Identity Crisis – Whose Side are We On?

luke skywalkerWhether in war or the Super Bowl, anyone who tries to cheer for two opponents gets called a traitor by both.

Serious opponents wrestle over fundamental differences.  Dreamy relativists dismiss debate and sing, “Why can’t we be friends.”

Although peace costs less than war, sometimes you must pick a side and fight. Peace-brokers risk becoming irrelevant to both sides, after the war ends. Those too eager for peace could incite civil war in their own ranks.

That’s not to say we should never call a truce. Calling a truce means, by definition, that there are two sides. You cannot deny differences and hope to win favour with both opponents.

Identity Crisis

Doctors are not on the same team as government. Politicians are on their own team. As soon as their interests do not align with ours, doctors often lose. Continue reading “Identity Crisis – Whose Side are We On?”

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Dreams of Co-Management

Blond Boy CryingWe start life ruled by passion. We clench our fists, howling at hunger pains and wet diapers. We swing from elation to rage, driven by desire.

Eventually, we grow up. We learn to control emotion. But passion continues to fuel our dreams throughout life. Life absent passion is death.

Dreams of Co-Management

Doctors have audacious dreams. They want a say in how patients receive medical care. They want an equal voice in decisions about medicine.

Some call these dreams arrogance. Continue reading “Dreams of Co-Management”

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Crisis of Trust – Doctors Vote No

harry-potter-philosophers-stoneOrphans make great fiction. Harry Potter leads a long list with Tom Sawyer, Anne of Green Gables and Oliver Twist.

Children need someone to trust. They cannot be children and fight the world at the same time. Abandonment is held with universal disdain.

Doctors feel abandoned. Over 61% voted No to a tentative deal that promised cuts and underfunding for 4 years.

The Wynne government has squandered money for medical services, by gambling on windmills and pension plans. Health Minister Hoskins makes a point of belittling doctors for working hard in the system his government created, while every other public union gets contracts, with raises.

Doctors feel abandoned by government.

Many doctors feel the same about the Ontario Medical Association (OMA).

No one can accuse the OMA of bargaining in bad faith. The OMA was determined to promote the 2016 Tentative Physician Services Agreement and spared no expense in advertising.

Robocalls, personal phone contact on the weekends, slick campaign ads by email, video interviews, dozens of roadshows, tele-townhalls, local medical meetings, letters to the editor and a massive social media campaign pushed doctors to vote Yes.

No one knows, but people guess it cost between $1 million to $3 million. This ignores hours of OMA staff time, as other work got put on hold.

The OMA has never tried so hard to convince their members to ratify a contract.

And that’s the problem.

The board endorsed the New Deal. It was wise to share it with members. But endorsement morphed into promotion and desperate advocacy.

Desperation creates blindness and drives odd behaviour. Superior Court Justice Perell ruled that the OMA Board’s Executive Committee had “abused the authority provided to it” and created an “unhelpful, unclear,  unbalanced, and unfair” voting process.

Perell called the Exec “sneaky”.

Addendum: One physician leader insisted that Perell called the “OMA” sneaky. Legal opinion did not back up that statement, although it is not 100% clear. Regardless, whether Purell referred to the Exec, the whole Board or the OMA writ large, his comments are damning. We must get on and face the fact that the comments exist and stop blaming people for drawing attention to them. 

We must not judge too quickly. Passionate beliefs make people double down and pour in more energy, precisely when they should step back. Double or nothing seems logical at the worst time.

A wise friend said that, People with weak arguments hold the bitterest resentment for those who do not support them. People with strong arguments do not need endorsement. Their case stands on its own merit.

The OMA bet everything on promoting a Yes vote and lost doctors’ trust in the process. Many of us might have made the same mistake.

Crisis of Trust

Warren Buffett said, “It takes 20 years to build a reputation, and 5 minutes to ruin it.” It takes years of effort, sacrifice and principled behaviour to earn the trust that creates lasting change.

Doctors need someone to watch their back, so that they can focus on patients. Doctors cannot provide care with one hand on their sword.

Many believe that the massive No vote is a vote of non-confidence in the OMA.

How to Rebuild Trust

Healing starts with taking other people’s beliefs seriously, regardless of our opinions about those beliefs.  Denying a crisis of trust guarantees more failure.

For leaders, staff opinion must trump leadership ‘facts’. When staff members firmly believe that leadership betrayed them, leaders cannot fix it by proving their staff has no right to feel that way. Leaders win trust with behaviours and outcomes, not arguments and facts.

Doctors know this. When grieving parents attack us, it does not help to debate the best way to resuscitate a dying toddler. We want to run away when lawyers show up, but that is exactly the time to engage with compassion.

Leaders must deal with beliefs and emotions before process and projects. We must take the accusations of our most passionate critics with utmost seriousness.

If government is a reckless, absent parent, then the OMA must be the dependable one. The OMA must win the right to be trusted. It can be done. But it will be costly, in many ways. We need the courage and humility to start.

The OMA must prove to doctors that it values its members before anything else; that it will never abandon them. That might require painful sacrifice. But it’s essential. Orphaned doctors do not provide great care.

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General Meeting of the Membership

AllStream CentreAnyone who has ever video taped an event knows that important things  happen off screen. The camera lies.

Historians write history long after collecting all the details and stringing them together. They interpret events and find meaning. They might even use video clips.

General Meeting of the Membership

Eight hundred doctors attended the General Meeting of the Membership, on Sunday, August 14, the second one since 1880.

The first one took place at Maple Leaf Gardens in Toronto, in 1991 over a rotten contract. That time, around 1500 doctors sat in hockey bleachers and left disappointed; the OMA President had collected thousands of proxy votes and crushed the uprising easily.

The contract was ratified. Doctors endured almost 10 years of ’Social Contract’ abuse that ended with 2 million Ontarians without a family doctor.

Almost Perfect

This meeting was different. The OMA pulled together one of its best-organized meetings, in less than 6 weeks.

No expense was spared.

Attendees stretched out in a room prepared to seat 4000, plus overflow. Everyone else watched it live online, from the middle of their summer vacations.

Hartley R. Nathan policed the meeting. He wrote Nathan’s Company Meetings Including Rules of Order and is the expert on parliamentary process in Canada.

Mr. Nathan whispered to the Chair all afternoon, until the Chair closed the meeting with: “This meeting is now terminated.

Doctors loved the opening speeches, an ersatz debate almost. They cheered as the underdogs approached the stage, brave upstarts challenging the establishment.

