breast” or “Doctor, I am only 17 and I think I’m pregnant”, or “Doctor, I was gang raped over a decade ago and I am finally telling someone now”. I never truly have ‘easy’ days. I understand that part of my job is to take on that emotional burden of the sorrows of humankind, and then file it away on the drive home so that I can be emotionally present for my husband, my friends and myself. I can do it. I’m learning how to do it. But it is exhausting.

I accomplished the goal of being a doctor, starting from the dream of a little girl in grade 5. The dream to help people. To be a doctor.

Last week, that dream was soured by the sweeping policy changes made by Tyler Shandro, Jason Kenney and the UCP. This is really not about money. This is about Tyler Shandro telling the little grade 5 girl that still lives inside me that doctors are ‘bad’ and then watching her heart break. After all these years of school, sweat, tears and misery, the government thinks doctors are simply expendable. We aren’t worth even the respect of proper negotiation. We aren’t worth honouring a contract. We are worthless to the UCP government.

We must bend a knee before our government and their wishes. We belong to them.

When I go into clinic on April 1st, start the time clock and turn to that woman who just lost her husband to cancer, and tell her “You have 10 minutes”, who do you think will be blamed?

Shandro? Kenney? The UCP?

No, not in this province.

The overwhelming majority voted UCP. When Kenney arrived, he came on a cloud with the voices of angels singing his praise, as he floated gently into the Alberta Legislature with money flowing from the deep oil wells in his pockets. He can do no wrong. He is as blue as the pure sky.

No, instead they will blame me for the decline in patient care. They will blame doctors. They call us greedy, money-grabbing, and irresponsible health care spenders.

I don’t want to work here anymore, Alberta.

I don’t want to be hated by you.

I am so tired of being surrounded by people who voted for men in suits who are using slimy propaganda and fake news to make me look like a greedy doctor who only did this for money.

I just want to live out the dream of that little girl in grade 5. To help people. To be a doctor.

But I am already so very tired. We all are – the Family Doctors of Alberta have been burned and we are just so tired. How long are we going to fight for you until we decide it isn’t worth our health and sanity anymore?

One of my palliative patients said to me before he died, “Dr Spencer. can you please take care of my wife when I die?”

I said to him, “I promise. I’ve got her.”

Please don’t make me break that promise Alberta.

Please give me a reason to stay.”

Dr. Tannis Spencer.

************************************************************************************

01-Care and crying02-Crying onions03-lost sleep04-Childcare05-Retire Rural06-Imaging delays07-PhysFamilySupport08-Suicide note09-Respect10-leaving AB11-Leaving12-lost graduate13-In training

Palliative- Lethbridge14-MH grad leaving15-Warren-116-Warren-2

Today I cried
(Dr. Charlene Dinakaran, Family physician, Edmonton Zone)

*************************************************************************************

 

Lest you think Doctors have not tried to educate the minister through his new preferred communication platform of twitter, or have not agreed to take fee reductions both under past governments and currently please see the below:

 

01-AMA-102-AMA-203-AMA-304-Against evidence05-Costs rise06-economic sense07-evidence-risk08-attack09-Negotiations failure10-Previous concessions11-Lies called out

 

Please add your voice to those of Alberta doctors to stop the drain of physicians out of the province, keep good family practice financially viable, and return to the negotiating table to find actual, sustainable savings in the health care budget. We are trying to sound the alarm before it is too late.

Thank-you,
Dr. Sean Wilde, MD, CCFP-EM

 

[EDIT: Please see this letter to the minister of health signed by 85 concerned Calgary emergency physicians. ER doctors have always advocated for more investment in primary care and home care as this is what reduces cost and crowding in emergency departments]

 

[EDIT: Please sign and share this change.org petition asking the Minister of Health to return to the negotiating table with doctors to find sustainable health care savings that won’t decimate Alberta’s health care system.]

 

Minister of Health: Tyler Shandro
423 Legislature Building
10800 – 97 Avenue NW
Edmonton, AB
Canada T5K 2B6

Phone: 780-427-3665
Fax: 780-415-0961
E-mail: health.minister@gov.ab.ca
Twitter: @shandro

 

Premier Jason Kenney
307 Legislature Building
10800 – 97 Avenue
Edmonton, AB
T5K 2B

Phone: 780-427-2251
Fax: 780-427-1349
E-mail: premier@gov.ab.ca
Twitter: @jkenney

 

Incompetence and Consequence: Alberta’s New Framework for Health Care

[Edit Feb 26/20: For a visual overview that summarizes the urgent crisis facing Alberta family medicine as described in this article, please watch and share this short 3 minute video.]

 

To anyone paying attention, it’s clear that Alberta doctors are very upset about the provincial government’s recent announcement over changes in physician compensation. It can be a little confusing to see through all the political spin and bureaucratic jargon to know what exactly is going on. The details are not that complicated, and it is important for Albertans to understand this is not simply a case of highly paid professionals upset about earning a little less money; when inadequately executed, changes in health care funding can have dramatic effects on the day to day healthcare provided to you. There are a few important things to understand.

How are doctors paid and where does the money go?

Click here to read my more detailed explanation about how doctors are paid (including fee for service vs ARPs) and where the money goes. In summary:

  • When the government “pays” doctors for care, the money is pre-expense and pre-tax business income, not a salary.
  • Physicians working in a clinic tend to spend 30-40% of this payment on overhead to pay for rent, staff, equipment and other office expenses.
  • Additionally, practicing as a physician requires multiple annual dues to various regulatory bodies to be allowed to practice medicine, maintain your certifications, keep up on mandatory continuing medical education, and holding expensive malpractice insurance. Annual totals can vary widely between specialties, but somewhere around $12,000 – $57,000 dollars per year is a reasonable estimate for most Alberta doctors.
  • Medical education is an investment of at least 10 years of time and for some upwards of $300,000 in borrowings that needs to be repaid.
  • Physicians receive no work benefits or pension, and need to budget for their own insurance, health expenses, time off, vacation time, and retirement savings.
  • Physicians have a high demand, low supply skill set that commands a high market value. These skills are in demand everywhere, so if under-compensated, there are many options for work elsewhere.
  • Physicians can and do earn a good living after a significant time and money investment, but are usually motivated by reasons other than money, as this career is not by any means a quick and easy path to wealth. It is worked hard for over a lifetime.

The information above is to help understand why when you hear that the average family doctor “earns $298,000” per year, it is not accurate to directly compare that to a generic salary in another field. When the government says they pay X amount to doctors, remember that this total includes (among other things) the salary and benefits of every single nurse, secretary and office assistant that works in any (non-AHS) physician clinic in the province. That includes almost all family medicine, walk-in and specialist clinics. These are all publicly funded private clinics, and that public funding comes under the umbrella of “doctor fees.”

 

Why does Alberta pay doctors more than in other provinces?

Part of the reason should be obvious when you understand the previous section. Clinic rents and employee salaries are on average higher in Alberta than elsewhere. To a run a business in Alberta costs a doctor more than in other provinces.

