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By Michael Kalin June 9, 2016 Health Promotion

Further Cuts to Important Services

Please read this powerful article published on CBCNews Montreal about more vital services being cut in our neighborhood…

The Douglas Hospital has suspended a successful program to treat teenagers with serious mental health problems, saying it’s exploring more “cost-effective” options over the next year.

The treatment, called dialectical behavior therapy (DBT), helps patients cope with severe depression, suicidal thoughts, eating disorders and self-harming.

It also includes group therapy and invites parents in to learn how to support and talk to their child.

‘The years from hell’

Andrea, whose last name CBC has agreed to conceal to protect her child’s privacy, said her 16-year-old daughter was part of the last group to go through the program.

She’s devastated other families no longer have access to DBT at the Douglas, which she calls a “miracle” program that “gave us our daughter back.”

“How can the government do this?” asked Andrea. “How can you let these kids just flounder like that?”

Andrea describes 2013 to 2015 as “the years from hell.”

Andrea says the first signs of her daughter’s mental health struggles began in Grade 7, when she became moody and withdrawn, often difficult to coax out of her room. (CBC)

When her daughter Jessica started Grade 7, she became increasingly withdrawn – no longer spending time with her friends and losing interest in everything.

“She just wasn’t her,” said Andrea. “There was no spark in her.”

Jessica had always been a strong student, but her grades started to slip.

A mediocre mark on a test or a critical remark from a teacher could easily send her into a tailspin.

After one of a series of visits to the emergency room at the Montreal Children’s Hospital for suicidal thoughts in May, 2015, Jessica refused to go home.

“I didn’t think I’d be safe if I was at home,” said Jessica. “I did not feel I was strong enough to take care of myself in a way that I should.”

Jessica’s therapist suggested the dialectical behavior therapy program at the Douglas Hospital.

For the first six weeks, Jessica did one-on-one sessions, followed by 20 weeks of group therapy.

“You were in a room, surrounded by people who had things going on that were similar to you, who were feeling ways that you felt and would believe you if you said something,” said Jessica.

“They all understood.”

How DBT works

Together, the teens learn how to identify their triggers and break down potentially stressful situations into smaller steps.

Parents also attend the group sessions to learn new skills which they had to practise at home.

“They really teach you how to talk together again,” said Andrea. “So the bond that was kind of lost has been re-established. I feel we can talk to each other about everything and anything again.”

According to the regional health agency that now administers the Douglas Hospital, the DBT program has helped around 225 teens since 2001.

The Montreal West Island Integrated University Health and Social Services Centre (known by its French acronym CIUSSS de l’Ouest-de-l’Île-de-Montréal) says a decision was made early this year by the DBT team to “temporarily pause” the program for one year, starting last April.

This step was taken in order to “examine new emerging best practices and enhance services provided to the clientele.”

A spokesperson for the CIUSSS de l’Ouest-de-l’Île-de-Montréal refused an interview but said in an email that some DBT services are still available on an individual and family basis.

However, the group portion is “very costly and time intensive” and is no longer being offered. Doctors who usually referred patients to the program were told to hold off this year.

‘We see very significant changes’

One of those doctors, Dr. Lila Amirali, the chief of child psychiatry at the Montreal Children’s Hospital, said she believes the DBT program at the Douglas is the only one of its kind for English-speaking teenagers with severe mood disorders.

Amirali said the combination of individual, group and family therapy is powerful.

“We see very significant changes,” said Amirali.

She said many of the adolescents in the program can go through intense mood swings in the space of a day.

She said some may be the life of the party, then something will happen that will cause them to become very suicidal. The program helps them to learn to use their judgement to make calmer, more sound decisions when they are feeling upset, she said.

“They learn how to adapt better,” said Amirali.

The chief of psychiatry said she wasn’t given any reason for the program’s suspension, but she’s hopeful it will be reinstated next year.

She acknowledges that every hospital is carefully scrutinizing how it uses its resources nowadays.

‘We have her back’

Until the fall, Jessica is still being followed individually by a therapist from the program.

Next month, she’s heading to Philadelphia for a month-long arts program – something that was unthinkable a year ago.

“This year, I am so excited. All I can think about is, just a few more weeks, and I’ll be there,” said Jessica.

Andrea and her husband did pay for private therapy prior to Jessica being admitted to the DBT program, but say the program made a huge difference.

“We have her back,” said Andrea, who no longer worries about what’s happening behind her daughter’s closed door.

Andrea contacted her MNA to raise her concerns about the DBT program’s suspension but was told the same thing: The program is just being put on hold temporarily.

“When people say they put something on pause, it’s never really on pause,” said a skeptical Jessica.