A reverent hush filled the room, while the next speakers assembled. No one dared whisper or fidget as the Co-Chair of Negotiations adjusted the mike.

The army of security guards had an easy day. Fearing the worst, organizers thought of everything. They made speakers line up at separate microphones, labelled ‘For’ and ‘Against’. It helped the Chair alternate sides and prevented shoving in the lineups.


Only once, a group of medical students and trainees swarmed the microphones.

One doctor had questioned whether trainees knew much about running a medical business in their ‘naiveté’: Did their opinion really matter?

With good reason, students responded. A few went too far. One said most working doctors could never get into a modern medical school.

The issue was not settled. Students do not get to vote on residents’ contracts.

Thankfully, the fracas ended quickly.

Many doctors said they wished that biannual Council meetings could be as fair and open. They loved debate that ran as long as necessary and only ended after speakers ran out of words.

The crowd discussed 3 motions over 5 hours. At that rate, Council might complete business in 7 days, instead of the usual Saturday – Sunday meetings.

Existential Impact

Now we wait to hear from the official counters-of-the-vote. As memories fade and blend with official records, we will decide what this General Meeting means, if anything at all.

Will it prove that activism can never change a nationalized industry?

Will it show that doctors cannot change their own organization from the outside?

Or will it mark a watershed in medical politics, the point when the populace rose up and said, “Enough!

In the tangled meaning that emerges, one thing is certain: healthcare in Ontario is in trouble, and this marks the start of change.

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Minister of Monopoly (Nat’l Post Article)

CorcoranTerence Corcoran, journalist at the National Post, captures the bigger issues going on in Ontario healthcare, in his article today: Minister of Monopoly

Regardless of where you land on the doctors’ New Deal, please take a few minutes to read Mr. Corcoran’s article (posted below).

Patients do not benefit when government holds all the power in healthcare. Even if doctors vote YES, let’s hope they keep the power imbalance in focus. 


Minister of Monopoly

National Post
Thu Aug 11 2016, Page: A10, Section: Issues & Ideas
Terence Corcoran

This coming Sunday, Ontario’s doctors will meet and vote on a proposed compensation agreement between their ersatz union, the Ontario Medical Association, and the Wynne Liberal government. It is shaping up as one of the most important events in the modern history of health care in the province.

The new agreement, known as the Physicians Services Agreement, has been superficially portrayed in the media as just another typical labour skirmish over cash between greedy overpaid medical millionaires and do-gooding politicians protecting the public good and the sanctity of universal health care.

Similar confrontations have been raging since the 1980s when the OMA was transformed into a mandatory Rand Formula organization and doctors lost the right to practice outside the system. But this year could – or should – be different. The Sunday vote is much more than a simple decision on whether doctors – along with nurses the only people in the $50-billion government funded system who actually deliver health care directly to patients – will be paid more or less over the next four years. The answer is less, but that’s not half the story.

The new compensation agreement (negotiated in secret unbeknownst to members before it was announced by the OMA in July) is the high-profile tip of a giant low profile health-care menace known as Bill 210, legislation that bears the unbearably cute title “The Patients First Act.” The objective, officially, is to improve primary care in Ontario and repair the bureaucratic shambles that currently exists.

Bill 210 was tabled in the Ontario legislature in early June by Dr. Eric Hoskins, Minister of Health and Long Term Care. It received minimal media coverage, perhaps because it arrived surrounded by vaporous clouds of bureaucratic babble, management consultancy jargon, impenetrable legalese and ideological sleaze. What can one say about a plan that promises a new system that “focuses on performance management and continuous quality improvement” and aims to improve “population health” and serve “community needs” based in equity and the delivery of healthcare “where people live”?

Underneath the sleaze and behind the clouds is the Ontario government’s attempt to put in place the power apparatus it believes it needs to install the next phase in the ongoing multi-decade effort to reconstruct the province’s perpetually failing healthcare system and install a more centralized top-down perpetually failing healthcare system.

When government holds monopoly control over any system, and the means of production of key suppliers have been nationalized, there’s no market to help patients, doctors and health-care managers make decisions. The only option for the system is to constantly increase bureaucratic control and progressively reduce the freedom for everybody else.

If doctors vote Sunday to accept the agreement, they will be pulling the first string that will allow the Wynne government to bring in reforms that will, among many other things, greatly reduce the already constrained freedom of doctors, hospital managers, and other organizations and individuals. As the OMA itself said in response to Bill 210, the legislation gives the minister of health and the government-controlled Local Health Integration Units (LHINs) “a significant increase in their command and control of the health system and many of the providers within it.”

To get that command and control, Ontario is using the oldest legal dodge in the command-and-control handbook: give the minister the power to do anything the minister wants so long as it can be said to be in the “public interest,” an undefined legal grab bag that provides command-and-control freaks near-unlimited power. “This is problematic,” says the OMA in an understatement.

As the all-powerful commissar of patient care, the Minister of Health (MOH) can reach high and low through the system in search of the public interest. The Ontario Hospital Association, in its response to Bill 210, calls the MOH’s new public interest powers “quite broad” – another understatement. It would, for example, permit the minister to issue direct orders to hospitals to lower parking fees – something the government has tried to do in the past but had no legal authority to enforce. Now it will. Moving up the chain of decision-making from the seemingly trivial business of parking fees, Bill 210 lays out a dozen instances in which the “Minister may” act in “the public interest.” One example:

“The Minister may issue operational or policy directives to a local health integration network where the Minister considers it to be in the public interest to do so.”

And on it goes: The Minister may in the public interest issue “operational or policy directives” to the board of a public hospital. Private hospitals “shall carry out every directive of the Minister” and such directions could be “general or particular.” The Minister may appoint investigators to “enter the premises” of a local health network “without a warrant” to inspect records and “report on the quality of management and administration.”

The MOH needs all these new command and control mechanisms to help it impose Bill 210’s major objectives, which is to expand the powers of the 14 local health networks that currently plan, fund and oversee health-care delivery across the province. Under the plan, the local networks – through which most of Ontario’s $50-billion health budget flows – are to take over another branch of the system, the province’s dysfunctional community and homecare operation. Also to be submerged under the centralized control model are local medical health officials. Even experts who support some of the power consolidation have their doubts. Michael Decter, a veteran of Canadian health policy, said the group he chairs, Patients Canada, supports the goals of Bill 210. But he said “we are unable to see how a major restructuring of boards and more bureaucratic management and oversight of health providers and health organizations will result in more responsive, effective, compassionate delivery of health-care services to patients.”