Another reason is that due to historically greater financial resources, Alberta could afford to pay more than other provinces, and intentionally did so to solve its physician shortage. These shortages stem from the Ralph Klein years of deep cuts to health care, which have taken the province almost a generation to recover from. Financial incentives to recruit and retain physicians have been central to the health care plan of Alberta governments for the last two decades. And it worked. The current government has cherry picked certain health indicators (like elective surgery wait times) to claim the province does not receive good value for its health expenditures (while ignoring the variable costs of doing business). However, in one of my last posts, you can see a long list of examples of terrible systemic health care problems faced by the rest of the country that have not been nearly as bad in Alberta. Does Alberta pay too much for health care or do other provinces not pay enough? The government frequently compares our spending to that of British Columbia. I’ve seen a lot of patients who left BC specifically because they could not get adequate and timely health care. If you know someone who lives there, ask them about it. Recent fee change discussions in BC have actually been using much of Alberta’s system as a model of a successful system to emulate in their future.  Health care is expensive no matter how you pay for it, and each society needs to decide what it wants – shorter wait times for hip replacements, or adequate doctors to provide preventative primary care and enough space in the hospital for everyone who needs it.

 

What is the big deal with the government’s new compensation plan?

First, trust.

Negotiating physician compensation has always been a complicated back and forth of asks and concessions from both sides: the government needs to control its budget, and doctors need to make enough to have a viable practice, fund their education and future, and feel they are receiving enough value for their skills to stay in this province. Friction is inevitable. Despite this, agreements have always been made and honored before returning to the negotiation table when it was time for another. Budget restraints have been a reality for a few years, and the AMA has made concessions, and found millions of dollars of savings already by cutting and adjusting the fees paid to doctors. You can argue it has been too little and too slow for the current reality, and yes, it is a challenge to get 10,000 people to agree on who is going to take what pay cut, but there has been a collaborative process. Until now.

Late last year the UCP offered “proposals” to physicians outside of the AMA negotiations to cut a number of fees. The response was both an explanation from doctors as to why these ideas would not work, and an insistence that they be put in with the rest of the renewed negotiations. Meanwhile the Minister of Health, and several government health agencies began a social media campaign disparaging the value the province receives from physicians, including the usual misleading information about how much doctors “get paid” (gross billings). Eventually the government agreed to take negotiations into mediation (Jan 31), and declared it a failure on February 15, despite the AMA offering concessions to save over $150 million, and informing them they were working on others. On February 20th the government announced they were using the new powers they legislated to themselves last year to rip up the current agreement with doctors, and give themselves authority to unilaterally dictate physician compensation. They simultaneously rolled out their original proposals to go into effect on April 1. It is hard to believe they were ever negotiating in good faith, and the entire process appears to have been a sham with the intention to find an excuse to take over full control of physician payment.

Incredibly, at the same time they have offered (but only on Twitter) to give doctors the option to quickly sign up for a 3 year ARP (basically a complex fixed income arrangement – discussed here). The Minister tweeted a document that he claimed was sent to doctors the week prior (no physicians I know have received it), that included an out of service phone number to get more information. Those physicians who have tried to get more information have found little more than an answering machine (eventually) and some form letters implying that the details will be worked out later. No information has been passed on to the AMA’s ARP negotiation group that has helped establish all former ARPs. Who would sign an incomplete agreement with a government who just used its new power to break any legal contracts it is in and has been tweeting about how over paid you are? At the best of times ARPs result in doctors handing a great deal of control over their practice and income to the government, trusting them to honor the agreement with little recourse if they don’t. They are complex and require mutual respect and trust between both sides. It is unlikely this government will be successful at convincing many or even any physicians to give them that trust. The UCP’s negotiation efforts seem to have been all smoke and mirrors propaganda; used against a group who regularly hold frank life and death discussions with the people of Alberta.

 

Second, competence.

In addition to fair pay, physicians have a vested interest that the health system works for our patients. We see them everyday, we care for them. We try to get them urgent care when they need it in a system that often makes it difficult. There’s a reason that health reform is a slow process. Politicians need to spend less and get more, managers have the pulse of day to day big picture business, and front line providers have the inside knowledge of how things really work, where the waste is, and what would work better. Collaborative efforts between these groups take time, but have always been the best way to reduce cost, increase efficiency, and improve health outcomes for patients. There are countless examples of this working well in Alberta and elsewhere.

The UCP government has never shown an interest in being collaborative. They have been adversarial from the start. It’s the government against doctors, against nurses, against all public employees. Patients are stuck in the middle. Anyone paid by taxpayers is a mooch on the system, and is the enemy of the current government. In an organization as large and complex as Alberta Health Services, and an expanded community health system that is even larger, how is that approach going to do anything but cause damage? Can the top down dictation by a handful of career lawyers and politicians make better decisions on healthcare than consultations with the experts? No one who works in the health care system wants it to fail or be financially unsustainable. But instead of inviting doctors, nurses and outside consultants to work with them to save the system, Premier Kenney and health minister Shandro have said we will tell you what to cut and what to change. We are not interested in your opinion. Does this approach make any business more successful? Or does it just drive people deep into their own silos, protecting their own livelihood, knowing they have no ability to improve or protect the whole? I would not buy stock in that company. It’s a recipe to destroy public health care, and maybe it is no accident.

The UCP’s new framework is an example of the incompetence this approach breeds, which I will explain next.

 

Third, this will immediately affect your health care.

While a number of fee cuts and physician benefit program reductions were just announced, the biggest, most short-sighted mistake is the decimation of family medicine time modifiers. When these codes were first introduced they were instrumental in giving Alberta one of the best “medical home” models of primary care in the world. It might be best explained in an allegory.

 

Imagine you are tasked with the upkeep of a large companies’ fleet of cars. Each requires regular maintenance to keep it out of the repair shop. You have a handful of mechanics who do this, and you pay them each $38 for a regular check up: change the oil, filters, top up fluids. Each mechanic takes about 10 minutes to do the basic work. It mostly works well, but as cars get older, some get more complicated and break down. When a car breaks down, it needs to be taken to the repair shop for urgent work. This costs $1000. If you’re lucky, it can be patched up and sent back to work. If not, it needs to stay in the shop for a week, usually costing about $8,000 for a full overhaul.

So you go to your mechanics and say “Hey, let’s keep cars out of the repair shop, it’s too expensive. I heard if you do a little extra work on them you can stop them from breaking down so often.”

Mechanic A says, “I tried to do that, but then I can only get 3-4 cars done an hour, I’d only make $1,216 a day at most, and it’s barely enough to cover expenses. Mechanic B over there only works on the easy newer cars, and whips through 6 an hour. He makes $1,824 and doesn’t help keep anything out of the shop. That’s not fair- I’d like to do quality work, but I can’t afford to.”

So you add in some money to encourage your mechanics to take a little extra time on those cars that need it. If they work on a car longer than 14 minutes, you pay them an extra $18 for every further 10 minutes they spend. Mechanic A is now happy to keep those older models running, and is making $1,648 a day, dealing with 1 simple and 3 complex cars every hour, as an extra 4-5 minutes is enough to deal with many of the extra problems. Mechanic B is still in it mostly for the money, hasn’t changed, and still makes about $1,824 on simple stuff. Others do a mix of both and make something in between. The mechanics willing to work on complex cars can now afford to do it, and you are saving a lot of money by sending fewer cars to the shop.