“Chances are, now that this program isn’t happening anymore, it won’t happen again for a long time, which is just terrible because there’s going to be people struggling because of this.”

She and her mother feel they have a responsibility to try and get the program back for other teens who need it right now.

Andrea pleads with the government to reassess its priorities.

“Step up and help these kids,” she said.

http://www.cbc.ca/news/canada/montreal/douglas-dialectical-behaviour-therapy-suspended-1.3623104

By Michael Kalin June 3, 2016 Clinic News, Health Promotion

Check-ups matter!

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Check-ups matter!

My 15 year old daughter is a skillful debater. We have lively discussions about politics, religion, school, and the Marvel Cinematic Universe. But when she wants to win the debate, she conjures up an obscure reference in a fictitious journal to prove her point – definitively. After all, who can dispute a prestigious scientific publication?

This week, the healthy check-up in Quebec fell victim to a “meta-analysis.“ Experts confidently announced that “medical science no longer recommends these types of exams.“ Even the Minister of Health challenged “What does an annual visit prevent? Nothing.”

Specifically, these experts were citing a 2012 analysis by Lasse T Krogsbøll of the Cochrane Collaboration. His analysis of sixteen randomized studies concluded that “general health checks are unlikely to be beneficial.”

Further words of reassurance were imported from the Maritimes where a media relations advisor for the Nova Scotia Department of Health and Wellness added ““We’re not aware of any concerns or issues since this change (eliminating the health annual check-up) took effect.“

And to allay any final concerns, the experts assured the public that when they “go to (the) doctors at any time for other reasons like an ankle injury or a bad chest infection, …a good doctor will use that opportunity to ask how things are going otherwise.“

With all this seemingly overwhelming scientific evidence condemning the relevance of the health check-up, why are we sad to see it go? Simply – because it shouldn`t.
We increasingly live in a world where human contact for the delivery of services is endangered – and it bothers us. Mail home delivery is threatened, bank branches are not profitable, established brick-and-mortar retail stores are restructuring. Seeing your doctor seemed immune – or at least it felt that it should be. Where else could a person go after accumulating a long “list“ of health problems full of fears, questions and concerns. Dr. Oz? Google? Just like the Crawleys in Downton Abbey, we all want a Dr. Carson to look out for and to look after us and our families. Someone who knows us, listens and cares.

The problem with scientific studies is that they are often misquoted and rarely read. The “definitive“ Cochrane review questioned whether general health checks in adults reduce morbidity and mortality from disease. It did not include geriatric trials. It did not study the value of the doctor-patient relationship. Most of the studies were not conducted in Canada, and according to the authors, “most of the trials were old, which makes the results less applicable to today`s settings because the treatments used for conditions and risk factors have changed.“

To be exact, nine of the fourteen studies included were conducted over thirty-five years ago. The most recent study was initiated twenty-five years ago. That`s like current Habs General Manager Marc Bergevin conducting the 2016 draft based on scouting reports from Sam Pollock and Irving Grundman in the 1970s and 1980s.

The Cochrane Review further qualifies its findings, commenting that “because the majority of the included studies were unblinded with considerable loss to follow-up, analysis of outcomes other than death and hospitalization may be subject to bias.“
Even the Canadian Task Force on the Periodic Health Examination from 1979, purportedly anti- check-up, recommended “ a specific strategy comprising a lifetime health care plan based on a set of age- and sex-related health protection packages.“ Maybe not annually, but more selectively.

Scientific meta-analyses are only as good as the data that is entered. There is lots of talk about the importance of Corsi scores in hockey, but as far as I can tell, neither the Pittsburgh Penguins nor the San Jose Sharks lead the NHL informatics race. Nevertheless, one of these two teams will be raise the Stanley Cup.

Interestingly, if experts are going to quote the merits of the Maritime experience, in which journal has this well-designed experiment been published?

In the end, we are quoting weak medical data from a generation ago, in another jurisdiction, with poor follow-up. None of these studies examine the essence of why general check-ups really matter. Seeing your family doctor on a routine basis fosters a trusting, lasting relationship. It does not exist to order tests; its existence provides comfort and security, knowledge and understanding. Health promotion is not a brochure or a pep-talk: it is a collaborative effort to live better. It is not a sprint, but a marathon.

Honestly, do “experts“ really expect family doctors to do a prostate exam because the patient conveniently limped in with an ankle sprain? Or discuss colorectal screening while the patient is febrile with a bad chest infection?

