Impediments to practice

We’ve learned that Nova Scotia’s doctors are feeling burnout and stress at greater numbers than ever. This has long been known, but was made “official” with the release of a Doctors Nova Scotia study in September.

Nova Scotia’s doctor shortage is the result of a combination of circumstances: practice-limiting restrictions, poor treatment and low pay.

Practice limitation:

The Nova Scotia Health Authority used a spread sheet to decide where doctors practiced. With an eye on court cases which overturned attempts by other health authorities to restrict where doctors practiced, NSHA introduced credentialing to the equation to decide where doctors practiced. Credentialing is essential for a doctor. Without it a physician can’t order medical tests, write prescriptions or send a patient to hospital. Without those abilities the physician can’t bill for services and patients are left without essential tests, treatments and medications. In essence it is a type of medical rationing they hope withstands a legal challenge.

The idea was to level out where doctors established their practices. For example, Halifax is, statistically, over-doctored. So rather than allow more doctors to establish a practice there, the idea is to encourage doctors to go to rural areas. The caveat is that they go to a rural area to work in a collaborative care centre.

There are several problems with this: while Halifax may statistically be over-run with doctors, many are specialists who don’t provide family practice services. The statistics don’t differentiate the doctors, which is why as many as 20 percent of Haligonians may be without a family physician.

Secondly, this type of geographic limitation to care is old thinking brought forward to a new unified system created to overcome the inefficiencies of the former silo system. Under the old system of nine regional health authorities patients were to be treated within their home health authority and not travel further than 100k for care. A laudable goal, but one that is quickly negated when it compounds and/or prolongs suffering or delay in delivery of care.

Since merging the health authorities we have been able to better utilize some facilities and assets. For example, hundreds of patients have accepted the option of driving to Amherst for knee surgery versus waiting a year or two to have it closer to home.

The NSHA’s current geographic focus overlooks patient mobility and our commuter society. A quick look at commuters driving Highways 101, 102, 103 and 107 would illustrate how many people travel daily to Metro for work. If these rural or non HRM residents had access to a city-based family physician most would not find it inconvenient.

Geographic silos created the backlogs which haunt us today. While some places had sufficient resources for the local population, others had waiting lists, while other authorities’ facilities and professionals were under-utilized.

Physician treatment:

Another issue with practicing medicine in Nova Scotia is how doctors are treated. Nova Scotia is currently divided into five health zones. A doctor told me that the head of their zone “speaks to us like we’re all idiots” and told a roomful of doctors, “If I were you I wouldn’t renew my lease.” His advice was based on population density numbers and the Physician Resource Plan, not actual need seen by doctors in that zone.

The NSHA refers to consultations. That is PR-speak. Their interaction with medical professionals is top-down. Whether written, in a teleconference or face-to-face meeting the conversation is one-way. It has let doctors know what has been decided about how they practice, where they practice, what they practice. Done without input from them.

I was told of a Cape Breton meeting where a roomful of doctors called the NSHA executive speaking to them a liar who should be ashamed of their bold-faced lies.

In December 2015 or January 2016, I’m fuzzy on the date, I was told of a meeting with family medicine residents set to graduate in June 2016, which students left in tears. This meeting changed the work options for both new graduates and practicing doctors.

At another meeting a health executive told a roomful of physicians they were a “privileged elite who had no concept of reality”. Hardly collegial.

The Money:

Finally, there is no financial incentive to practice in Nova Scotia. The Canadian Medical Association says the average income for a general practitioner in Canada is $251,362. In Nova Scotia the average is $214,567. That’s a practice income, not the physician’s take home pay.

https://www.cma.ca/Assets/assets-library/document/en/advocacy/37-avg-gross-ffs-e.pdf

To make ends meet in this province many doctors have been reducing patient appointments to 15 minutes. That production-line like scheduling means a family physician sees four patients per hour, 32 per day, 160 per week and 7,680 per year. Recently, I have learned of some doctors who have shaved appointments down to 10 minutes. Their numbers become: five patients per hour, 40 a day, 200 a week and 9,600 a year! Like a teacher, there’s unpaid evening and weekend work on files. No wonder there’s burnout.