 

This is an exact allegory of primary care as it currently stands (or stood). Doctors are the mechanics and patients are the cars. A trip to the shop is an emergency department visit, and a prolonged stay is a hospital admission. The numbers are actual billing numbers, and estimates of the cost of average ER and hospital stays. Wise past negotiations have made it possible for good doctors who need and want to spend a little more time with their patients to do so, and run a financially viable practice. This revolutionized primary care in Alberta, making it possible to offer good care, and break out of the “10 minute medicine” paradigm that no one wants. Experts in medicine will tell you that every dollar spent on primary care saves many times its value in reduced ER hospital costs. We have an excellent primary care system due almost entirely to the existence of these fees.

To return to our allegory, what the UCP has just done is say: “You now don’t get paid that $18 extra unless you spend at least 25 minutes working on a car.” So if mechanic A keeps doing what he is doing, he will go back to being paid $1,216 a day. Maybe he will try to spend even more time on the needy cars, and see 2 each hour + 1 quick one, but that is only $1,200 a day. His only choice is to take a substantial pay cut, or return to mechanic B’s plan, and just do the bare minimum. He won’t be able to do the extra work needed to keep cars out of the shop very often, but can at least stay in business.

 

This is the sudden reality facing many Alberta doctors on April 1 who have built a practice on being able to spend 15-20 minutes with complex patients. Their average hourly business income will drop from $224 to $152 –  a 30% decrease. Perhaps the government is encouraging them to spend even more time with complicated patients to get the bonus. Nope – doing that works out to $134 per hour when averaged over a day. This loss either comes out of their take home income, or their overhead – firing clinic staff. For most clinics there are only 2 viable solutions – return to 10 minute appointments (which will cost the government MORE per hour than they are currently paying) or close up shop. In musings on worried physician discussion groups on social media, I have seen doctors already making plans for both.

It’s not hard to see the insanity of this “solution.” The change is a clear incentive to spend less time with patients- to return to a model that provides inferior primary care, will result in sicker people making more visits to the ER, needing more hospital admissions and will ironically increase physician expense in both primary care and the much more expensive hospital care. This is only one example of the unintended (presumably) consequences that will stem out of one ill conceived change. Other initiatives announced at the same time will almost certainly impact front line care. The loss of stipends (bonuses) for being on call means specialists will need to book clinics or surgery at the same time they are on call. This will delay specialist consults in emergency departments and hospital units by hours, further compounding the problem of hospital and ER overcrowding. Wait times will rise. The loss of stipends in rural areas may lead to complete loss of emergency and/or hospital coverage in some communities. Deep cuts to AMA liability support programs risk making some obstetrics practices unsustainable because of the enormous insurance cost, especially for rural physicians. None of these payments were initially established without a good reason, and ignorantly eliminating them will dramatically affect front line care. This is why politicians should not vote themselves the power to make uninformed health care decisions all by themselves.

 

What can I do about it?

Please contact your MLA, Premier Kenney, and the Minister of Health. Insist they return to the bargaining table with doctors to negotiate a stable and fair deal. There is still money to save, but they are proving themselves not experienced or competent enough to do it without making short sighted decisions that will cause irrevocable damage to the health care system, and increase the very costs they are trying to cut. Consult with health care workers and they will show you more ways money can be saved – if they feel they can trust you. Do it genuinely, not with meaningless AHS “surveys”  incapable of collecting information useful for anything beyond propagating a pre-determined agenda. Work with doctors and nurses instead of against them. If there is no acceptable way to lower costs enough to balance the budget, stop ignoring government revenue as a factor in the equation. Canadians are proud of their equitable health care system, and Alberta probably has the best one in the country. Don’t go down in history as the government that destroyed it.

 

[EDIT Feb 27/20: Please see this followup post for a brief snapshot of the impact of these changes on Alberta physicians just one week later as they struggle to find a way to continue practicing good medicine under a fast approaching deadline.]

 

[EDIT: Please sign and share this change.org petition asking the Minister of Health to return to the negotiating table with doctors to find sustainable health care savings that won’t decimate Alberta’s health care system.]

 

Minister of Health: Tyler Shandro
423 Legislature Building
10800 – 97 Avenue NW
Edmonton, AB
Canada T5K 2B6

Phone: 780-427-3665
Fax: 780-415-0961
E-mail: health.minister@gov.ab.ca
Twitter: @shandro

 

Premier Jason Kenney
307 Legislature Building
10800 – 97 Avenue
Edmonton, AB
T5K 2B

Phone: 780-427-2251
Fax: 780-427-1349
E-mail: premier@gov.ab.ca
Twitter: @jkenney

How Doctors Are Paid and Where the Money Goes

This information is provided in conjunction with this post about the February 2020 UCP termination of its contract with Alberta doctors.

  • As a rule physicians are usually not salaried employees – they provide medical service either inside government health facilities or private clinics, and then “bill” Alberta Health and wellness (AH) for the work they do. This is called “fee for service.”
  • The fee paid for each service is set in the “Schedule of Medical Benefits” (SOMB). The rates and any changes are negotiated periodically between the government and the Alberta Medical Association (AMA) which represents doctors for collective negotiations.
  • With the money received through billing, doctors must first pay their operating expenses. For doctors working outside a hospital, this includes rent for the clinic, salaries and benefits of all the staff working at the clinic, and all the medical supplies, office supplies and utilities and services needed to run the clinic – normal business operating costs. Most clinic doctors report these costs represent about 30-40% of their billings. This is called overhead.
  • All doctors must also regularly pay substantial fees for the ability to continue practicing medicine. Currently in Alberta these include:
    • Annual license with the College of Physician’s and Surgeons: $2,360 (legally required)
    • College of Family physicians (required to maintain status as a registered family physician): $1,113
      • Specialists will pay a similar (or higher) fee to their own regulatory body
    • Optional but important membership dues in organizations like the AMA, or a sub-specialty focused association. My costs for these are typical and run about $2,760 a year.
    • There is a regular continuing medical education requirement (to keep up to date with changes in the field of medicine). This can include medical journals, conferences and online subscriptions. Obviously cost varies, but they usually cost me in the neighbourhood of $2,000-$4,000 per year.
    • Liability insurance to protect physicians and payout successful lawsuits to patients. This is also mandatory and varies by specialty – higher risk practices like surgery or obstetrics pay more. This currently varies from about $2,050 to $47,350 per year.
  • After all this, is your gross take home pay (what most people see on their paycheck before deductions). Then like everyone else you pay taxes, and then you deal with your personal budget.
  • Keep in mind that unless they came from a wealthy family, most new physicians end their education with at least $100,000 to $200,000 in educational debt to pay off. Canadian banks currently will offer up to about $320,000 in credit to doctors and doctors in training to manage their expenses over time. This is in addition to government student loans. In Alberta the lifetime cap for medical education is currently $175,000. Individuals like me who were married with young children during our medical education tend to use a lot of that credit. I’m still paying loans off 8 years into practice with a son graduating from high school himself in 2 years.
  • Physicians also have no paid benefits: no health plan, no pension, no sick leave, so need to plan for their own unexpected expenses and retirement out of what is left.
  • Physicians have a skill set that is in high demand for good reason, and should be compensated accordingly. Personally, if I need to miss a shift at work for any reason, there are only about 15 other people in my whole community of 90,000 people that are qualified to “cover for me,” 6 of whom are already working a different shift that day. If a few others are out of town or busy with other commitments, there are very few coverage options, and you can’t just not have a doctor working in a busy emergency department. I have to be very sick before I avoid a day of work. Family doctors who miss work often cannot be replaced, and need to cancel entire clinics.