Air Canada (hopefully) does not wait for the airplane to make funny noises before checking it out. They don`t wait for one wing to fall off before checking the other. Routine maintenance is neither a luxury nor superfluous – it is common sense. Let`s not embrace a crisis-initiated medical model – but improve our efforts towards health promotion. Let`s design a system that rewards doctors for keeping healthy people healthy.

In the end, all the analysis to devalue the annual check-up simply cannot compete with the primal benefit of nurturing a meaningful, trusting, patient-physician relationship. Studies, even “scientific“ ones, need to be understood and properly applied.

Consider the 2003 systemic review of parachute use to prevent death and major trauma related to gravitational challenge published in the prestigious British Medical Journal. Despite a rigorous review, the authors “were unable to identify any randomised controlled trials of parachute intervention.“ As such, they concluded, “the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomized controlled trials. Advocates of evidence based medicine have criticized the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organized and participated in a double blind, randomized, placebo controlled, crossover trial of the parachute.”

Please use a parachute – and please continue to see your family physician for general check-ups.

By admin April 1, 2016 Uncategorized

The Case FOR the Annual Check-Up

Blink and it will be gone. Make no mistake about it: the “Annual Check-up,“ once the pillar of our preventative health care system, is on the verge of becoming obsolete – or `medically “insignificant“.

Already, the Annual Health Exam has been de-listed in several provinces:
British Columbia, Nova Scotia, New Brunswick, and Newfoundland and Labrador no longer cover annual physicals in patients without symptoms of illness. Ontario offers “personalized health reviews” in which the doctor focuses on the health risks specific to the patient and the patient’s age.
If you live in Alberta, Manitoba, Saskatchewan, Quebec, Prince Edward Island, and the Northwest Territories – appreciate the Check-up while it lasts.
Calls to eliminate the annual physical examination are not new. In 1979, the Canadian Task Force on the Periodic Health Examination recommended “that the annual checkup, as practiced almost ritualistically for several decades in North America, be abandoned.”
In 2013, the Choosing Wisely campaign (see poster below) recommended against annual preventive examinations in asymptomatic patients.
Despite these calls, many people still want an annual physical. Not surprisingly, surveys show that the majority of both patients and physicians remain strong proponents of the annual check-up.
Ironically, while experts are divided on whether there is a benefit to getting an annual exam, the federal Affordable Care Act (ie. Obamacare in the United States) requires insurers to cover annual physicals free of charge.
So, what exactly is the controversy? Simply, some research has demonstrated that regular physicals do not reduce rates of illness or mortality. At best, the researchers suggest that these exams are an egregious waste of health-care resources, and at worse, they are dangerous by promoting “superfluous,“ expensive testing.
The research most frequently cited against the annual physical is a 2012 analysis of 16 trials by the Cochrane Collaboration. This study concluded that “physicals“ do not reduce mortality or illness. Critics point out that the trials excluded elderly patients and were predominantly performed in Europe, where most patients were already regularly seeing doctors. In other words, do these results really reflect our reality in Canada?
In more detail, the Cochrane review included 16 trials and 182,880 participants. While the authors concluded that they did not find an effect on clinical events or other measures of morbidity, one trial found an increased occurrence of hypertension and hypercholesterolemia with screening and another trial found an increased occurrence of self-reported chronic disease. One trial found a 20% increase in the total number of new diagnoses per participant over six years compared to the control group. Two trials found an increased number of people using antihypertensive drugs, and another two trials found small beneficial effects on self-reported health. The authors also comment, “we did not find an effect on admission to hospital, disability, worry, additional visits to the physician, or absence from work, but most of these outcomes were poorly studied.“ Of note, two additional studies were excluded from the analysis.
In the end, the author`s concluded, “General health checks did not reduce morbidity or mortality, neither overall nor for cardiovascular or cancer causes, although the number of new diagnoses was increased. Important harmful outcomes, such as the number of follow-up diagnostic procedures or short term psychological effects, were often not studied or reported and many trials had methodological problems. With the large number of participants and deaths included, the long follow-up periods used, and considering that cardiovascular and cancer mortality were not reduced, general health checks are unlikely to be beneficial.“
Why did the author`s conclude that the General Health Check, or Annual Check-up, were “unlikely to be beneficial?“
The authors suggest:
1. “One reason for the apparent lack of effect may be that primary care physicians already identify and intervene when they suspect a patient to be at high risk of developing disease when they see them for other reasons.
2. Also, those at high risk of developing disease may not attend general health checks when invited.
3. Most of the trials were old, which makes the results less applicable to today’s settings because the treatments used for conditions and risk factors have changed.“

I have included a few clippings from news organizations on this heated topic (see below). But I was amused by the “observations“ of the following physician to the Wall Street Journal article:
Observations as a physician:
1. Nothing ultimately improves mortality since everybody dies. Unfortunate fact overlooked in medical trials.
2. Ironic that presumed liberals (Ivy League affiliated) want universal healthcare but don’t want patients to be seen.
3. If they don’t come in yearly, how else will I be able to nag them every year to quit smoking and tell them that they’re too fat?
4. Hypertension: the “silent” killer because often there are no symptoms until a stroke or heart attack. But don’t see me unless you have symptoms.