Most agencies and associations have adopted a wary wait-and-see attitude toward Bill 210, which will come up for detailed review and amendment in the legislature later this year. The OMA has many clear concerns. Requirements that physicians report their office operations to local authorities, including practice policies, profiles, wait times and coverage, is “intrusive” and “erodes physician self-regulation.” Other parts violate agreements the OMA has with the government.

A recent commentary by lawyers at Osler Hoskins portrays Bill 210 as a “sweeping expansion” of government and local health networks over physicians and other health-service providers. Bureaucrats will have the power to identify and plan for “physician resources” and unilaterally impose accountability agreements. The bill will impact physicians in family health teams, individual hospital departments, entire services in a single hospital, and emergency services. None of this is directly on the proxy ballot doctors will be completing for tabulation on Sunday. But it is clear the new compensation agreement is part and parcel of the Wynne government’s Bill 210 master plan.

The OMA’s position is that while the new compensation agreement may not be all that great (“Not a perfect choice. Far from it.”), they say doctors will benefit in the future because the OMA has negotiated certain clauses that will mitigate some of the worst aspects of Bill 210.

For example, to help alleviate the fact that many Ontarians have no family doctor, the OMA has agreed to work with the government “to ensure that every Ontarian who wants one has a primary care provider.” To meet that objective, the OMA will work out improved evening, weekend and holiday coverage, and produce reports on physician resource and access issues. If the OMA meets these commitments, then the government will amend a couple of clauses in Bill 210.

But that clawback still leaves physicians under increasing government control. In another concession to Bill 210, the last clause in the compensation agreement says government and the OMA “are committed to ongoing engagement … regarding health system reform and design.” Four decades of fractious government-doctor relations suggest cordial engagement between doctors and demagogic politicians over health-care reform is a political long shot.

On the other hand, Virginia Walley, president of the OMA, said in an interview this week that the compensation agreement includes an “ironclad” legal commitment from the government “not to take unilateral action” to reverse or impinge on the compensation agreement the doctors are debating on Sunday.

That would be a step forward, but how far does it go?

Enhancing bureaucratic power can only come at the expense of the people supplying the services. The last Ontario budget called for healthcare spending to increase by about 1.5 per cent a year over the next three years. With rising health-care demand, growing population and inflation alone running at 1.5 per cent, something is going to have to give within the healthcare envelope.

The OMA’s members account for 23 per cent of Ontario’s health-care spending. Doctors took unilateral cuts of up to seven per cent in the past, and the new compensation deal to be voted on Sunday suggests doctors will collectively see their real incomes fall over the next four years.

A new analysis of the proposed agreement by University of Toronto economist Jack Carr on behalf of doctors opposed to the deal concludes that as health-care demand rises, doctors will have to bear more of the costs. Carr says that under the agreement “doctors implicitly accept financial responsibility for increased utilization.” If utilization rates rise four per cent a year from three per cent currently, doctors will be forced to face reductions of almost $1 billion. If utilization rises five per cent a year – not an improbable proposition – doctors will face payment reductions of more than $2 billion.

Should Ontario’s 42,200 OMA members (including 3,000 medical students) say no to the agreement, it would send the province’s bureaucratic central planners back to the drawing board. If they accept the compensation agreement, the OMA will have helped advance the Wynne government’s imposition of its massive interventionist Patients First command-and-control healthcare system.

The hallmarks of central planning are maldistribution of resources, inadequate supply, shortages, waiting lists, lineups, price controls and breakdowns. If the economic history of command and control teaches anything, it is that you can’t put patients first by putting the suppliers of patient care last.


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Tragically Hip & Summer ’16 – Guest Post

Owen and Darren CloseupDarren Cargill offers a post for #TragicallyHipDay and Doctors New Deal. Check out Darren’s other post here.



Summer of 2016 through the eyes 

of an unrepentant Hip fan

The summer of 2016 has been a tough one for Ontario’s doctors. Entering the summer, the OMA had been without a contract for over two years with no end insight.

At the same time, fans of the Tragically Hip, “Canada’s band,” were reeling from the news that Gord Downie had been diagnosed with a deadly brain tumor, a glioblastoma, and that the band would undertake it’s final tour, crossing Canada one last time over the summer.

As a physician and a Hip fan, I came to view this summer with mixed emotions. As we turn the corner on summer and move headlong into August, we move closer to the end of era and the grey of another.

Looking back, here is how I seem to remember it:

It started with a group of docs known as the Concerned Ontario Doctors or COD. They proclaimed they had had it UP TO HERE with unilateral cuts and health ministers who skip out on parliamentary votes for playoff baseball.  We all muttered about a track off MUSIC@WORK when the Health Minister attempted to shame physicians with a press conference in April.  With a Facebook site and near daily articles in the Huffington Post and Toronto Sun, reporters remarked to Drs. Alam and Kaur “YOU ARE EVERYWHERE.” And it seemed they were right. FIREWORKS and VAPOUR TRAILS were common on the COD site until leadership stepped in to lay down THE RULES. A battle for hearts and minds ensues.  Out of the wilderness comes bloggers and POETS. Every day we are drawn from one side to another Whatley, Gandhi, Alam, Elia, Wooder and Warsh.

A Physician Services Budget that will FULLY COMPLETELY fund both population growth and utilization of health care services is what they asked for. Relativity is the FIRE IN THE HOLE that threatens the very fabric of our organization. The difference between some specialists and those who are SO HARD DONE BY continues to grow, rather than shrink.

New grads and med students look on with trepidation and fear. Med school does not prepare you for the cut throat world of provincial politics.  Thankfully they are reassured by senior statesmen that medicine is still “A GOOD LIFE IF YOU DON’T WEAKEN.” Now some may claim “THE KIDS DON’T GET IT,” but I beg to differ. I welcome their enthusiasm and a reminder of why we all entered medicine in the first place.

Then along comes Theresa Boyle of the Toronto Star on quest of blame and shame to BLOW AT HIGH DOUGH, to expose OHIP high billers while simultaneously ignoring the overhead and expenses inherent in medical practice. Asking the Privacy Office for the Top 100 billers betrays her motivations and a court injunction grants us a reprieve from another Kangaroo Court about “out of control” doctors like the Minister’s press conference in April.‎

Over two and a half years, negotiations crawled along, seemingly at an INCH AN HOUR. Hope began to fade as a negotiated settlement seems an IMPOSSIBILIUM. The years have been lean since 2012 and this one was shaping up to be THE DARKEST ONE yet.