 

What about ARPs?

ARPs (Alternative Relationship Plans) are an alternative to fee for service billing that is used in some places. Each plan is unique and the rules can be complicated. The general idea is that a hospital physician is paid a fixed rate for a specific number of hours of work. If you work less, you don’t get the full amount, but if you work extra you do not get paid anything extra for it. In a rural or clinic setting, an ARP physician group is paid a fixed amount every year for each patient on their roster, and sees them as often as necessary. If your patient is seen by an outside clinic, there is usually a penalty deducted from your payment as incentive to make sure you are available for timely appointments. There are also blended models that use some of each to account for the many physicians with complicated work schedules who work in multiple different capacities. Just as in a fee system, this money is all paid before expenses, and there are no benefits provided.

 

ARPs are attractive to governments as they make payments to doctors a more predictable expense than fee for service. They also decrease the unfortunate revenue generating “pill-mill” practice some walk-in clinics are accused of where good patient care is sacrificed for high volume billings. They can and do work well in many different places, but as they should not create either unfair work hours or payments when compared to fee billing, they tend to be complicated to setup and monitor. Most are tailor made agreements between doctors and government in certain practices or communities that take a long period of study and consultation to develop.

 

One potential downside to ARPs can be the volume of patient care provided. Imagine you are working in a busy clinic with a waiting room full of people waiting to see you. There is always an incentive to help as many people as possible, but when you are being paid for each person you see, it is human nature to be more willing to skip taking a break, miss lunch, or stay late to fit a few more people in, because at least you are being paid to do the extra work. However, if you get paid the same amount of money to take work at a more reasonable pace, there is little incentive to run yourself into the ground, or work unpaid overtime, especially day after day, year after year. While ARPs make budgets more predictable, implemented inappropriately they can result in lower output per physician and longer waits for patients. Physicians within ARPs tend to lose some autonomy to alter their practice, and become very dependent on the government holding up and not unilaterally altering the deal. This is one reason they tend to be complex to establish, and require a high level of trust between both parties.

“Bringing Down” Health Care in Alberta

Recently, Alberta Health Services employees and physicians received an email from the new UCP Health Minister, Tyler Shandro. Mr. Shandro echoed Premiere Jason Kenny’s prior commitment to “maintain or increase health spending, and strengthen our publicly funded health system.” In the next paragraph among a list of the usual platitudes of improving this and that, was the goal of “bringing down Alberta’s health spending to national norms by 2022-23.” Here is the UCP pre-election health platform.

 

There’s no question that Alberta has been fortunate in the past due to the revenue provided by the successful monetization of our natural resources. Whether this excess was squandered or not is perhaps a matter of opinion, but Alberta has historically benefited from the ability to spend more on health care than other provinces. The UCP would have you believe that this extra spending is a frivolous excess that provides no real benefit, as alluded to in their above election platform- an assertion that seems mostly based on wait times for hip surgery. Perhaps patients and health care providers in other provinces who have lived with those smaller budgets would see it differently. Every system has its challenges; health care is expensive, and there’s always something that you could do better with more money. More hospital beds and more long term care beds means better care and lower waits times. So does hiring more nurses. Paying doctors a bit more than they can get elsewhere encourages them to work in your province and eases community and physician shortages. It also enables them to hire the essential clinic support staff to provide better care and jobs in the community. Did you know that your family doctor’s billing “income” is used to pay for clinic rent, supplies, administrative staff, nurses, nutritionists, psychologists, and anyone else who works out of the same clinic, before they get their own take home pay? The government does not directly pay for any of that.

 

Now that the oil gravy train appears to be on an extended, or maybe even permanent hiatus, there are tough decisions to make. Everyone gets that. Health care providers of all stripes have accepted little to no pay increases for several years in Alberta, despite living with the same rising costs as everyone else, and dealing with an aging population with increased health care needs. Physicians have helped identify antiquated fee codes that could reasonably be reduced or eliminated in a modern health system. We have all participated in multiple “streamlining” exercises over the last several years that have identified inefficiencies and cut down many AHS expenses. In this recent letter, the current president of the Alberta Medical Association section of family practice outlines some of the initiatives to cut costs and improve patient care that physicians have recently collaborated on, and expresses the professions interest in working collaboratively with the current government to further streamline care.

 

However, the actions of the UCP in the days and weeks before and after this mail out have me seriously questioning their actual commitment to the publicly funded health system. In addition to targeting education, post secondary students, and many other public sector workers, the government has used recent omnibus bills to give itself the power to withdraw from all previous or future contract agreements with doctors and nurses, and given itself the power to dictate where newly licensed doctors are allowed to practice in the province. Since then, there has been loud signalling towards doctors to expect deep unilateral fee cuts, and notice of hundreds of expected front line nurse layoffs. There is no way eliminating front line nurses is going to improve or speed up any aspect of patient care in an already struggling system. You can argue political ideology all you want about who should pay for what in health care, but when you directly remove front-line health staff, and provide dis-incentives for doctor’s to work in the province, there is no way that the public health system is not going to be severely weakened. Patients (you and your families) will suffer for it. Other provinces have tried to “force doctors where to practice,” and have abandoned it when they started running out of doctors. Who wants to work in a socialist dystopia where the government gets to tell you where to work, and unilaterally cut your income with little to no notice without negotiation or consultation? Just two months ago New Brunswick announced it was abandoning this approach, the health minister saying: “It is flawed because it restricts the number of physicians practising, restricts the mobility of physicians and impedes recruitment.”

 

How is it possible the Kenny government doesn’t know this? It’s very hard not to conclude that they are trying to decrease the number of doctors in this province, because that’s what these policies are designed to do. It will certainly lower costs if there are not as many doctors to pay- for a while at least. It will also cause a lot of other problems. Perhaps it will weaken the public system enough that the UCP will have a good excuse to “give private health care a try.” That’s a supposition on my part, but if that was my goal, this is exactly how I would start.