In the end, I am reminded of Malcolm Gladwell`s brilliant bestseller “Blink.“ Sometimes we simply overthink the obvious. We become all-consumed with the analysis that we ignore the simplicity in front of us. Annual check-ups, like everything, need to evolve. Preventative medicine should be personalized – but it needs to be planned. Air Canada (hopefully) does not wait for the airplane to make funny noises before checking it out. Routine maintenance is neither a luxury nor superfluous – it is common sense.
We cannot and should not base care or conclusions on old studies that are “less applicable to today`s settings.“ We should make recommendations on well-designed, up-to-date studies that reflect our current health care needs.
Why do the majority of patients and physicians remain strong proponents of the annual check-up? Because it feels right. All the analysis to devalue the annual check-up simply cannot compete with the primal benefit of nurturing a meaningful, trusting, patient-physician relationship. For my part, I certainly hope the annual check-up lives on.

 

By Elizabeth Jack September 28, 2015 Clinic News

Doctorless clinic has higher costs

Santé Kildare’s very own Dr Michael Kalin recently had an editorial published in the Montreal Gazette!

Re: “Clinics without doctors viable, U de M report finds” (Montreal Gazette, Sept. 11)

The focus of the study, Quebec’s only “doctorless clinic,” registered 1,700 visits over a nine-month period ending in June 2015. In other words, the nurse practitioners assessed less than 200 patients each month or about eight patients per day.

Régine Laurent, president of the Fédération interprofessionnelles de la santé du Québec, concludes, “What this report shows us, is that changing primary care to include more health professionals — not only doctors — really works and greatly improves accessibility.”

In the midst of the Bill 20 ceasefire between the health minister and the province’s family doctors, I am not sure how or why this clinic is being presented as a model for effectiveness and accessibility. The minister’s intentions were clear to the doctors: more patients, faster care.

Maureen Guthrie, a nurse who works at the clinic, comments that many families in the neighbourhood use the clinic “because they have no family doctor.” In fact, according to the researchers, 64 per cent of the clinic’s patients said they had a family doctor. The problem was getting a timely appointment with their own physician.

Of note, the estimated cost of $68 per patient visit in the doctorless clinic is almost 50 per cent more than the cost of a family physician seeing a walk-in Groupe de Médecins de Famille (GMF) clinic.

Working together to improve patient care and accessibility should be everyone’s goal. A multidisciplinary team of doctors, collaborating with nurses and other health-care professionals, as promoted in the GMF model remains the best option.

Michael Kalin, Montreal

http://wpmedia.montrealgazette.com/2015/09/montreal-que-january-24-2012-stock-photos-for-use.jpeg?quality=55&strip=all&w=840&h=630&crop=1

By Alexandra Orr July 9, 2015 Health Promotion

Sun Safety

It’s that time of year – school’s out, La Ronde is open and the sun is shining! So let’s take a look at how to stay safe in the sun!

 Sure there are definite benefits to sunlight:

 – It can help with mood (for example people with seasonal affective disorder have improved mood when they are exposed to sunlight, which is why sunlamps are used for therapy during winter months)

– UVB is an important ingredient for the skin to be able to make Vitamin D (all you need is 15 minutes to a couple hours depending on skin tone and on the amount of skin exposed to make more than 10,000 units of vitamin D!)

– Some skin conditions can improve in sunlight (eg. eczema, psoriasis) which is why PUVA is a treatment sometimes used by dermatologists for people with really severe cases

But don’t forget the risks!

– Dehydration! Heat exhaustion! Heat stroke!

– Sun burn

– Skin damage: sunburns, wrinkles, skin cancer!

– More sun burn

– Damage to eyes leading to cataracts and cancers of the eye

– Even more sun burn

            Ever had a really bad sunburn? It can be excruciating, it can blister and you can even get a fever. It’s not worth missing a few days of summer to sit at home covering yourself in aloe vera. So here’s what you can do to protect yourself!

1) Stay informed!

 – Check out the UV index each day (for example the weather network broadcasts it daily). More than 3? Protect yourself!

2) Avoid the times of day when the suns’ rays are strongest

 – 10am until 2pm is peak sunburn time

3) Wear a hat!!!

