My wife is a doctor. I have been listening to what she, her peers, and current med school students are saying. I also follow the politics of the island and am starting to get a handle on where things are at. We are new to the island but these are my observations having been here for over a year now. My wife and a lot of doctors won't take the time to write this stuff down but I am a degen Redditor so here I am. A lot of what I have below comes from an Emergency medicine perspective first, a family medicine perspective second, and general medicine third. I am sure other specialties have their own unique particularities that could help as well.
- Remove restrictions on where doctors can open practices.
The idea behind the restrictions is to push doctors to rural areas of PEI. It doesn't do that. All it does is reduces doctors coming to the island in general. Tell me which you would pick; our current state, or some rural folks needing to travel for medical services? Having a doctor that you need to travel for is better than no doctor, right?
The incentives PEI offers for doctors to move here are quite competitive, when the doctor can live and work in an urban center. They are mid at best when compared to rural incentives in other places in the country. Once we have the doctors on the island we can incentivize them to work rurally. Which leads to suggestion two;
- Increase incentives for doctors living in urban centers to travel to rural areas of PEI to do work.
This doesn't mean they open a practice in a rural center, the though they might. It means that say once a month or so, a doctor goes to a rural community and works there.
This program kind of exists already and should be expanded. My wife does this as an ER doc. She gets extra pay per hour, travel costs covered, some hotel costs covered if she works in a rural hospital. The thing that limits my wife doing this more is that those shifts don't count towards her contract. Say for example, the contract says you need to do 20 shifts a month at her main hospital. If she travels to Montague and does shifts at King county hospital, she is still on the hook for 20 shifts are her main hospital. There should be some flexibility here.
That is just one example for one person. I am sure there are other incentives that would work for other individuals and branches of medicine as well. Just make it easy for them to pick this if what we want to more doctors working in rural settings. A common theme you will see in some of these suggestions is that doctors hate admin crap. They just want to be a doctor so get out of their way. Make it easy for doctors to pick this and incentivize them to do it, and they will.
- Hire Nurse Practitioners to work out patient services for hospitals.
NPs are great in some roles. In terms of taking over from family doctors, they do tend to over refer and over order tests compared to doctors in similar roles. It might seem like a good idea to bring in NPs to replace doctors but studies show that in many roles they end up costing the system more than hiring doctors would. Don't get me wrong. NPs are not without a use. They are a valuable addition to the healthcare community, they just need to be placed into roles where they are as cost effective as doctors or better.
A role that NPs would be really good for on PEI would be out patient services from emergency departments. Right now, many people go to the ER for things family doctors normally would do. I get that. What happens though is that ER docs need to order tests and then later follow up on those tests. That reduces the number of patients they can see in the ER. Instead, offload the follow up to NPs.
- Simplify and automate billing.
Doctors get paid via two mechanisms. Firstly, they get an hourly wage/salary like the rest of us. Secondly, they bill for services. For example, seeing a patient in the ER has two top level billing codes, one for a simple visit and one for a complex visit. On the doctors own time or by hiring someone to do this (I do this for my wife) they have to go through their paper work, determine who they saw when, compile the billing codes, diagnosis codes, etc and submit it to health PEI for reimbursement.
Where this is painful is on its administrative complexity and bureaucracy. We have to pay a yearly subscription fee for software that somewhat simplifies this process. We spend probably 4-5 hours a week dealing with this. We have stacks of paper with PHI on it in our home we need to secure and make sure isn't out when guests come over. We get rejected submissions for all kinds of silly reasons that requires follow up and interpreting silly response codes. Plus, there are staff on Health PEI's side dealing with all our submissions, questions, rejections, etc. Doctors hate this shit.
BC recently simplified their billing system and doctors moved there simply because of this change. PEI could do better. A lot of it could be automated. All the info we enter for the billing is already entered into the medical system in the hospital. Just pay the doctors their billing and get rid of the administrative burden. Stop nickel and dining them. Spending money here to simplify this process and understand the needs of the doctors would be worth it. It will make the doctors we have happier and less likely to leave. It alone would be an incentive to bring more doctors in.
You might ask, why not just scrap the system all together and just pay the doctors more to compensate. The billing system does serve two key things. Firstly, it is an incentive for doctors to see more patients. More patients means more billings means more money. Secondly, it keeps doctors egos in check. If two doctor work at the same hospital, both make the same pay, but doctor 1 sees more patients than doctor 2 or doctor 1 sees more complex patients than doctor 2 then doctor 1 is going to be upset. The billing system means doctor 1 gets paid more than doctor 2 and that some what balances out the problem. Without billings doctor 1 might just decide to do the same level of work as doctor 2 which wouldn't be great.
- Abide by the spirit and words of the contracts you sign.
This is pretty straight forward. The most prominent example of this is the family medicine contract. Melanie Fraser technically stayed within the words of the contract but she absolutely went against the spirit of it. This caused doctors to leave their practices and stopped doctors from coming here. My wife does emergency medicine but wants to do some family on the side. She doesn't because of those shenanigans.