With a combination of career limitations, adversarial workplace and some of the lowest income in Canada, why would physicians flock here?

Ironically, in the 1990s and 2000s Atlantic Canada promoted the concept that lifestyle trumped cash. A number of business voices touted the message that employers could find an educated workforce willing to work for less for the opportunity to stay home or return. Interestingly, while business media, organizations and government adopted that message, governments and health executives took a different tract when it came to hiring for their ranks – and setting their pay. We were told that we had to be aggressive in executive compensation in order to attract the best people for the job. That’s not the way their treat medical professionals.

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Corporate governance, confidence and care

In spite of the scandal involving the IWK’s CEO expenses and role the Chief Financial Officer played in smoothing over the bumpy, uncomfortable details, confidence has been expressed in the IWK.

Confidence is the pro-forma, generic response. In attempting to contain the damage comforting sounds have to be made. It’s PR101. Expressions of confidence are primarily for internal face-saving. Public opinion is messier, more blunt and contrarian.

No one has called into question actual patient care at the IWK. The rot isn’t on the patient floor, but executive suite and board room. Confidence seems to be a flexible word. The previous board chairman told the CBC, and by extension the public, that he and the board had confidence in the CEO, CFO and processes in place. Now the CEO and CFO are the “former CEO”, “former CFO” and the processes are under review by the Auditor General.

To repeat, it’s not the patient care that’s in question it’s the management and corporate governance. It’s going to take a lot of work to convince the people that the board hasn’t been asleep for 27 months.

When this scandal broke, a patient rights group sent me a PDF of the boards of the IWK and Nova Scotia Health Authority. The IWK has a 19-person board for a $250 million budget. The NSHA has a 13-person board for a much bigger budget. The Province of Nova Scotia has a 17-person cabinet to manage a $10.5 billion budget.

Corporate governance is always a challenge. How big is too big, when is a board too small? What are the proper mix of skills, experience and knowledge? Is the IWK board too big to be effective? Or could the NSHA board be too small? And given the problems with governance at the IWK, what is happening at the ultra-secretive NSHA?

Prior to the unfolding of the IWK expense scandal, the complaint was that the NSHA board lacked representation from medical professionals. Whatever is the right size for a health board, what is missing from both is strong patient representation.

The system is unlikely to ever achieve public aspirations until those who have used and experienced the system have a voice. A patient voice represents one of the real measures for effectiveness. We’ve had top-down directives. It hasn’t worked. Patient floor up is what hasn’t been tried.

 

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Imagine there were no doctors

To highlight the depth of Nova Scotia’s doctor shortage I’ve studied the 2016 census figures to provide a geographic perspective and give these statistics a sort of face. Picking up on John Lennon’s theme of imagining, imagine there are no doctors…

If Corporate Research Associate’s recent finding that 13 percent of Nova Scotians, roughly 123,500 people, don’t have access to a family physician is accurate, here’s what that means:

nscounty

Block out counties as you read to grasp the scale of our physician crises.

  • imagine no one in all of Cape Breton having a physician. That’s 122,311 people. Imagine 12 hospitals and health centres without doctors.
  • or imagine no doctor for the residents of nine of our 18 countries: Antigonish, Annapolis, Digby, Guysborough, Inverness, Queens, Shelburne, Victoria, Yarmouth. That’s 124,860 people. That would leave 20 hospitals and health centres without physicians.
  • consider the 132,525 people who live in Kings, Annapolis, Digby, Yarmouth, Shelburne and Queens counties without family physicians. That’s a doctor-less Southwest Nova. Not only that, there would be 16 hospitals and health centres without access to a doctor.