– I don’t care if hats don’t suit you. Do it. The tip of your nose will thank you.

4) Wear sunscreen – and wear it properly!

 – Choose broad spectrum sunscreens that cover UVA and UVB rays. Use at least SPF 15, but better to aim for SPF 30. Don’t bother with anything higher than SPF 50, the increase in sun protection is negligible (in fact the FDA is making companies in the US market products as 50+ because the difference between 50, 60, 70 and up is almost zilch!)

 – Put it everywhere and apply liberally

 – Reapply every 2 hours, or more often if you are swimming or sweating

 – Don’t forget the tops of ears, the tops of feet, backs of hands, back of the legs! And double up on the nose!!

5) Wear protective clothing

 – I hated it as a kid but wearing a t-shirt over my bathing suit at the beach saved me from a lot of burns!

6) Check your medications with your pharmacist

 – Some medications (for examples some antibiotics, chemotherapies, diabetes medications, heart medications, diuretics, antidepressants, anti-inflammatories, antihistamines, birth control pills and topical creams) can increase your sensitivity to the sun.

7) Drink LOTS of water – heat exhaustion can sneak up on you. Be on the lookout for warning signs, especially when doing physical activity in the sun.

            – Signs of heat exhaustion are: weakness, fainting, muscle cramps, headache, nausea and vomiting, cool clammy skin and fever

            – It’s important to prevent heat exhaustion by staying cool and drinking lots of water because heat exhaustion can lead to heat stroke, which can be dangerous.

8) And don’t forget about your eyes!

 – Wear sunglasses whenever possible

 – Check that they protect against UVA and UVB rays

What about kids??

All the same advice holds true for kids – but you have to be even more careful. Kids’ skin is extra sensitive to the sun and they are more at risk for getting dehydration and heat stroke.

 Basically follow all the aforementioned rules but BE MORE STRICT with little ones!

And what about babies under 6 months? Well, really they shouldn’t be in the sun. But that’s a lot easier said than done! So keep baby as protected from the sun as possible, remember that babies can burn from reflected sun or even dappled sun. Dress baby in loose, cool clothes and a hat to cover as much skin as possible. And then if you can’t avoid having baby in the sun definitely put a little bit of SPF 30 on only the sun exposed areas (like the hands or feet or face).

For more information check out the following:

The Canadian Pediatric Society

http://www.caringforkids.cps.ca/handouts/sun_safety

Health Canada

http://www.healthycanadians.gc.ca/healthy-living-vie-saine/environment-environnement/sun-soleil/index-eng.php

Canadian Dermatology Association

http://www.dermatology.ca/programs-resources/resources/sun-safety/

 

By Elizabeth Jack March 11, 2015 Health Promotion , , , , , , , , ,

We Walk the Walk……We Talk the Talk

Have you seen Dr. Mike Evan’s video 23 ½ hours?  If not, I urge you to click on the link.  It will change your life.

Ok, now that you have watched it you know what to do.  Why not do it with it us?  Every single day of the work week, weather pending, we walk at lunch time.  The benefit of walking with Group Santé Kildare is that there will always be a healthcare professional walking with you.  Our professionals include nurses, dietitians and over 20 doctors.  Imagine how motivating it would be to walk with people who practice what they preach!

Dr. Mike explains in his video that you don’t even have to do the 30 minutes of walking consecutively.  You can stay fit by doing three 10-minute slots  or two 15-minute session powerwalks.  Keep your intensity at a moderate pace. Your heart rate should be elevated and you are sweating a bit, you can talk but not carry on a whole conversation.    If you are not sure about your pace, you can always sport a heart monitor like the new Fitbit Charge HR.  It also tracks steps taken (10,000/day is ideal), calories burned and quality of sleep. 

Sometimes walking in a group can break the isolation and monotony of walking alone.  Your healthcare professionals will provide a hefty dose of motivation and encouragement.  Come join us!  Bring a water bottle and a good pair of walking shoes. Let’s go!

 

 

 

By admin February 28, 2015 Clinic News

“Supernurse” or what?…

On my first visit to Clinic Santé Kildare I was showered with welcoming smiles, the atmosphere of a friendly and reassuring environment, and enthusiastic promises of the opportunity to work at the Best GMF clinic in Montreal.  Today, two weeks into working here in my “newfound home”, I am happy to admit that I am savoring each moment of being a part of such a cohesive and supportive multidisciplinary team. While holding a belief that many of us, primary care nurse practitioners (NP), have to deal with a range of fears and anxiety when first stepping into our field I cannot overemphasize the importance of the work environment.