When a tentative PSA was abruptly announced, COD claimed “TROUBLE AT THE HENHOUSE!” stating that this breakthrough failed to bring the binding arbitration that Council had demanded. In spite of concerns regarding the process followed, this deal was presented to the MEMBERSHIP by the Board as an opportunity to move forward.

Those who support the PSA claim that no better deal can be found. Pundits like Steve Paiken and Andre Picard agreed. COD feel a vote of “No” will not bring about the calamity that is foretold, rather they shout that we shouldn’t  be SCARED that the time is “NOW FOR PLAN A” and that we must hold strong for a proper negotiation. They tell the OMA in no uncertain terms not to “TWIST MY ARM.”

Trouble is, this government is broke. Money has been wasted on scandal after scandal. The debt has topped $300B, with $350B just on the horizon.  The doors to Deb Matthew’s Treasury no longer lead to ELDORADO but to the thread bare coffers of a government past due.

Criss-crossing the province with road shows and teleconferences, the OMA Board and staff have been met by members either YAWNING OR SNARLING with little middle ground in between. “Yes” is ready to move on; “No” is ready for another fight. But soldier on they do, providing the facts with deliberate calm, talk of renewed trust and GRACE, TOO. Our President soldiers on IN VIOLET LIGHT.

The OMA argues this deal brings stability and predictability. It prevents the unilateral cuts that has the Schedule of Benefits ALL TORE UP. It also allows our Charter Challenge for binding arbitration to continue. Armed with his THREE PISTOLS of Labour Trilogy, Brian Burkett assures us we still have a strong case against an unconstitutional government.‎

Served with a petition, the OMA must now call a General Members meeting. Only once has this been done before. Known only as “THAT NIGHT IN TORONTO,” the only other meeting of its kind took place in 1991. Events seem to change not on a daily but  hour to hour basis. Members look to one another and exclaim: “this SUMMER IS KILLING US!”

But where exactly to hold such a meeting?  OMA staff scramble about town LOOKING FOR A PLACE TO HAPPEN. Not many venues can hold our entire Association under one roof. No matter where we end up, we know it would have been better off in BOBCAYGEON .

No referendum. No Special Council. This is a winner take all vote, a meeting of minds, a clash of philosophy and a PUTTING DOWN for the ages.

Soon, we shall meet and soon we shall vote. Vote Yes, Vote No.  It is important to remember that at the end of the day, whether COD, OAR or OMA, that WE ARE ALL THE SAME.

On one hand, I can’t wait for this summer to end. On the other hand, I wish this summer could continue forever.

The first cross Canada “tour” I can recall was that of Terry Fox. I was six.  Many of us remember when Terry began his Marathon of Hope.  We followed his run which began in St. John’s, NFLD, expecting to end in Victoria, BC.  Growing up on the mean streets of Oakville, I attended W.H Morden Elementary School and I still remember my first day of school in 1981. The library was brand new, having just which been converted from a gymnasium. An assembly was called. We thought it was intended to showcase our new home for books.  Instead, we were told that Terry had been forced to stop his run. Later that year, in the same library, we were told Terry had died.

Today, Gord Downie is crossing Canada as the Tragically Hip make their farewell tour after decades of service to Canadian and music fans around the world. Their music is a theme to generations of music lovers and often the soundtrack of summers at the cottage, by the pool or just hanging out.

While I dread yet another day like that one in that library at Morden, my job has helped me to understand that the music ends for all of us, one day or another.  As a palliative care physician, I deal everyday with the INEVITABILITY OF DEATH .

But, it also gives me pause to smile. For when the day arrives, no matter where I am, no matter what I’m doing, I will know with great certainty that HEAVEN IS A BETTER PLACE now.

We can all learn a little something from both Terry and Gord. About what really matters.

Written by a self-proclaimed DARK CANUCK.

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Let’s Talk TPSA – Guest Post

Dr. Nadia AlamEditor’s Note: Dr. Nadia Alam shares an extensive and balanced PRO-CON diagnosis for each plank of the Tentative Physician Services Agreement, 2016. 

Dr. Darren Cargill offered input, too. You will remember him from his “9 Steps to Deciding on the Doctors’ New Deal” guest post. 

Please find contact info for Nadia and Darren at the end. [CONs went out vetted by OMA to D5 earlier.]


Funding Utilization

PRO: The TPSA will provide set funding that increases by 2.5% per year for four years. Any overage in 2016 is forgiven; any overage in the other three years must be reconciled. As long as growth stays below 3%, physicians will likely not see a significant reconciliation. There is a possibility that there will be no shortfall; there may even be a surplus. The most recent ICES data suggests that growth is 1.9% per year. Anything higher is attributed to physicians as drivers of utilization — which can be controlled.

CON: In the TPSA, funding for utilization is capped at 2.5%. However, utilization fluctuates unpredictably from lows of 0.6% to highs of 4.9%. The lows correlate with government-imposed clawbacks and hard caps; the highs correlate with healthcare transformation. Taking the two extremes out, the average sits around 3.5% according to the OMA Economics chart (attached). Given this, there is a very real probability that an annual increase of 2.5% will not match actual patient need for physician services. Reconciliation of any and all differences will fall to physicians to shoulder. Since utilization is unpredictable, reconciliation will also be unpredictable, making it difficult for physicians trying to manage the business end of their medical practices.

The ICES average is a descriptive analysis looking back at the past 15 years. It only looks at fee-for-service payments, ignoring the impact of alternate funding arrangements including patient-enrolled family medicine models. Alternate funding models make up 30-40% of physician remuneration (according to CIHI) so there is a big chunk of data missing from the ICES figure of 1.9% utilization. Moreover, utilization increases in recent years reflect more physicians in the system not changes in individual billing practices — none of this is reflected in the TPSA calculations.

One-time Payments

PRO: As long as growth in physician services remains at or below 2.5%, physicians will receive bonus payments each year to use as they wish above and beyond the budget of:

$50M in 2016-17

$100M in 2017-18

$120 M in 2018-19

$100M in 2019-20

Should utilization exceed 2.5%, these one-time payments will offset this overage first before reconciliation. Any remaining will be distributed based on appropriateness, relativity and value for money. Funding for new or Ministry-driven initiatives will be provided separately (example, IVF program).

