CMA General Council (#cmagc): A Success for Canadian Health Care

Advocacy and policy making is just one of the levels I am working at in order to improve health care for Canadians. Sometimes there are direct links to a "Less is More" approach. The Canadian Medical Association (CMA) calls this kind of topic "appropriateness." Although the CMA's annual meeting (General Council) this year only had a few ties to this way of thinking, a few readers have asked me about the event as a whole and so I share my reflections here:

It was an incredible General Council (GC) in Halifax, NS this August. I was able to participate as a Delegate for British Columbia and I cannot explain the feeling of immense purpose and privilege involved in voting on the policy and positions of the national organization of physicians; I was elated to be a part of the formation of some incredibly socially progressive resolutions that will have a real and positive impact on the health of Canadians. We resolved to divest our organization of investments in fossil fuels, to support the principal of a universal/national pharmacare program and a basic guaranteed minimum income, to encourage informed discussions around childhood vaccination in all school age children, and to endorse harm reduction strategies like a national guideline for naloxone availability (for opiate overdoses).

There was some outcry, understandably, from those who live in areas of the country whose economies depend almost entirely on the fossil fuel industry. They were out-voted. We cheered when we made the symbolic gesture – it was not a lot of money for our organization to re-invest in other industries. It was just an incredible statement for our organization to show that the health of the planet affects the health of its people, and we are willing to take the longer view.

The general assembly agreed to disagree on the exact details of how a patient would access physician-assisted death; council continued to extend the privilege of speaking to all attendees which allowed many conscientious objectors (observers, not official delegates) to express their concerns about participation in this, now legal, act. We all trusted in the process of consultation involving government, the public, the CMA (through various other channels besides GC), and other interested bodies (regulatory colleges, insurers, etc.) and will wait to see what this more broad process concludes as far as the exact process for physicians and patients.

It was all quite cordial, actually. The conscientious objectors were respectful and registered their concerns clearly. The voice of youth was loud and clear, with many young physicians and medical students participating as non-voting ambassadors, and a few of us resident and early career physicians voting as delegates. Our push for change was LOUD! The momentum built in the room and many of us felt like serious headway was made for our patients.

As ever, we heard: “you young people are what is ruining our society.” In person the meeting was quite pleasant but those physicians following online, especially on twitter, were outraged.

Mainly, it was those who opposed universal healthcare who were ashamed of what the CMA General Council had done. Everyone voting must be “left wing radicals” and “communists.” All the young people “lack the context” to create and endorse the correct resolutions. 

But, we were there, and we did it. Yes, many of the resolutions we made and voted in may never come to fruition this year. We don’t have unlimited time and finances as an organization and to be effective we must focus on a few narrow issues. However, it is still a big win for Canadians to be able to reference this groundbreaking policy. Setting precedent and having a public record of endorsement of an organization as respected as the CMA may be just enough to help grassroots initiatives get the edge they need to grow into persuasive bringers of change.

Thinking specifically about the “less is more” approach to health care, we also passed many resolutions to help strengthen palliative care programs to make them accessible for more people, and called for regulations around genetic testing/precision medicine and telemedicine [I was a Mover]; we warned that Canada cannot blaze forward with these technologies without consideration of the considerable risks they may pose for patients.

We also recommended that our National Senior’s Strategy and the policy paper "A Prescription for Optimal Prescribing" be updated to include a specific section addressing polypharmacy, which passed on the consent agenda [I was a seconder]. See the video of my colleague, Mover Ralph Jones, speaking briefly to this motion after we knew it had passed, with what I suspect is a nod to Johanna Trimble of IsYourMomOnDrugs? 

The CMA's incoming president for 2016-17 (our choice from BC), Dr Granger Avery, and our colleagues Drs Horvat and Routledge spoke to a disallowed motion that called for efficiency in our health care system. See their video here. Perhaps next year we can refine and submit more motions on appropriateness and efficiency? I have a few drafted already!

In a few narrow ways and in the broader sense, GC was a key step forward in advancing efforts for more appropriate health care. With a strong emphasis on addressing the real determinates of health, the solution of de-emphasizing tests and treatments that are harmful or not necessary also gains strength. Slowly, recognition for the importance of health in all policies is emerging. If a person cannot afford food, it doesn’t really matter if their dose of blood pressure medication is optimized. Right?

It feels fantastic to be a vocal part of an organization of 80 000 Canadian physicians that “get it.”

RADIO INTERVIEW: Dr Iona Heath: Too much medicine is making us sick

Dr Iona Heath is one of the foremost voices of the movement that confronts overdiagnosis and medicalization. She is in Australia to deliver a Sydney Ideas talk, "Too Much Medicine: Exploiting Fear for the Pursuit of Profit," on August 5th.

Testament to her ability to draw a crowd as she speaks frankly, humanly, and persuasively about this controversial subject, it has been moved to a larger venue!