As a relatively new profession in Quebec we face numerous challenges due to the lack of public awareness. While NPs have been successfully practicing in US for over 40 years in Canada there are few people that are familiar with our profession. All provinces and territories currently have legislation in place for the NP role however the level of autonomy of the nurse practitioner varies greatly province to province. Quebec was one of the last provinces to introduce NPs. It was not until 2003 that we had our official legislation. Is it any surprise then that the very first primary care NP graduates could be counted on the fingers of one hand – only 3 in 2007?! Meanwhile, in July 2010, Quebec announced it will spend $117 million to boost the number of nurse practitioners from 56 to 556 before 2018. In 2012 we almost made it to 100.

Increasing the numbers is great, but what about public awareness?! The media has dubbed our profession “super-nurse”.  I do not know how that is helpful. Every time I introduce myself or mention my title to a patient or a health care professional it feels like one interaction is merely not enough to shed some light on the whole scope of our role and responsibilities. Some patients still think I am a doctor; I am not. Others believe that nurses and nurse practitioners are one and the same… yet another misunderstanding. Although we do start off as registered nurses, we have a minimum of two years of clinical experience in primary care, and receive graduate level education and training. To become a nurse practitioner upon successful completion of the Graduate Diploma Primary Care Nurse Practitioner program we are required to pass the advanced practice licensing exam of the Order of Nurse of Quebec. We work in collaboration with clients partnering physicians and other health-care providers in the provision of high-quality patient-centered care.

We are not there to replace nurses or doctors! We are there to integrate our in-depth knowledge of advanced nursing practice and theory, health management and health promotion, disease and injury prevention to provide comprehensive health services. The application of these equips us with necessary skills to

·      make a diagnosis i.e. to identify a disease, disorder or condition;

·      communicate the diagnosis to the client and other health-care professionals as appropriate;

·      initiate, order or prescribe consultations and referrals (with some limitations);

·      order and interpret screening and diagnostic tests (with some limitations);

·      recommend, prescribe or reorder drugs (with some exceptions).

We can also help the residents who don’t have a family doctor to get primary care. As NPs we are trained to look at the person and his or her lifestyle and work together on a strategy that not only addresses the illness but also ensures illness maintenance and prevention.

You would certainly agree that for Canada’s health-care system, which faces long wait times and a shortage of doctors and money, this is a good thing. We all hope that spending health-care dollars on more nurse practitioners will help bridge the gaps in the system.

http://cwf.ca/pdf-docs/publications/December1998-Nurse-Practitioners-and-Canadian-Health-Care-Toward-Quality-and-Cost-Effectiveness.pdf

http://www.cbc.ca/news/canada/montreal/quebec-to-create-500-supernurse-jobs-1.901121

https://www.youtube.com/watch?v=F91gqaQs7Lc

http://www.longwoods.com/content/22268

By Michael Kalin February 27, 2015 Clinic News

The Death of Family Medicine

The Death of Family Medicine

Moments ago, while sitting on the ward completing a death certificate, a disturbing thought entered my mind. It should have been of the lonely man who just died of esophageal cancer, but instead it was of my profession. Tonight, after months of reading and studying Bill 20, it felt like I was writing a death certificate for Family Medicine.

It might sound melodramatic, but this how many of us feel – abandoned, powerless, misunderstood, betrayed. Despite our eloquent speeches and thoughtful editorials, the Minister of Health stubbornly pushes ahead with proposed Bill 20.

What is Bill 20? Truthfully, most of us don`t know. The Minister of Health has provided few clues besides threats of unspecified quotas. We know he will restrict IVF based on age, and deny women the choice to discuss and seek care publically and privately beyond age 42. We know he will demand proof of sexual relations for women under age 42, as well as psychiatric assessments in certain cases, before funding IVF. However, for Family Physicians, there are few to no details.

The Minister has stated one clear objective – a Family Doctor for each citizen – but the Bill to improve access will likely accomplish the opposite because it fails to recognize who Family Doctors are and what we do.

Let`s assume Bill 20 passes and each Family Doctor is legislated to increase his or her patient roster to 1000-1500 patients. Simply, one of two outcomes will happen: Family Doctors will comply or not. For those who choose not to increase the number of patients, a salary cut of 30% will be imposed. For the remainder, the practices will swell and patients, who already experience long wait times to see the doctor, will have to wait longer.

Next, the Minister will impose minimum daily quotas. Again, doctors will have the same two options: comply or absorb a 30% pay cut. Predictably, patient care is compromised: appointments are shorter and hurried.