CON: The annual one-time payments are awarded to physicians only if they constrain costs within the hard cap. Given the probability that the hard cap will not match reality, many physicians wonder if they will have to limit patient services to earn the one-time lump sump payments? Many worry about the ethics of accepting bonus payments for rationing care.

If instead the lump sum payments are meant as a cushion in case of overage, then it is obvious that the MOH knows that 2.5% clearly cannot match future patient need.


PRO: The government has recognized that physicians can and should help manage the physician services budget. This will be done in a bilateral manner to achieve the goals of the PSA.

With great power comes great responsibility” – Uncle Ben

It is no longer acceptable for physicians to feel that they are not part of the solution for sustainable healthcare. This solution involves, physicians, government and patients. As front-line physicians, we see waste, redundancy and ineffective practices on a regular basis. Bringing our experience to bear on this issue of sustainability is crucial. Allowing government to continue its unilateral management of the healthcare system has proven disastrous in just a short period of time.

CON: Bilateral management of physician services was awarded to physicians years ago. It is called the Physician Services Committee. It is unclear what additional benefit a redundant process will offer physicians even if it is under a different name. Furthermore, there has been no analysis into the outcome/ success/ failure of previous efforts at co-management; so it is unclear whether bilateral management has ever achieved its goals. What we do know is that despite all previous attempts, physicians were subject to unilateral actions in 2015-2016, so the power imbalance between physician and government remains despite having a seat at the table.

The OMA has warned that rejecting the TPSA means further unilateral actions. If this is true, then the TPSA is little more than another ultimatum and the government is not engaging in good-faith negotiations. This erodes the assumption that co-management can exist much less succeed between physicians and government without binding arbitration to level the playing field.

Modernizing the Schedule of Benefits & Other Payments

PRO: The Schedule of Benefits is out-dated with many services that are redundant or unnecessary. Currently there are over 7000+ fee codes. Technology has changed the speed and ease with which we deliver healthcare, one example being cataract surgery and diagnostic imaging (it is worth noting these specialties have already been subjected to unilateral cuts). Modernization will remove $100million in fee codes and other payments in 2016-17, and another $100million in fee codes and payments in 2019-20. This will be off-set, in whole or in part, by the one-time payments (as long as growth is below 2.5%). This process will occur bilaterally with a binding facilitator available in case of disagreements.

CON: As part of the 2012 PSA, physicians found $850 million in modernization/ cost-savings from the Schedule of Benefits. There is no information on whether such previous modernizations achieved their intended goal of streamlining physician services. There has been no analysis done to see if an additional elimination of $200 million is even possible. There has been no information made available to see where these cuts will occur and which specific codes will be impacted. There is no information on if and how non-FFS payments will be affected. This creates significant unpredictability for physicians trying to manage the business end of their medical practices.

Progressive Cuts to Group Practices

PRO: Co-management will consider group practices that generate billings of over $1 million a year to identify value, appropriateness and relativity. High billers are also significant service providers. This “soft cap” may provide opportunities for new graduates as the work previously done by one physician could be redistributed to multiple physicians. Proper use of individual billing codes or application for a group billing number can mitigate concerns.

CON: Many community-based radiology, cardiology, ophthalmology, and gastroenterology clinics operate on a group-billing model that bills over $1M per year; many of these have significant overhead costs in the range of 50-75% of billings. The TPSA will cut the clinics that bill over $1million dollars. Many of these clinics already saw severe reductions in funding for services because of the unilateral actions and revocation of IHF funding; as a result, many reduced staff, hours or service. More cuts will worsen this scenario, meaning that as more community clinics close, local hospitals will be forced to take on more patient care. Given that hospitals themselves are chronically under-funded, the reality will be that patients will see longer waitlists, compromising timely access to care. One example is the Barrie Endoscopy Clinic that is closing next year. All endoscopy and GI services will be funnelled to the hospital and undoubtedly, waitlists will balloon.

2015 Unilateral Actions

PRO: Given the acrimonious relationship between government and physician in 2015, the TPSA provides a framework that lets government and physician move towards a trusting relationship. Trusting, collaborative relationships like this produce successful healthcare reform ventures like the primary care enrolment models. The TPSA prevents the government from enforcing further unilateral actions until the Charter Challenge has received its first decision.

CON: The cuts and policy changes imposed by the government in 2015 will have ongoing repercussions. This cannot be ignored. Many clinics have had to cut services — including on-site labs, hours of service, staffing, and flu shot clinics. Many clinics have closed. The TPSA ignores the past at its peril. The codes that were cut in 2015 affected patient care in countless ways. For example, cutting the E078, the chronic disease fee, undermined doctors providing care for diabetes, IBD, liver disease, and kidney failure.

New Family Medicine Graduates

PRO: The Managed Entry Program restrictions will be lifted so that 40 new family doctors can enter FHO arrangements per month, as it was in 2012. This is better than the restriction of 20 per month in 2015. This will help address access issue that nearly 1 million Ontarians have who are without a family doctor.

CON: Since their introduction in 2004, FHO-based practices are the primary way new family physicians are trained during residency. Prior to 2012, there were no restrictions on the number of family physicians wishing to set up FHO practices. 2012 saw the introduction of the Managed Entry Program that limited FHO applicants to 40 per month. 2015 saw further restriction to 20 per month. The TPSA lifts that restriction back to 40. However, it does not eliminate it, nor does it eliminate the impractical New Graduate Entry Program.

Worse, the TPSA does not restore income stabilization or rostering fees — programs cut in 2015 that are considered crucial to meeting the overhead expenses of the first year of community family practice.

Binding Facilitation

PRO: There will be a neutral Third-Party Facilitator who will help physicians and government achieve the goals of the PSA. This person will be jointly recruited and vetted. Their decisions will be binding on both parties. This will help bridge the gap between what we have now (no dispute resolution) and binding arbitration (reliable dispute resolution). Aside from stability, this may also address concerns that OMA no longer has ability to advocate against cuts its membership feels are improper.

CON: 2012 saw introduction of the Facilitation-Conciliation process; this process was supposed to improve the power imbalance between physician and government so that further unilateral actions could be avoided. Regardless, 2015 saw unilateral actions. Binding Facilitation is expected to be a bridge to Binding Arbitration. However, the details of this process are not defined. The Facilitator will rule on how the conditions of the TPSA are met. So, they don’t rule on how much of a cut is acceptable, just where it must occur.