If the actual number of Nova Scotians is the 155,415 orphaned patients suggested by the October 2016 Freedom of Information request, then stretch the imagination to this doctor-less geography:

  • most of Southwest Nova (Kings, Annapolis, Digby, Shelburne, Queens and Lunenburg counties) without a physician. That’s 155,232 residents. That’s the bulk of our agricultural, fishing and forestry sectors at risk.
  • imagine driving from the New Brunswick border by Amherst to Meat Cove on the tip of Cape Breton without crossing any community with a doctor. Cumberland, Colchester, Pictou, Antigonish, Richmond, Inverness and Victoria counties have a population of 156,214 Nova Scotians. They’re home to 18 hospitals and health centres.
  • finally, imagine no doctor for the 156,150 residents of Halifax’s commuter counties: Annapolis, Kings, Hants and Lunenburg.

Imagine driving through county after county without a single physician available. This is how severe our doctor shortage is. It’s more than being down a few physicians here and there.

There aren’t just the current vacancies to fill, there is a rising wave of physicians about to retire, who must be replaced. Our current health care executives are not adequately addressing the issue of physician retention or recruitment.

And given how badly physicians are paid and treated in this province, why would they want to practice here.

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Doctor shortages by the numbers

A new poll by Corporate Research Associates says 13 percent of Nova Scotians (approximately 122,000 people) don’t have a family doctor. That’s probably an optimistic number.

Statistically, Nova Scotia appears to almost qualify as a medical nirvana, with one of the highest doctor-population ratios in Canada.

However, some suggest the ratios are skewed by the medical mix. Of the 177 new hires NSHA claimed between April 1, 2015 and March 20, 2017, 71 are family physicians and 106 are specialists. That leaves a significant portion of the population waiting years for a family physician.

Figures for orphaned patients range from 25,000 to 95,000, but could be well in excess of 150,000.

The 25,000 figure represents the number of people who, in the first five months it was available, called a doctor registry hotline instituted by the Nova Scotia Health Authority (NSHA). Later the NSHA adjusted that to 33,000 people looking for a doctor. Doctors Nova Scotia (DNS) says a freedom of information request filed by the Progressive Conservatives found that a study done in October 2016 “was quite startling. We’ve always run on a premise of as many as 10 per cent of Nova Scotians don’t have a family doctor (95,000). This survey indicated in the Halifax Regional Municipality (HRM) about 20 percent of residents and in rural Nova Scotia about 14 percent (didn’t have a family physician) so both of those numbers are higher than what we expected.”

Using the October percentages, that means 155,415 Nova Scotians (78,019 in HRM and 77,396 rural residents) don’t have a family physician. The orphaned patient numbers grow even worse if the projections from a 2012 Physician Resource Plan are used. The Plan predicts that by 2021, the population health services needs will be equivalent to a population of 1,100,000.

That 1.1 million population figure is based on our current aging population, not an influx of new residents. In other words, it is adding the needs of 60,000 more people to the system. That’s basically the population of Kings County to squeeze into our existing system.

One of the problems in attempting to quantify the doctor shortage is the NSHA’s inability to say how many doctors there are in the province. In April, a NSHA representative said, “Given daily changes with retirements, deaths, relocations, etc. and the complex roles that family doctors play, this number fluctuates regularly. On any given day in Nova Scotia there are more than 1000 doctors seeing patients in a family practice.

“If you include specialists, there are more than 2600 doctors in Nova Scotia.
“The best source for these numbers are CIHI Physician Migration Studies.
https://secure.cihi.ca/estore/productSeries.htm?pc=PCC34

“Family physicians are independent contractors; they are not employees of NSHA. NSHA does maintain a list of vacant positions by zone and positions that are coming vacant when a physician has given notice that they will be leaving or relocating.

“NSHA does not maintain a centralized list of physicians.  We do work with family physicians to better understand when they are planning to retire or leave the province.”