You see, it`s easy to manipulate statistics, or in this case, patients and Family Doctors. After all, is it not more convenient to blame the lack of Family Doctors on Family Doctors as opposed to, say, Government policy? It seems as if there is nothing that Family Doctors cannot be faulted for nowadays – spending too much time with patients, spending too much time with our families, spending too much time at the hospital, spending too much time teaching, etc.

However, the paradox of Bill 20 is that while it will increase the number of citizens who have a Family Doctor, it will actually worsen access. After all, how many hours a day can each Family Doctor legitimately work? The dirty secret of Bill 20 is that patients actually lose choices and access by being limited only to their Family Doctor. Forget about calling the walk-in clinic around the corner on nights and weekends – you are contractually bound to your Family Doctor. Break this bond and your Family Doctor gets fined. How much? You guessed it – 30%.

The great irony of Bill 20 is that not having a Family Doctor improves access. Having a Family Doctor should improve care but only if patients are treated as individuals not numbers.

All this brings us back to the essence of Family Medicine. Who is a Family Doctor? Unlike “GPs“, Family Doctors are specialists who provide community-based, skilled, comprehensive care to a defined population. This care is forged through the doctor-patient relationship and emphasizes evidence-based health promotion and disease prevention while advocating for patients and respecting community resources.

But Family Doctors are people to. We are husbands and wives, mothers and fathers, children and caregivers. We are not civil servants; we do not receive pensions or vacation time or sick time. We pay for our supplies and our equipment, our rents and our staff, and we do not get paid when we do not work. We all made choices to go in to the service of others, and at times, made sacrifices for this education and training.

So, why the obituary for Family Medicine in Quebec? Frankly, who will choose to stay? Would you accept a 30% pay cut? The older Family Doctors may choose to close shop; the younger doctors may not consider starting at all. For the rest of us, will we be content practicing a form of medicine that bears little resemblance to our chosen and beloved profession? The heart of Family Medicine lies in the special doctor-patient relationship: a professional friendship cultivated over a lifetime, built on trust and caring. Family Medicine is about listening and teaching, educating and treating. We may click more cards with fast-food medicine, but we won’t be healthier.

So on this lonely evening, I fear for the future of Family Medicine in Quebec. The deliberations for Bill 20 have just begun. Make your voice heard. Don`t settle for a system that makes you Patient #1499; insist on a system that gives you choices, timely access and quality care. Every patient deserves a real Family Doctor who has the time to listen.

By Michael Kalin January 7, 2015 Clinic News , , , , , , , , , , , , ,

King Pharoah

It’s no secret that doctors often make lousy leaders. Just think of Francois (Papa Doc) Duvalier (Public Health, Haiti), Bashar Al-Assad (Ophthalmology, Syria), and Radovan Karadžić (Psychiatry, Bosnia).

There are many reasons for the dearth of physicians in politics – after all, the qualities that make the best politicians are not necessarily the same attributes of the finest clinicians. Great politicians may be opportunistic, ambitious, partisan, and calculating. Alternatively, the best clinicians are driven by humility, empathy, curiosity, and passion for patient care. When the physician and politician collide, one is reminded of the famous joke – “What’s the difference between God and a Doctor? God doesn’t think He’s a Doctor.”

To be successful, in both fields, one must understand the limits to one’s skills and power. A leader must recognize what he or she can realistically accomplish; to control situations not simply react to them.

Regrettably, our neophyte Health Minister, Dr. Gaetan Barrette, has charged to power as a victorious conqueror. Like so many before him, he is determined to save us from ourselves. With swift edicts and magisterial decrees, He alone will fix the health care system. Apparently, the solution is simple; like Pharoah, Dr. Barrette has commanded that we all work harder or be punished. Mercifully, Minister Barrette’s proposed contraception policy only imposes steep fines and not discarding in-vitro newborns into the Saint Lawrence River.

Some aspects of Dr. Barrette’s proposed Bill 20 purpose are noble – to promote access to family medicine and specialized services. However, towards this end, Dr. Barrette has prescribed a disappointing, misguided and unimpressive treatment. Like an overbearing parent, Dr. Barrette demands “certain obligations…to provide medical care to a minimum caseload of patients” likes chores for an allowance. Failure to comply will result in monetary punishment to be judged and executed by the authority of the Minister of Health Himself.
Other aspects of Bill 20 are simply nauseating. Women over age 42 are forbidden to have children by IVF, public or private, in Quebec and elsewhere, with fines of up to $150 000. Moreover, the Bill legislates a mandatory prerequisite “period of sexual relations…determined by government regulation.” This is not a typo.
In the end, the Minister will inform us, “by directive, of the rules that [we] must follow.” Supreme Ruler Barrette, like Kim Jong-un, claims to speak for the people and to act in their best interest.