Moreover, the first quarter of the year is over, deadlines are looming and consequences are firm; yet there have been no steps taken to recruit or vet the Facilitator. It is unclear how disputes will be managed if it takes longer than expected to find a Facilitator.

Health Human Resources

PRO: It is unfair to license physicians when we cannot guarantee jobs for them. Medical training is a costly investment requiring years of sacrifice. That sacrifice is justified if physicians can reliably find gainful employment upon graduation. That is not in keeping with current conditions. Many physicians right now graduate and find that they have unpredictable employment consisting of locums and mainly on-call work. This can be assessed through broad consultation and co-management of health human resources.

CON: Much has been made of how the current number of 950 net new physicians entering the system is “unsustainable”. The reality is that many new graduates struggle to find a job. The reality is also that waitlists for specialist services are out of control. There is a mismatch between available funded healthcare resources and actual patient need.

Many specialists in fact no longer accept elective referrals because their waitlists are too long. It is short-sighted to say that the solution is to limit the number of physicians entering the system to an arbitrary number that “should be” funded (approximately 700). The TPSA does not address the larger issue of chronic under-funding of the healthcare system. In fact, the risk of insufficient funding of physician services budget in and of itself will exacerbate this issue.

Patient Accountability

PRO: At the moment, many patients will draw on limited healthcare resources for reasons that are not medically necessary. This is the first ever PSA where government is willing to acknowledge patient accountability and its impact on the healthcare system.

CON: The words “patient accountability” are in the TPSA, however detail is lacking. There has been no analysis done of the financial impact of patients requesting and obtaining services that are not medically indicated. So it is unclear whether patient accountability will yield expected savings. It is also unclear how patient accountability will be established. What is clear is that there is no extra funding for the added cost to cover the resources, education and publicity required for this to be successful.

Primary Care Improvements

PRO: There are 1 million Ontarians without access to primary care. Only 40% of patients are able to access same-day/ next-day visits with their primary care providers. These metrics will be assessed and corrected via the TPSA, with the expectation that it will improve patient care. Most physicians in patient-enrolled models are living up to the their contracts; some are not. Currently the only option available to government is a stern letter and termination of the contract. There needs to be intermediary steps to ensure physicians are living up to their contractual obligations.

CON: Physicians are expected to improve primary care access metrics: namely, access to primary care for unattached patients, access to after-hours and weekend care, access to urgent appointments, as well as reporting on physician resources and availability. There is no extra funding to cover the additional cost of the administrative and clinical requirements; it will have to come out of the capped physician services budget. There is no analysis available of the short-term and long-term impact these changes will have on one of the largest sections in the OMA.

What’s more, many patients rate their access acceptable — even if it doesn’t fit the performance standards that the MOH has chosen as a goal. Many physicians find that even when they do have same-day/ next-day availability, the timing does not work for the patient; so the data that the MOH is basing its baseline statistics on is suspect.

The changes to Bill 210 are contingent on meeting these requirements.

Bill 210, The Patients First Act

PRO: The OMA has been advocating against Bill 210, the Patients First Act, for over a year now. Despite that, it has passed its first and second readings in Legislature. After the third reading, the Bill will likely pass into law. The TPSA allows the OMA to change some of the objectionable parts of the Bill (specifically Section 29 and 38).

CON: Removing Sections 29 and 38 allows the OMA to retain its representational rights. However, these modifications will only be recommended by the government if and only if physicians meet the conditions set out in Primary Care Improvements.

What’s more, the more objectionable parts of Bill 210 remain unaddressed. There is no discussion of the added bureaucracy of 80 new sub-LHINs will burden a strained healthcare system. There is no discussion of how MOH-appointed investigators will be able to access patient medical records without patient permission. Bill 210 remains a concern that is only somewhat mitigated by the TPSA.

Appropriateness of Billing Practices

PRO: There are many physicians who bill inappropriately and who “game” the system. At a time when healthcare resources are scarce, as responsible fiscal stewards, physicians need to find every efficiency and root out every bit of waste they can.

CON: Many physicians fear the form such billing audits will take; many worry that this will be similar in consequence to CPSO’s Medical Review Committees. On a practical level, the MOH already has a billing audit department, so it is unclear why the task is being replicated on the OMA side. It is unclear where funding for the added administrative costs will come from. It is unclear how billing profiles will be analyzed and deemed appropriate or inappropriate. It is unclear how among the thousands of physicians, the OMA will drill down on just the ones who are indeed “gaming” the system without collateral damage — which is what happened with the CPSO’s MRC.

Value for Money

PRO: As fiscal stewards, physicians should not provide medically unnecessary or low-value services. If we expect the government to clean up the waste on their end, we must do the same on ours. We must balance standard of care with fiscal responsibility.

CON: In 2012, physicians undertook projects to reduce unnecessary or low-value services, like annual physicals and routine pre-operative testing. While the goal is laudable and should be continued from year to year, it’s unclear how much of a financial benefit will be derived from reducing more of these so-called “unnecessary” physician services — especially since other providers can now obtain those services for patients including nurse practitioners.

Charter Challenge

PRO: The TPSA allows the Charter Challenge to continue uncontested. Likely, a first decision will be made by 2018-19. Likely, the decision will be in our favour. However, if Ontario’s court system awards physicians Binding Arbitration, the government can apply for a Stay — in which case, physicians will not get to enjoy the security of BA until the Stay has been appealed and overruled. This could delay an effective BA for up to a decade. The government has offered to give up its right to a Stay if the TPSA is ratified.

CON: The Charter Challenge for binding arbitration will continue. However concern has been raised by various lawyers that absolving the government of all responsibility for the damages caused by the unilateral actions weakens the Challenge. What is also worrying is that there is added language in the TPSA about injunctions on further government unilateral actions. The necessity of adding this in raises the possibility that despite the TPSA, government can still impose unfair UA on physicians. This contract does not fix the power imbalance already present between government and physician.


PRO: The OMA has been attempting to address relativity for decades, with varying amounts of success and failure. The OMA has been using a process known as CANDI to provide an objective approach. As you can imagine, however,  this has been a source of fierce debate and met with great resistance. There remain fee codes that are over-valued and fee codes that are under-valued leading to great revenue and income disparity between the various specialties. The co-management process will allow physicians to address this issue of relativity. In fact, if growth remains below 2.5%, the one-time lump-sum payments can be used to address some of the relative inequities between specialties.