Since the NSHA doesn’t know how many doctors are in practice in the province, they can’t guess at how many Nova Scotians don’t have a doctor.

Physicians complain about the age of data and methodology used to make guestimates. The Physician Resource Plan, which is the guiding document for the NSHA, was published in 2012 using data gathered in 2008. So the Resource Plan was launched with old numbers and five years later relies on what front-line doctors feel are unrealistic numbers.

How can you fix a problem you can’t quantify?

 

 

 

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Rot at the top of the IWK

The IWK CEO expense scandal illustrates there is rot at the top.

As the CBC peels away the layers of this scandal and subsequent cover up I think Nova Scotians and Atlantic Canadians, since the IWK is the regional children’s hospital, have been caught off-guard. It is like the region has taken a punch in the gut.

What seemed like an innocent accounting issue has grown into the type of misused public funds and subsequent cover-up on a scale and style worthy of a Washington scandal. The selective reporting/withholding of information eclipses the misuse of money to shake the foundations of public trust.

http://www.cbc.ca/news/canada/nova-scotia/iwk-expense-reports-officials-tracy-kitch-stephen-d-arcy-1.4292637

If this can happen at such a highly-regarded institution, what is happening at our other boards, commissions and agencies? And yes, what about the Nova Scotia Health Authority and predecessor authorities? A line has been crossed which opens all to scrutiny.

We now rightly have questions about the veracity of the executive, of senior management and the board. Boards of directors are supposed to be the public’s guardian. They are supposed to have the inside information and access to ensure operations are true, accurate and managed according to the rules and regulations as well as being in line with the moral expectations of the public. This is a massive violation.

Where was the board? Robert Hanf, former president of Nova Scotia Power and former chairman of the IWK board, said he was never alerted to any inaccuracies. He only became aware of a potential problem following the CBC’s freedom of information requests. How is it that someone put in the position of board chairman because of his business expertise didn’t notice documents were incomplete? A reporter, who probably hasn’t the business background of Hanf, noticed it and challenged it. Hanf told the CBC, “the IWK board put confidence in the assurances we were provided. I trusted the information being provided to me had been properly reviewed internally and therefore that it was accurate.”

That sounds like lazy over-sight. And lazy over-sight is probably more rampant across public boards than anyone wants to admit. What do we expect with drop-in volunteer boards? I have repeatedly asked how many times any health board ever said no to an executive request? Has any board ever held executives to account for missed deadlines, spending, performance and patient outcomes? Or are public boards just rubber stamps for all too unaccountable public executives? The rot comes from relying on – and knowing how to play – the incestuous old boys clubs that populate public boards.

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Liberal math is bad for doctors

The Federal Liberals have announced plans to change the tax law with regard to small businesses.

The federal Liberal message is that people who earn $50,000 shouldn’t pay more taxes than those who earn $250,000. It’s an offensive message because it’s a vacuous sound bite that illustrates the bubble Parliamentarians and their advisors inhabit. A small business may earn $250,000 or more, but that’s the company revenue, it’s not the owner’s income.

It costs money to generate income. The government doesn’t recognize how many people live off that $250,000 – there can be employees plus the owner and any family he supports. That $250,000 gross pays for company operations, supplies, services, as well as taxes.

This sudden, ill-conceived policy change can have negative impact on health care. Most doctors are incorporated. Their practices are a small business, so they need the liability protection incorporation offers and the ability to manage business costs in a simple, straight-forward way that is acceptable to the tax department.

Here’s a crash course in family practice math:

In March 2017 a Halifax doctor, who is incorporated, told me their 2016 take-home pay was $60,000! In comparison, the Nova Scotia Health Authority has established a $144,000 pay rate for a nurse practitioner. The NP is also provided with $32,000 for an assistant, plus an office paid for by the health authority. The NP qualifies for benefits that doctors don’t (paid vacation, access to unemployment insurance, CPP, maternity leave, sick days and so forth). For this the nurse practitioner is expected to see 800 patients a year. New doctors are expected to have a patient load of 1,400 patients. Old doctors have patient files numbering from 2,000 on up.