There’s a lot more I could say about this, but I have a different purpose in this post. The Kenny government wants to “bring down Alberta’s health spending to national norms.” As a member of the Canadian Association of Emergency Physicians, I receive a monthly email that contains multiple articles of interest on the current state of emergency medicine across Canada. Each one usually contains a handful of stories about challenges faced by various emergency departments across the country. I reviewed the last several months of those letters, and pulled out all the articles that describe a system challenge that results in poor or dangerous patient care because of a lack of resources- things that are going wrong because there is inadequate staff, beds or other resources. None of them were about Alberta. Not because we don’t have challenges- we face all the same challenges to some extent in parts of the province- but because ours are generally not as bad. Why? Because we have been able to allocate the resources necessary to prevent or minimize many of these problems. So I present to you below some of the  “national norms” for emergency department care. All articles are from this year. This is just from the perspective of the emergency department, but the ER has always been the canary in the coalmine of health care- when it becomes overwhelmed and non-functional, it is almost always a symptom of unmet problems at other levels. Is balancing the budget a good enough reason to accept moving further in this direction? Is a modest provincial sales tax perhaps worth the pain to keep the good thing we have in Alberta going? Isn’t it easier and cheaper to maintain what we have rather than to try and rebuild it in some hopefully more prosperous future? Those are the questions Albertan’s should be asking themselves.

 

CIHI Data: Emergency department wait times on the rise in Canada

“Canadians are waiting longer to receive emergency medical care, according to new figures from the Canadian Institute for Health Information (CIHI), with patients in Quebec and Manitoba enduring the longest emergency room visits in the country. …Alberta and Ontario had the second and third lowest emergency wait times, respectively, with B.C. in fourth place.”

 

N.B. hospital diverting ambulances due to overcrowding, staff shortages

“Hospital closures have been a problem across Atlantic Canada. In Nova Scotia, 11 of the province’s 37 emergency rooms were forced to close in August due to the unavailability of doctors. One doctor said that she’d seen people who’d suffered cardiac arrests in the waiting room and triage area.”

 

 

One-fourth of Moncton Hospital beds occupied by people waiting for nursing homes

“We need a much more efficient process for moving them from the hospital to the nursing home,” says Dr. Ken Gillespie. “Right now, the average length of time that patients are in hospital is about seven months. But we’ve seen that go longer. In some cases, even two or three years that patients are in hospital waiting for a placement.”

 

Action needed to address Nova Scotia emergency room closures: reader

“Emergency room closures in Cape Breton, Richmond County, along with all other Nova Scotia county hospitals need to be addressed as a crisis throughout the health-care system.”

 

As Clinton ER to close overnight, other rural hospitals face similar issues

 

“A shortage of qualified nurses is to blame….She says there are other hospitals in rural Ontario that are “one retirement” away from facing a similar nursing shortage.”

 

Offload delays, no downtime and other problems are stressing out metro St. John’s paramedics

“ST. JOHN’S, N.L. — Offload delays in which paramedics are left waiting in hospital corridors to hand over their patients to staff have ballooned from minutes to hours in just a few years at overcrowded St. John’s emergency rooms.”

 

‘People are dying’: Life and death at level zero: Paramedics, doctors and patients sound the alarm about lack of ambulances in Ottawa

 

“The problem isn’t unique to Ottawa: hospitals across the country deal with similar overcrowding issues in their emergency departments, said Dr. Howard Ovens, an emergency physician and chief medical strategy officer at Sinai Health System in Toronto.

“It’s just soul-destroying. It goes against every reason you’ve come to work that day,” Ovens said.

Paramedics are feeling the strain, too.

“Paramedics go into work and they feel despair. And we feel it for our patients,” Wilton said.”

 

Hamilton’s hospitals overflowing heading into flu season

“In June, when overcrowding should normally be easing off, HHS had an average occupancy rate of 107 per cent — meaning it had more patients than beds funded by the Ministry of Health. Known as hallway medicine, hospitals are forced to open up beds on their own tab, sometimes in unconventional spaces like sun rooms, hallways and family rooms.

The problem is now so severe that HHS hasn’t been below 100 per cent occupancy since August 2016.

It’s tough for Hamilton hospitals to afford the extra beds at a time when they’re also cost-cutting $42 million by March 31.”

 

‘That’s a crisis’: P.E.I. senior spends 9 nights in ER waiting for long-term care bed: More than 200 Islanders are waiting for long-term care services

 

“According to the province, as of the start of October, there were 201 Islanders waiting for long-term care services, and as of Oct. 10, 46 people were in hospital beds waiting for access to a long-term care bed. Nine of those people, like Gallant, were waiting for dementia care in Prince County.”

 

More than 100 Toronto emergency room professionals urge province to reverse public health cuts

 

“In Toronto emergency departments today, many patients have to be ill, first of all, in a chair — so there are no stretchers available for many patients and many patients ask me directly: ‘Can I please lie down,’ and when they can’t lie down, they lie on the floor. They lie on the floor in the waiting room, they lie on the floor in treatment areas,” Venugopal said.

 

Hospital employee unions call for end of “hallway medicine”

 

“patients are being treated on stretchers outside of emergency wards      without access to bathrooms, privacy, or the ability to have a confidential discussion about their medical condition.

Hurley notes people have even died in these environments, and others have had to stay in broom closets and other inadequate accommodations.

“As recently as July 12, 2019 [Premier Doug Ford] said his government would     eliminate hallway medicine within a 12-month period,” says Hurley. “It’s a great promise, but we’re very concerned because that’s not born out by the budget that was passed in the spring.”

Hurley explains Ontario has closed more than 20,000 acute care beds over the last 20 years.

“This leaves us with the lowest capacity in terms of beds to population, and staff to population, of any hospital system in Canada, or, in fact, of any country with a developed economy…,” he says.

This includes countries such as Turkey, Mexico, and the United States.”

 

New numbers show rise in wait times at Winnipeg ERs, urgent care centres

“Newly released numbers show wait times this July were worse at all but two of Winnipeg’s emergency rooms and urgent care centres when compared to the same time last year.”

 

A doctor’s warning: Safety is at risk in Ontario’s ERs

 

“Do the math. A 30-per-cent reduction in acute care bed capacity and a further 20-per-cent reduction due to patients with nowhere else to go. The healthcare dividend never materialized and now hospitals and more specifically emergency departments are crowded and dangerous.”

 

Report finds Montreal emergency rooms over capacity

“On the Island of Montreal, 14 of the 21 emergency rooms have more patients than beds to accommodate them, according to an Index Santé report. This is also the case for the Cité de la Santé Hospital in Laval, three of the six hospitals in the Laurentians and eight of the 10 hospitals in the Monteregie.”

 

 

NSHA, Doctors Nova Scotia clash over emergency department closures

“10 of 37 emergency departments across the province will be closed at certain points this week. The ED at Musquodoboit Valley Memorial Hospital will be closed for a total of five days reopening its doors Saturday.”

Needle debris: some thoughts from the ED.

[18 Sep/18 Edit: This post is getting a lot of attention which is great. Comments are welcome, but overtly derogatory or threatening ones will be deleted. Thanks for your respectful discussion.]