CON: For decades, the OMA has unsuccessfully tried to address relativity. This TPSA is defined by an impractical hard cap, unpredictable reconciliation and obvious demands for more services; it is unclear how it will improve equity between low-billing and high-billing specialties.

Ontario already has the lowest fee-for-service payments for all specialties. Given the probability of inadequate funding for physician services, it’s unclear how low-billing specialties will be built up. The flip-side — cutting high-billing specialties — was tried back in 2012. Further cuts to high-billers will not improve the lot of low-billers. It will however drive many of these high-billing specialists out of the province meaning less access to care and longer waitlists.


The TPSA is an exercise in weighing risk and benefit. It is an imperfect deal. Regardless of what you vote, please read the TPSA itself and vote with your conscience!

Nadia Alam

Family Doctor & Anesthesiologist



Blog: Huff Post Nadia Alam

Twitter: @DocSchmadia

with contributions from:


Dr. Darren Cargill

Palliative Care, Windsor

Twitter: @ReasonableWlvrn


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OMA Primer – Who Calls the Shots?

Mind the GapBrexit surprised many of us. So did Trump. Political chatter takes too much time to digest.

We can ignore most of it and never suffer for our ignorance, until something big happens.

Most doctors pay attention to medical politics once every few years. They hate meetings and see politics as stealing time from patient care.

But everything changes during crisis. Politics suddenly causes pain and suffering. Doctors demand to know how a decision got made, who made it, and why they weren’t asked.

OMA Primer

The OMA has 3 main groups: the Board of Directors, Council and staff. In addition, the Board of Directors has a powerful sub-group: the Executive Committee.

The Board of Directors

The Board meets approximately 10 times each year, plus occasional teleconferences or special meetings. It has 25 elected doctors from across the province.

The Board sets strategy, oversees how money gets spent and deals with occasional details, when the CEO asks for help.

The Board deals with high-level issues. For example, the Board will vote to endorse a contract and send it to the membership. But the Board does not dictate details about how it gets sent, communicated or ratified.

The Executive Committee

The Board elects some of its members to an Executive Committee: 6 people that include the Secretary, Treasurer, Board Chair, President elect, President and Past President.

(Technically, the Board elects a nominee for President Elect, and council passes the official vote to this position. Council almost always agrees with the Board’s nominee).

The Executive Committee (Exec) meets twice as often as the board and holds many special meetings as needed.

On paper, Exec acts on behalf of the board, between board meetings. In reality, the Exec works hard on many other things.

Exec regularly gets drawn into operational work that the Board does not need to see. For example, Exec shapes and approves campaign details and deals with urgent legal matters, with the CEO and staff. The President then reports to the Board on behalf of the Exec.


The Board has one employee: the CEO. The CEO leads several hundred staff members to execute the strategy set by the Board.

Rarely, a CEO will make a bad decision that upsets the Board. Most of the time, CEOs stay out of trouble by getting approval from the Board Chair and President, or the whole Exec.

Take home message: Do not blame OMA staff. If they misbehave, they get fired. If they have not been fired, they are just doing what the CEO directed.


Council holds the ultimate authority in the OMA, at least on paper. OMA Council consists of around 270 elected doctors from across Ontario. It meets twice yearly.

The Board shares a report to Council on how the Board has run the association on behalf of Council.

Council can pass motions about the Board report. Motions about the report force the Board to act; they are binding on the Board.

Council can also pass dozens of other motions that tell the Board to do all sorts of good things. These other motions are not binding; they only advise the Board as it sets strategy for the next year.

Council holds a special meeting, whenever government offers doctors a new contract. Council votes to accept or reject the new deal; it has the final say.

All doctors get to vote Yes or No in a referendum on a tentative contract, but Council gets the final say on whether the contract gets accepted (ratified). Only a General Meeting of the Membership can change this process (see below).

Council holds tremendous power. But it only meets twice yearly, so it cannot impact the organization in the same way as the Board or Exec.

If you watch carefully, the Exec, Board and staff will usually go out of their way to say that they were simply doing what Council told them to do. This shows deference to Council, and it lets Council take responsibility, when it asks for work that produces silly or wasteful results.

Black Swan Event

Once every millennium, regular members – those who do not hold elected positions – demand a General Meeting of the Membership. It only happens when a few thousand doctors get so upset with a decision that they demand a meeting where any member can attend.

The General Meeting acts as a safety valve: a way for members to have a say, get more information or simply ask for a sober second thought. The second General Meeting in the history of the OMA will take place Aug 14.

Ask Questions!

Next time you read a news article that says, The OMA did something, ask yourself, Who did that? Was that a decision by Council, the Board, the Exec or someone else?  Do the same thing with information you get from the OMA.

Look at how motions were worded. People often twist a motion to mean something it did not, especially if the new meaning makes exciting news.

The public can usually separate doctors from the OMA, but for many people, the OMA is the doctors.

Physicians can usually separate decisions made by Council, from those made by the whole Board or those made only by the Exec. Sometimes it is not clear.

For the most part, members blame the whole Board for everything. Or they blame one person on the Board. That’s understandable, but often incorrect.

Mind the Gaps

Watch carefully for flags such as “The Board voted to…” or “Council directed the Board to…” or “The Executive Committee decided…”  Also, watch for when those flags are missing and ask, Why?

Hopefully, this OMA primer helps you see through political news. It won’t prevent a medical Brexit or Trump, but at least you will know what hits you when it does.

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Desperate Doctors

20160802_082259I almost drowned at summer camp. I told everyone that I could swim.

I just didn’t say that I could only swim as far as I could hold my breath.

I always wore a face-mask.  It let me see my next hand hold, somewhere to pull my head above water.

Our summer camp offered one, main activity: swimming.  Kids spent all afternoon jumping off a raft, avoiding the leeches near the shore.

The raft floated far out on the water. Could I swim there on one breath? After 2 ½ days of avoiding the water, I started drawing attention. Wanting to play with the cool kids, embarrassment overcame fear.

My breath took me within 10 feet. I saw flashes of raft and swimmers, whenever my mask broke the surface. I flailed, and sank. Kids cannonballed and wrestled around me. They shoved to get on the raft. I gasped and coughed and lost sight of my target.

The next thing I remember, my hand gripped the ladder. Shaking with exhaustion, I crawled up, rolled on my back, and faked a smile. Kids pushed and jumped in the water like I did not even exist.

Desperate Doctors

Doctors tell patients, “Everything is going to be all right. Your lung has collapsed. But we can fix it. We need to place a tube between your ribs…

What happens when desperate doctors start to panic?