In Nova Scotia we treat physicians like old-style assembly-line workers who are paid on a piece-work basis that we call fee-for-services. And some of those services, like refilling a prescription, aren’t a billable item, so those become the doctor’s un-deductible donation to the health care system.

When a doctor in Nova Scotia is paid for a qualifying service, they receive an average of $31.45 per patient appointment vs the $70 paid to the corporation which provides the 8-1-1 answering service. A telephone call earns a major foreign corporation more than twice what a doctor’s appointment pays.

Here’s what the federal Liberal Party is attacking:

A family practice doctor sees four patients per hour. $31.45 x 4 = a gross hourly income of $125.80.

An 8-hour day seeing 32 patients @ $125.80 = $1006.40.

A five-day week seeing 160 patients @ $1006.40 generates $5,032 in gross income.

Allowing for two weeks of unpaid vacation for the physician, plus 10 statutory holidays per calendar year gives the physician a potential for 240 working days (snow days will reduce that number). So $1006.40 x 240 days = $241,536 for the practice’s annual gross income for handling 7,680 patient appointments.

From that gross revenue, deduct average costs like: $38,000 for a receptionist/secretary, plus a part-time person to fill in when she is ill or on vacation (that’s $8,770) and $100,000 practice costs (rent, utilities, supplies, equipment, insurance and so forth). These expenses amount to $146,770. This leaves the family physician with a pre-tax income of $94,766.

In Nova Scotia, $95,000 can provide a decent lifestyle. But that’s a pre-tax figure. And consider the years of education required to train and qualify as a doctor and then the student debt to pay off. And there should be some consideration given for the stress and responsibility placed on a physician’s shoulders.

And when it comes to retirement the medical system doesn’t end its abuse. Physicians are required to maintain patient records for 10 years past the last appointment. Pediatric files have to be maintained for 10 years past the patient’s age of majority. For some that can mean preserving and making files available for 29 years! There’s a cost for safe, secure file storage and time to find and make available any requested files.

There is a huge financial disincentive to being a doctor in Nova Scotia. On top of that we have a health authority that doctors privately describe as “abusive”. And now, on top of low pay and poor working conditions, the federal Liberals are attempting to remove some of the accounting tools available to physicians and other small business owners (including farmers) to smooth out their cash flow and retirement planning.

Effective delivery of health care involves more than a spreadsheet. Doctors are in such demand that we shouldn’t be knowingly implementing regulations to drive them away.

The federal government’s math doesn’t add up. Their proposed changes dis-incentivize physicians from practicing in Canada.

 

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No hardship in paid leave of absence

Having the IWK’s Chief Financial Officer take a paid leave of absence sends a mixed message. Does it suggest he failed in his job or was bullied into submission by the previous CEO or that the individual is an impediment to investigations by outside auditors?

Part of a memo from the IWK’s board chair, Karen Hutt, printed by The Chronicle Herald says the CFO, “fully understands the importance of an external review and we appreciate that he wants to ensure that the integrity of this process is not compromised.”

I suppose this goes to the concept that “Caesar’s wife must be above suspicion.”

Being asked not to come to work while still being paid $760 a day/$3,800 a week is not a hardship. So, the question for the IWK Board, the Health Minister and the Government is this: if an employee on paid leave is found to have failed in his/her duties is that paid leave considered part of the severance package or are taxpayers left to flush out a package which is built up by money paid for not working?

Is executive severance a bottomless pot of gold?

 

A postscript: An Ontario judge who, on a lark, wore a Make America Great Again hat to work was suspended, without pay, for 30 days.

https://beta.theglobeandmail.com/news/national/ontario-judge-who-wore-trump-hat-in-court-suspended-for-30-days-without-pay/article36235840/

 

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