Like many places, my medium sized Alberta city has been experiencing a crisis of illegal drug abuse, and a second crisis of outrage over the public risk from drug associated crime, needle debris and other fallout. While frustration and fear for the community and public safety is completely understandable given current conditions, I worry that misinformation and a lack of background understanding is generating a lot of unfocused or misdirected anger towards people and institutions that are either not responsible for or are unable to directly address people’s concerns. There is a lot of blame being placed on organizations trying to address the problem, and while feedback and accountability are important, so is understanding what they are doing and why. With a bit more background perspective, I’m hopeful this public energy could be better directed towards efforts for realistic and workable solutions.

I work as an Emergency department physician in the city, but my views are my own, and I’ve had no direct professional involvement with the safe consumption site or the organization that runs it. While I can’t speak for the program or its management, I can provide a few insights on the nature of the drug crisis as I have seen it. I also can’t tell you what the best solutions may be, except to reassure you they are neither quick nor simple. Perhaps what I say will at least broaden a few perspectives, and stimulate someone to learn more about the roots of the crisis in our community and explore how they can be part of the solution.

Illegal drug abuse and the associated crime, violence, disease and death is not new here. It has been in our city for a very long time. There have been community outreach programs for many years offering clean needles, disease screening and treatment, addictions counselling, and access to nearby detox facilities. It is a hard thing for people to escape and a hard thing for health care providers to treat. The roots of addiction often run deep within communities and families, and are often linked to inter-generational trauma and childhood abuse and abandonment. There are a lot of poor choices being made for sure, but often by people who never had the benefit of someone to teach them how to think about making choices.

Getting out of this addiction requires a community of supports and often complete socioeconomic and cultural life changes. This requires deliberate and repeated choices by the addict to accept help and make these hard changes, often developing an entirely brand new way of thinking. That’s in addition to traditional medical detox. Detox can be an important step, but if you leave a facility and return to an old life with family and friends who are addicted and have little to no resources to change their circumstances, you have a very poor chance of staying clean. There are success stories, but not enough. The purpose of harm reduction is to hopefully keep a person alive and healthy enough through their addiction years that they have the chance to go through this process when they have decided it’s time to change, and can achieve a reasonably healthy life in recovery.

Drugs have always ruined too many lives, but a few years ago the illegal drug market in North America changed. What we call “synthetic opioids” arrived and started killing users in unprecedented numbers. Opioids are powerful pain killers. They are effective but can be dangerous if misused. They are addictive because in addition to numbing physical pain, they can also temporarily release you from emotional pain and distress, and replace it with a sense of comfort and euphoria. Those who have lived lives of pain and disconnection from loved ones are primed for opioid addiction. Additionally, regular use will make you more susceptible to both physical and emotional pain when you stop using them. Too much will sedate you. A little more will slow your breathing and eventually stop it. This is how they kill.

Over-prescription and street diversion of medical opioids is a problem that has been around for a while that the medical community is working to address. However, when the “meth lab” industry learned how to make cheap synthetic opioids the game changed. This is the fentanyl crisis you may have heard of. It is NOT diversion of carefully regulated prescriptions, but the black market distribution of crudely made crystals, liquids or pills containing entirely variable and unknown doses of synthetic fentanyl (or its more potent cousins carfentanil and remifentanil). Because small amounts are so potent, and illegal drug labs are not known for their quality control, drug concentration is variable and dangerously unpredictable. One pill might give you a bit of a buzz. The one next to it might kill you. Distribution of the drug spread quickly because it was cheaper to get than other drugs, and it could be cut into anything else (cocaine, meth, marijuana) to provide a “better buzz,” that would bring customers back more often, and at less cost to the supplier. If they survived of course.

Front line police, paramedics, and emergency staff began to see the effects immediately. Opioid overdoses became common, daily occurrences. When a new batch of drugs hits the streets we see dozens of cases a day for several days, slowly tapering off over a few weeks until the next batch arrives. Administering Naloxone (brand name: Narcan) – a medication that rapidly reverses opioid effects – became the obvious first treatment for almost any suddenly unresponsive patient, and often quickly turned around a life threatening event. During my residency training not many years ago, I hardly saw Narcan used at all. Back then, it was rare to see someone who had managed to consume or inject a life threatening dose of opioids outside of a few inner city hospital centers. Now it is common almost everywhere.

Not only is fentanyl killing regular drug abusers who risk death with each high, but it is a serious risk to more casual drug users. You might not know this, but there are people around you living normal lives, holding good jobs who indulge in the occasional “cocaine party” or similar on the weekend. These people’s bodies are not as accustomed to opioid exposure as those of a drug addict, and a lower dose of fentanyl cut into whatever they think they are taking is often enough to kill them. Despite a few years of this madness, drug abuse continues. In fact, I suspect for whatever reasons, rates of abuse are even higher.

Consider this: right now, nearly every drug addict I and my ED or EMS colleagues treat and pull back from the brink of a self induced death, has at least one – usually several – dead friends and family members, recently killed by the same drugs they are still taking. These people know they are risking their lives every time they indulge. I have discussed it with many of them. To anyone who believes the threat of greater legal consequences for drug use is going to be an effective deterrent, or that this is just the life users have chosen, consider how damaged a mind and disordered a thought process this activity suggests. It’s literally playing Russian roulette with every pill or injection, but they still do it. If a gun to the head won’t “change a druggies mind,” then will a fine, a court date, or a jail cell? The answer is obvious to anyone who works with this population.

Let’s look back to about a year ago- perhaps the height of the opioid crisis so far [EDIT: from my local ED perspective at least]. We did see periods of decreased overdoses, I suspect in large part due to stepped up police enforcement to get the deadly stuff off the streets. We handed out a lot of home administered Naloxone kits- saving a few more lives for a time. Still, when more opioids hit the streets, there were deaths and near deaths in droves. While I was not personally involved, it was during this time of many calls to “do something,” we heard word that the city would be rushing to set up a supervised consumption site (SCS). This was not specifically to distribute clean needles – that is something that was already long in place in our city to prevent transmission of HIV and hepatitis. This was to provide a place where someone was supervising drug consumption that was already happening in order to reduce and respond more quickly to potentially fatal overdoses. It is not a new idea, has worked elsewhere, and ideally comes as just one part of a greater package to treat drug addiction and address the multiple social and economic factors that prevent people from getting and staying clean.

I was not on any planning committees, but my suspicion is that in order to address the alarming death rates, this facility was rushed more than it would have been in less pressing times. I’m certainly led to understand that when opened the facility was immediately overwhelmed by the unexpected level of demand, and since implementation has continued to increase its capacity and hours. Predictably, this site has become somewhat of a destination for drug abusers, many of whom are homeless and do not generally have other places they are welcomed to go. I don’t know if there are more or less users than there were previously, but this centralization effect has certainly made the population more visible. It has also increased the public’s sensitivity to the negative impacts of drug abuse on the community; crime, public drug consumption, and needle and drug paraphernalia debris in particular. These are not new issues, and not caused by the SCS. They are the result of a growing drug abuse crisis, and have become more visible because 1- the crisis has deepened over the last two years, and 2- the SCS has made the issue more visible, and probably shifted more of the problem to a single area where people now know to look for it. Additionally, more public awareness and controversy also means people are more likely to publicize their experiences with drug users and needle debris on social media, and these experiences are more likely to be widely circulated than they would have been in the past.