How does this Bill improve access? What brilliant, insightful and innovative mechanisms are established to improve access? Simply – none. The Minister is convinced that doctors that can be scared into seeing more patients, women can be intimidated to work longer hours, and women in their 40s can be frightened not to have children. It is a Bill befit for the “Democratic People’s Republic of Quebec “– not our Quebec.
Our goal for this Bill should be access to quality and timely care – not patients seen. We should be building on a model that allows young physicians to balance family and work, decrease stress, improve flexibility and encourage part-time physicians to carry a broader work load. A load not defined by quantity, but in its complexity (ie. mental health, chronic illness, elderly, etc.).
We need a Minister who listens, a leader who collaborates, and a government that cares about people more than numbers. We need to celebrate families and diversity. Dr. Barrette has no place in our bedrooms or in our offices.
Bill 20 is not bad medicine, it is poison. Bill 20 criminalizes fertility in older women. It antagonizes and discourages young doctors who wish to make a life and family in Quebec and will push older doctors to early retirement. Take note Minister Barrette – Pharoah’s regime ended with the great Exodus. Bill 20 threatens us all.

Dr. Michael Kalin is the Medical Director of GMF Sante Kildare located in Cote Saint Luc.

www.assnat.qc.ca/fr/exprimez-votre-opinion/petition/Petition-5029/index.html

By Michael Kalin December 25, 2014 Uncategorized

Bill 20

OPEN LETTER TO MR. DAVID BIRNBAUM, MNA DARCY MCGEE

Bill 20 – will adversely affect Cote Saint Luc’s only GMF Clinic

 

Dear Mr. Birnbaum,

As the Medical Director of Cote Saint Luc’s only GMF clinic, I must express my concerns regarding the proposed Bill 20.

GMF Sante Kildare serves almost 20 000 registered patients in our community.  We are a group of 25 family physicians – offering medical services 365 days per year, including evenings, weekends and holidays.

We have an open, daily walk-in clinic for any patient (even “orphaned persons”).  We provide services to local Foster Homes, collaborate with McGill, coordinate with CSSS Cavendish, conduct research studies – all in an effort to provide the best, comprehensive and timely care to all persons.

We started with two physicians in October 2011 – and now pride ourselves on exceptional growth with a stellar and superb team of 25 committed doctors, nurses, and other health care professionals.

Of the 17 family doctors based at my location, 14 are female.  In fact, most are young doctors who recently completed their Family Medicine Residencies.  They were attracted to Sante Kildare for many reasons: our inclusive philosophy, teamwork, supportive network, flexibility and GMF status.

And this is my point – GMF works.  The incentives offered by previous Ministers of Health were working.  We actively remove orphaned patients from the CLSC Guichet list.  We keep doctors in our territory.  We offer extended hours.  We keep patients out of the ERs.  We cover young female doctors during maternity leaves.  We cover patient practices when doctors are away fulfilling their AMPs.

Group GMF coverage is the only solution.  80% of Family Medicine graduates are female!  While I personally work 70 hours each week, most doctors don’t.  It is ridiculous, unrealistic and unreasonable to demand young, female doctors to work 36+ hours/week.  They have made sacrifices to continue schooling to serve and heal others.  They should not be penalized for striving to balance home and work.

But this Bill punishes everyone.  Why should I be fined (or docked pay) if my patient sees another physician – even if I am open and available?  If you live in Quebec City and your family doctor works in Cote Saint Luc, should he/she be penalized if you seek urgent or semi-urgent attention locally?  What if someone lives in Dollard and works downtown?  What about chest pain at 3 am?  In all scenerios, it’s the family doctor who pays.

I care about quality.  I book 30 minutes per physical.  The RAMQ agrees that a check-up requires more time.  Am I to work 15 hours each day to meet the Minister’s quota of 30 patients?
Should I tell patients to book multiple appointments to “get through their list of problems?”

We need a system that rewards productivity – not a plan that punishes.  We need a Bill that recognizes the reality of our workforce – not an outdated, punitive vision that frowns upon families.  We need an open dialogue – not a demagogue.  Quality and commitment should be recognized and embraced – not attacked.  The family physician is the backbone of the health care system – the quarterback – the human face.  We only succeed by developing and nurturing the doctor-patient relationship – not timing it.

Family Medicine is not radiology.  We see patients – not their films.  We talk to patients – teach, advise, advocate, heal.

Please, please, please.  I urge you to visit our clinic and see how this Bill will devastate us.

Leadership should not be achieved through bullying.  We desperately need collaboration, discussion, vision.

Thank you.

Dr. Michael Kalin