Premier Wynne’s government has attacked doctors and treated them worse than any government in recent history. Wynne has unilaterally cut almost 8% of gross funding, in less than 24 months, and has completely ostracized doctors from decisions about medical care.

Then without warning, in the middle summer, when no one reads newspapers or blog posts, the Wynne government decided they want peace with doctors and offered doctors a new deal.

No one even knew doctors were negotiating, including doctors. The government offered another take-it-or-leave-it deal, like they had in 2012, 2014 and 2015.

The government sweetened this offer a bit. They promised to fund 2.5% of growth, double what they had been funding, but still less than the historic 3.1% growth to cover new patients and doctors.

Most importantly, government offered the Ontario Medical Association (OMA) a spot in ‘co-managing’ healthcare. They offered doctors a spot on the raft.

Thick as Thieves

The Wynne government faces 5 criminal investigations. Premier Wynne’s approval rating sits at 18%. The Ontario Liberals are famous as the most indebted sub-sovereign government in the whole world, having borrowed to win votes and fund windmills, gas plants and pension plans.

Health Minister Hoskins boasted for two years that his government has given 1.25% percent more to medical services. He sounded like a deranged parent boasting to Children’s Aid that he gave another 1.25 oz of formula to his baby, even though the infant needed at least 3.5.

Now the government – under criminal investigation! – has offered desperate doctors a spot on the government raft.

The OMA rejected a deal in 2014 because it underfunded growth and offered a fixed budget.

The board faced a sharp decision this time: Do we choose more unilateral cuts, uncertainty and no voice in the system? Or do we choose collateral cuts, less uncertainty and trust that we will get a ‘voice at the table’?

If the OMA is shunned from all decisions, how can it advocate for members?

Aren’t predictable cuts better than unilateral ones?

Isn’t it better to sit on the raft, while government throws Bills like 210 and 119 into the water?

Or should doctors fight back, on principle?

Regardless of the pros and cons, or what you think of this contract, government has doctors over a barrel. Either way, doctors must dance. They lost their say in the matter in 1967.

Doctors Vote

The OMA has done everything – short of parades and door prizes – to convince doctors to accept this deal, leveraging every ounce of good faith in the process.

A large group of doctors has called for a ‘General Meeting of the Membership’, the second one ever. The last Meeting occurred in 1991 over a similar, less than ideal tentative contract. It foretold a decade of cuts. Doctors accepted the contract, and the next one in 1995. By the end of the 1990s, 2 million patients had no family doctor. Bestsellers like, Code Blue, predicted the collapse of Medicare.

Not Cool

After nearly drowning, I sat on the raft and hugged my bony knees all afternoon. The kids ignored me. I was not cool. I do not remember getting back to shore, or ever going back to the raft.

Desperate, divided, powerless and panicked, doctors must make a terrible decision. The government will do what it wants. Doctors can be part of a dysfunctional government or have dysfunction forced upon them.

Faced with any other option, everyone chooses to not drown. People get that. But it’s a terrible way to make an important decision. Surely, patients deserve better than this?

(Disclaimer: In case it was not obvious, this post tackles the nature of the decision, not the content. Please do not read into this any more than it says. My official, approved, public opinion on this deal can be found here.)

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Crisis Management for Doctors – 7 Tips

hurt lockerAs a rule, Keep your mouth shut works almost everywhere. Most things get worse when we speak.

However, silence can cause trouble, too. Even a pause can be deadly:

Who do you love most: me, or my sister? 

Mom, was I a surprise pregnancy?

If we want safety, silence offers the best protection. It makes sense to hide and keep really quiet, when danger prowls – but not for leaders.

Doctors must lead. And leaders need to speak; precisely when everyone else is sliding down in their seats around the table.

Leaders must say something, even when there is nothing perfect to offer. Silence does nothing for a team. But we have to be careful, too: empty platitudes can come across like ‘Get Well’ cards at a funeral.

Medical Politics Thriller

If this were a spy thriller, Ontario sits at the point in the story when a bomb has just been found under the parliament buildings.

Helicopters circle. People run around screaming, and a sweating bomb tech, in safety gear, extends a shaking set of snips towards a jumble of wires.

Will he cut the blue wire…or the red one?

If you Google crisis + leadership, millions of results pop up like:

 These offer great advice. But doctors need something a bit different.

In Ontario, leaders have stepped forward from all sides: within the establishment, without, and in between. For all leaders, here are 7 tips:

Crisis Management for Doctors

1) Be cool – Lighting our hair on fire comes naturally for some. The heat and smoke releases energy and feels good, I suppose. Resist the urge, no matter how much better it makes you feel.

Everyone who looks to your reaction feels much worse when you lose control, even with an audience of one.

2) Avoid the simplistic – Us against them wins on a football field, but not with large groups. Black and white works well until kindergarten.

Oversimplifying complexity might seem to add sanity for a moment, but it never leads us out of a crisis.

3) Keep making friends – Fights during Thanksgiving dinner often leave deep, irreparable scars. Remember whom you are fighting with.

You may need to see them for your heart attack next week.

4) Forgive more – People make dozens of mistakes every hour, at their best. Under duress, we make many more. Itemized lists of all the ways other people messed up, acted poorly, or otherwise disappointed us rule out reconciliation.

Do not assume maleficence, when ignorance explains behaviour well enough.

5) Plan for the future – Force yourself to imagine life after this crisis has past. Even if things do not work out in your favour, this crisis, too, shall pass.

Your response will shape your experience of life afterwards.

6) Stop and think – Surviving the next minute blocks out all other thought in a crisis. We need more time to reflect, at the exact moment when there isn’t time to breath.

Stop. Think. Take 10 minutes to read. Pseudo-dementia comes from cognitive overload.

7) Remain positive – I think it was Dee Hock, founder and CEO of Visa, who said something like, “The times are too tough, and the outlook too dire, for negativity.

We need hope the most, when hope seems most unreasonable.

Crisis and Silence

Trauma and crises are not all bad. Birth is traumatic, violent even. Full lives have very few dull moments. Dreams of peace and quiet come true only for the most heavily sedated, on locked wards.

The excitement in Ontario will pass, eventually. We will go back to working together, sharing patients, and finding ways to work with others to improve our healthcare system. But during a crisis, many people find it safer to clam up and keep silent.

We need people to offer reasons for hope, no matter which direction this turns. Silence is not an option in crisis management.

Photo credit: The Hurt Locker

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