From my perspective in the ED, I am seeing fewer fatal and near fatal overdoses. I don’t have any stats to share, but many of my colleagues have noticed the same thing. We certainly don’t experience the regular parade of overdoses we used to, including days when we ran out of Naloxone. It’s hard to confidently state cause and effect in these type of phenomena, but I believe the SCS almost certainly is behind much of that decrease.

I am very concerned about the risk to children and the public from contaminated needle debris. No one wants local businesses or tourism to suffer because people feel unsafe in certain parts of their community. Of course I want to let my children play in city parks without worrying about them encountering dirty needles or individuals using drugs nearby. But wishes don’t solve problems, and neither does attacking those who are trying to help. There’s another part to this story that might not be on everyone’s radar right now. I heard about it from a friend who works security at the safe consumption site. The site has contracted a firm to provide 24 hour security for their site, and a certain radius around it. You might assume this is to protect people and property from drug addicts, and you’d be partially right. Their mandate includes watching for crimes (including theft, drug dealing or displaying drugs in public) and either intervening or calling the police depending on circumstances and exact location. The friend I spoke with indicated he spends a surprising amount of time protecting these same people from other members of the community who seem out to cause harm.

[Edit: I have removed details of a few alleged events of violence in the proceeding and following paragraphs, not because I disbelieve the source, but because I have no first hand evidence to share, and the readership of this post has spread far beyond my original expectations. A subsequent report by global news has confirmed with both the police and SCS that violence against facility clients has been a problem. The Global report details some incidents. My intention in sharing these anecdotes in the first place was to bring attention to the fact that violence around the SCC is not only perpetrated by some site users, but also against them by members of the public]

I bring up this less publicized side of crime associated with the safe consumption site mostly to urge caution in the spreading of inflammatory material that demonizes addicts, and stokes anger at the public and non-profit facilities that help them. There may be more people than you think in our community who are easily incited to vigilante violence and will feel more justified to commit it as they hear the outrage and frustration of others.

We are well aware in the health care field that drug abusers tend to be very unpleasant people to deal with. We have all been sworn at, spit on, and assaulted by someone whom we just saved from death, while they were about to storm out and try to reverse the help we just gave them. They can be aggravating, threatening, unthankful, and frustrating to treat, and it’s hard to make a positive difference in their lives. We also know they are still people who are vulnerable and living terrible lives with very few options and opportunities to turn things around.

So yes, I would like to see fewer needles in the community. Yes, I’m concerned about crime rates, and the safety of public spaces in the city. But I know closing the doors of facilities that serve users and hoping the problem will go away is not going to solve the problem. It certainly won’t stop needles from showing up in parks. It is a complex issue, and won’t quickly or easily be resolved. All large cities, and even many smaller deal ones with it. If it is a bigger problem here than in other similar sized cities, then we need to look at the socioeconomic reasons why, and try to address them. We need better addiction treatment facilities, so when someone tells me in the ED that they want to change, I have a workable and accessible program to immediately point them towards. We are opening new detox beds at the hospital in November (EDIT: changed from October with new information]. That’s a good next step, but won’t make a big difference alone. Hopefully there are more solutions coming, and I’d encourage anyone passionate enough about seeing change to get engaged and find out how they can help these changes come to pass. We need to continue good law enforcement to keep drugs off the street. We need to continue educating kids that yes, drugs are still bad – even if there is a trend towards more legalization and less punishment for use and possession, they are still potentially life destroying.

And yes, it’s appropriate to talk about how needles are being distributed to achieve harm reduction while minimizing risk to the community. It’s important to continually re-examine harm reduction programs to make sure we are helping without enabling, and minimizing unintended negative consequences that may arise from these programs. It’s important to talk about neighbourhood solutions in trouble areas and respect local businesses, homes and parks. Accountability on the part of city and organization officials working on the problem should be expected. Making those expectations reasonable requires some education about the problem and thoughtful consideration on the solutions. I hope my musings have been helpful to some. Thanks for reading.

The Craziest Thing

“Oh, you’re an emergency doctor? That must be an interesting job.”

It’s true, it is. And I know what’s coming next.

“So, what’s the craziest thing you’ve ever seen?”

Why is it with the number of times I’ve been asked this question I still don’t know how to answer it? I have never once felt like I was able to give any type of a satisfying answer to it. I understand the question and the curiosity behind it. I work in a fascinating world that few people regularly see into. For a time, every day before work I would ask myself, “What crazy thing am I going to see today?” At the end of the shift, I always had a few good answers. So why is it I never know what to say to you, at the dinner party, the church function, barber shop, games night, or whatever it may be when you ask me?

Yes, I do this job to help people – to listen, test, diagnose, treat, refer, comfort and reassure – as do all of us in the health care field. But it’s true- some parts of my job sometimes seem like a human side show. Drama, tragedy, comedy, pathos, heroism- some days are like seeing a parade of people and events straight out of a Shakespearian play. As many before me have observed, we in the emergency department see people at their worst, and in their most desperate of times. Sometimes, because of that, we also see them or those around them, rise to their best. Some people we see over and over again, and wonder how long they can stay at their own rock bottom.

It’s not like we don’t share our stories with each other. Those of us who spend our days working in this strange place regularly exchange vignettes about some of our recent noteworthy encounters. A rare disease we saw, or a diagnosis we just barely made, and how we did it. A difficult patient, an exceptionally bizarre or unlikely injury, a death we didn’t see coming and couldn’t prevent. A story of a patient we felt inadequate in helping, along with the asked or sometimes just implied question; “would you have done anything different than I did?” Sometimes we just need to share our experience of a crazy shift full of a statistically unlikely number of simultaneous severe medical emergencies- always followed by the legions of less urgent patients and their accusing “I’ve-been-waiting-for-six-hours-to-see-you-so-you-better-not-brush-me-off” eyes. It’s easy to share with one another, because we know what the job is like, and we know what makes one shift stand out from the others. We do it to bond, to commiserate, to teach and to learn from one another. My colleague knows how exciting and difficult it is to catch an early diagnosis of a dissecting aorta in a patient who is still stable enough to fly out and into emergency surgery before it is too late to survive. You, asking me at the dinner party might not think that experience was as cool or crazy as one more guy who accidentally shot himself in the hand with a nail gun. Yawn.

Maybe I don’t know what to tell you because as curious as you may be, you don’t know what I see on a daily basis, and have no idea what is or isn’t normal in the ER anyway. My crazy story is lost on you because you don’t know my world. On the other hand, your fascination with injuries or emergencies that are the bread and butter of my days work is lost on me, because I am too deep in my world to remember that anesthetizing, cleaning and closing a gaping 10 inch knife wound on another person’s forehead is not part of a normal person’s day.