While the Sydney Ideas talk may not be made available online, she has also given an interview with ABC Radio Conversations in Australia.

In the discussion, she frames the problem of 'too much medicine' and helps to define the difference between illness and disease, explaining how we make well people into patients.

With reference to A Fortunate Man and drawing on experience and connection with patients from her own 30 years in practice, she speaks about the role of the general practitioner and our inability to address the social determinates of health - the real underlying risk factors for poor health. 

Challenge by an interviewer who is not familiar with the science behind risks and outcomes of screening mammography for breast cancer, Iona emphasizes that the key message is not that a test or treatment is wrong for everyone, but that patients must be given informed choice. They must be fully informed of the potential risk and benefits of any intervention, and think about how it may impact them personally.

When the interviewer sticks to the common rhetoric 'prevention is better than cure' and insists that listeners should not run out and cancel their mammogram, Iona answers this bravely and personally. She shares that she, being in a low risk category, has decided that the harms of a mammogram outweigh the benefit for her. The paper she wrote in the BMJ in 2009, It is not wrong to say no, summarizes the arguments fully.

Iona does not state this explicitly, and I'm not sure it is fair to suggest it is implied, but our professional oath guides us such that: where there is risk but no benefit, the medical expert has a duty not to harm and so will encourage avoidance of the unnecessary test or treatment.

I am hopeful the lecture hall tonight is bursting at the seams with contemplative fence-sitters who may be persuaded by her words. Every event like this brings us closer to transforming the culture of care and being able to improve the lives of our patients.

Source: http://www.abc.net.au/local/stories/2015/0...

CHANGE Alberta: Reversing Metabolic Syndrome with Exercise and Diet

The whole point of a "Less is More" approach to Medicine is to focus on things that really help people live well. If we take resources from unnecessary tests and treatments, we could instead invest in social determinants of health, preventative health, and the tests and treatments that actually make a difference to the quality (and quantity) of people's lives.

It's no secret that an active lifestyle and a reasonable diet correlate with better physical and mental health. While unfortunately the studies have not been yet done to show that exercise prevents cardiovascular events in people with increased cardiovascular risk, we do know that generally, people who exercise can gain up to 4.5 years of life compared with sedentary counterparts. However, it is very hard for family doctors, and even NPs who may have a bit more time with each patient, to help patients alter their eating and exercise habits in a meaningful and lasting way.

Enter CHANGE Alberta. The Canadian Health Advanced by Nutrition and Graded Exercise (CHANGE) Alberta project seeks to find a way to reverse metabolic syndrome by supporting patients with nutrition and activity plans. Explore the website to learn more about the team-based approach, involving dieticians and kinesiologists, that they employed in primary health care settings.

I met Dr. Doug Klein (@DrDougKlein) at the Family Medicine Forum in Quebec in November, where he was sharing their promising results; with 302 patients enrolled, at one year, 28% had reversal of Metabolic Syndrome and overall 52.4% had reversal of at least one feature of Metabolic Syndrome.

Is this something you could integrate into your primary health clinic?

Social Determinants of Health (#SDOH); the bigger solution

When thinking about the health of a population, it seems that many acknowledge the role of public health and preventative medicine. We talk often about the context of the patient, their "Social Determinants of Health."

On a 1:1 clinical encounter, I often feel like I'm hardly doing anything useful. I'm just treating some numbers, doing something to the patient, not really doing anything for the patient.

It Seems I'm  'spit-polishing' the giant dent in the car, when I help an obese, diabetic patient adjust their dose of insulin.

You  could  take it in for repairs... but maybe better to have prevented this? (Image from  Bob Ottenhoff )

You could take it in for repairs... but maybe better to have prevented this? (Image from Bob Ottenhoff)

It's not clear how much of a difference this test-ordering, medication optimizing, target-setting, or patient educating makes. It feels like we are "helping" but at the same time, it feels often that we are just occupying time and resources when we could be investing these in a more effective way.

Dr. Leana Wen, writing Help patients by addressing the health of the community for KevinMD, puts it well:

We need comprehensive strategies that promote health and target problems “upstream.” We need to recognize that health does not exist in a vacuum, that it is intimately tied to issues such as literacy, employment, transportation, crime, and poverty. An MRI here, a prescription there — these are Band-Aids, not lasting solutions. Our communities need innovative approaches to pressing issues like homelessness, drug addiction, obesity, and lack of mental health services.

The Canadian Centre for Policy Alternatives "gets it." Their paper, Sustainable health care begins with the social determinants of health: It’s time to get it right concisely summarizes the data and emphasizes that solutions that decrease spending on the medical aspects of health (eg. private healthcare) will only worsen economic disparity, worsening health.

How do we convince governments, who must work within the bounds of election cycles, that a long-term plan that addresses patients bigger needs is the wisest choice?