My wife gets asked this question on my behalf too she tells me. Her first reaction is “Do you think he tells me the most crazy thing he’s seen?” Oh, she hears a lot of it, for sure. We have a little routine where she asks me how work was today. I tell her briefly about a few unusual things I saw or did that day (all respecting your confidentiality of course). She listens, shakes her head and says, “you have a crazy job.” She tells me how she often answers the question these days. By explaining that the longer I’ve been working in the ER, the less crazy the things that happen there now seem to me.

I also often wonder what you mean by the “craziest thing” that I’ve seen. If I stop and think, I can remember a lot of people, events and circumstances that qualify as “crazy” in my books, but they are all very different. Are you wondering what the most horrific injury is I’ve ever seen? (often I know you are). Yes I’ve seen limbs amputated, blood spurting to the ceiling, brain where it shouldn’t be, and other things out of a Tarantino movie. Not normally dinner conversation. Maybe you’re asking about the rarest medical condition that I’ve encountered? (I know you never are). Those might mean something to a medical student or another physician, but few else. The most tragic death? Most sudden? Most people I’ve told at once that their father/son/husband was dead in a car accident and the noise they made? Most tumor you can have growing in your abdomen and pelvis before the poop starts leaking out of your skin from a dozen places? Most people my age or younger I’ve seen dying of cancer in one shift? Youngest dead child I’ve seen? The feeling in the ER when we were trying to bring life back into a dying toddler, and got word that a second child under one year old was coming in with a possible cardiac arrest at the same time? Oh yes, that counts as crazy in a department that sees at most a handful of child deaths a year. I know the question is never asked as an insensitive one, nor do I take offense at being asked; we want people to know something about the world we live and work in. Yet when the truly tragic events that we see all too often are fresh in our minds, there is really no other response to this small talk question at a casual social function than a shrug and a, “it’s all a little crazy sometimes.”

Maybe you mean the crazy people. The guy high on cocaine with handcuffs and Taser leads dangling from his chest yelling “Juice me again! Juice me again!” The vivid hallucinatory delusions of the untreated schizophrenic patient who’s yelling at the electrical outlets in the secure psychiatry room, warning the CIA agents on the other side preparing to gas him again that his alien friends are arriving soon. The drug addicted woman unhappy at being discharged making sure to stop by every staff member she sees on the way out to tell them to Eff-off. The homeless man who is so covered in bodily fluids that even a fully gowned and masked and very experienced ER nurse has to come running out of his room gagging several times while trying to get him undressed to get at the maggot ridden wounds on his legs. I won’t lie and say we don’t find amusement at times in the eccentric personalities that cross our path. But it’s a humor that is part of our coping mechanism at dealing with people on the bottom layers of society on such a regular basis who are so hard to meaningfully help. Drug and alcohol addictions, mental health disorders and crushing poverty are singly or in combination some of the primary contributors making people into our “craziest” patients – dangerous at times, entertaining at others, but always in unenviable circumstances. Although we may grin or shake our heads at one another at their words or antics, we will still clean them up, check them out, treat them if possible, and provide access to medical care, counselling or social services. Through the swearing, spitting and resistance they often put up we will make their lives a little better, and try to offer them the resources they will need when they choose to take on the colossal challenge of trying to make a bigger change.

Since the question of craziest thing is usually asked in casual light-hearted conversation, perhaps I should just think of the little things that we regularly laugh at in our jobs. There is always a litany of amusing, unlikely stories or situations that come through our doors. Like the men driving a poultry transport truck who opened the back door to find a very agitated cat among the birds “Attacked by stow-away cat in chicken truck,” the chart read. Or a colleague of mine who told me once about a group of guys unloading a clothes dryer from the back of a pick-up truck, as they had been unable to free their friend who was trapped inside it. The brief triage primary complaint note in itself can sometimes tell a whole story. “Lost sex toy- doesn’t know where,” “Drunk on trampoline at 3AM- leg deformity,” “Cat stepped on eye ball,” “Hit on head with frying pan by wife.”

Or there’s the “I can’t believe they came to the ER” people. The mom who comes in screaming carrying her toddler. He had been playing outside and now had a pinhead sized black spot on his foot. It was dirt. The guy who had been having sore feet at the end of the day ever since buying new shoes. Yes, he admitted after some questions, they were probably just too small for him. “Tight fitting shoes,” I wrote on the diagnosis line on the chart, wondering what the official disease code for that might be.

To be honest, I don’t think I could ever say what the craziest thing I’ve ever seen was, because every week or even day it seems like there is something else that I have never quite seen before. That’s the nature of the job and it’s one of the reasons we love it. It’s bringing order, comprehension and healing to the craziness that keeps us coming back. Maybe we are just adrenaline junkies who get our rush trying to solve the problems caused by other peoples’ poor judgement or misfortune. But there is nothing more satisfying about this job than bringing someone back from the brink of death or serious illness when you know they have a lot of quality time left to live because of the knowledge and skill brought by you and the health care team you work with.

An emergency department is a busy place to work, and literally anything can come through that door. Many people we see are upset about how long they’ve been waiting, but most understand that we are doing the best we can with what we have. It’s the only place you won’t be turned away, but no you can’t make an appointment. “Wow, you guys sure are busy today. Is it always this crazy here?” Most of the time my answer is “yes, it’s often like this.” Sometimes though I’ll admit that no, this has been a particularly crazy day. Crazy day usually means there a lot of people waiting with minor problems (still important, still ER appropriate often, but not urgent), AND we have an unusually high number of urgent “sick” patients. You don’t want an ER doctor to label you as sick. That’s not a man cold or even 2 weeks of diarrhea with mildly failing kidneys due to dehydration. Sick is the ER code for someone with a true emergency in danger of imminent death or significant disability from whatever is happening to them. A handful of especially sick patients can bring the rest of the ER to a grinding halt. They need doctors, nurses, IV’s, medications, lab tests, imaging, consultants, admissions or transfers. This takes time and people, and sometimes the “almost sick” and the walking wounded have to wait longer because of this. We all have stories of crazy days: multiple traumas, simultaneous cardiac arrests, bad drugs at a house party. More often it is just a case of several unrelated bad things happening to different people at the same time.

So with all the crazy things we see, and the number of people streaming through our doors, what does it take to raise an ER doctors eyebrows? For us, I think it’s something that is different or unusual enough from what we usually see to stand out. It’s those stand out events that usually come to mind when I am asked the question, even if I don’t have a quick or meaningful way in which to answer it.

I received an email recently from an ER colleague sent to our working group with the title, “we don’t see this every day.” It was a picture of an empty chart rack at 6:30PM. No patients to see. I looked back through some of my picture collection of notable cases at work. An x-ray of a pitchfork in a knee. A cardiac tracing of a rare, but potentially fatal heart rhythm that I had only ever seen in a text book before- a future sudden death averted only because we recognized it. A child’s nose nearly ripped off, texted to a plastic surgeon to convince him to come in to work late, and many others. There among them, was a picture of our patient tracking board at 3AM on a night shift a few years ago. It was empty. Not a single patient on it. Next to it is a picture of an empty waiting room. I remember that night. We went for 3 hours without a single patient in or arriving to the emergency department. It’s not always busy, but that was very unusual. And I think that just maybe that was the craziest thing I have ever seen in the ER.