What we haven't seen yet is that the next time a contract negotiation comes around with the family doctors, they will want everything in writing. That will make negotiatuons harder and contracts more complex. Doctors hate admin bullshit. They just want to practice medicinez not read and interpret legal contracts.
Another example of this was in the ER in PCH. The doctors have an exclusive contract to provide emergency medicine services at PCH. Without consulting anyone, PCH attempted to bring in an NP to also do emergency medicine. Not only was this a breach of the words and spirit on the contract, it out doctors in a compromised situation.
For example, doctors were suddenly expected to sign off on work being done by this NP without knowing her or understanding what her scope of practice was. This is a huge liability for them. Imagine in your place of work, they hire someone to do your job, but they aren't as experienced as you are. You have to sign off on everything the new person does and if they screw up badly enough, you are on the hook for it. This means you lose your job and potentially your ability to do that job anywhere in the country. Would you be okay with that?
It also absolutely screwed that NP as she didn't make these decisions, seemed to be misled, and didn't end up getting to do the job she was hired to do. People in the medical community talk. I am sure this story was shared in NP circles and will have a non-zero effect on PEIs ability to attract NPs.
This crap has to stop. The relationship between doctors and the government needs to be built on trust. Again doctors hate admin horseshit. They just want to practice medicine. Don't get in their way and make sure they can trust you to do what you said you would. Stop trying to squeeze more out of the doctors we have. Every doctor on the island is better than no doctor even if they only roster 500 patients or work 0.2 FTE in an ER.
- Waive IRAC non-islander rules and other non-islander regulations for doctors with firm commitments to the island.
If a doctor wants to move to PEI and buy an ocean front property, they can't because of IRAC. If a doctor moves to PEI, they have to pay non-islander rates for property taxes for a year (depends on municipality). These rules and this idea that a doctor moving here with a firm commitment to serve the community for multiple years isn't an islander is insulting and makes them feel like outsiders. It is a barrier to doctors coming here and a barrier to wanting to stay here.
Even after we have been here over a year and most of these rules don't apply to us anymore, we are still bitter about them. We didn't get to buy the property we intitially wanted because of the IRAC rules. We bought a different home. The property taxes got reassessed almost doubling them from what the previous owner was paying and then on top of that we got charged another 50% percentage for being "non-islanders". Our property taxes were triple what the last owner was paying. I get reassements, but the non-islander tax is bullshit.
Government rules aside there is also a cultural component to this. We still feel like outsiders. I cannot tell you the number of times that I have mentioned to someone that I moved here from Ontario, only to get side ways glance. I often then sneak in that my wife is a doctor and then suddenly all is forgiven. We read the Facebook posts, we read your comments here on Reddit, we see the side ways glances, we know what conversations are happening behind our backs, we know what you mean when you say, "oh that isn't an islander name". This attitude is toxic and something that needs to change.
Frankly, I don't think it should be just doctors that get these rules waived and this outsider attitude dropped but the scope of this post is doctors so I will leave my commentary on that aside.
- Accept all medical licenses from all Canadian provinces, no questions asked.
PEI is part of a compact with the Atlantic provinces in this respect. If you can work on PEI as a doctor you can work in Nova Scotia for example. If you are an Ontario doctor, you cannot automatically work in PEI. Every province in Canada has its own rules and requires doctors to go through admin paper work to be licensed to practice in that province. PEI does not need the other provinces to be onboard to change the way we do things. We can make this way easier for doctors. Again, BC did this and doctors travel there more. And I have said it multiple times already but I am saying it again. Doctors hate this admin bullshit. They just want to practice medicine.
- Pay doctors the incentives you promise them in a timely manner.
This is something that is well known by the doctors here. The government takes forever to pay moving expenses and signing bonuses. It requires constant follow up and that follow up often receives no reply or "just one more week". For example, it took us 13 months to get the promised moving expenses reimbursed by Health PEI.
Doctors talk. This is a well known problem that prospective doctors are aware of. Heck, I know a doctor that wants to move here that can barely get a recruiter to respond to them. It literally took a threat to go to the media to get a response. She really wants to live here so she is jumping through those hoops, but others are just going to skip PEI.
- Increase the barriers for patients to submit complaints about doctors.
I want to be very clear here. Patients should be able to complain about their doctor. Doctors should have oversight. None of that should go away. There was a prominent case against a PEI doctor that shows this system working well. That needs to stay. What does need to change is how the system responds to frivolous complaints.
Many people submit complaints as if it is a Yelp review. It isn't. Every complaint is a direct threat to a doctor's license. It potentially requires the doctor to hire a lawyer or lean on medical society lawyers. It requires the doctor to spend admin time dealing with the compliant. Boards need to be assembled to review the complaint. So on and so forth. The compliant might be something as simple as, the doctor was curt to me.
Besides what is already stated, the other impact here is that doctors often don't speak their mind. For example, if a patient is in the ER of a hospital for a cold, most doctors won't tell the patient they shouldn't be there because it risks a complaint. If a patient won't vaccinate their kids the doctor won't argue with the parent and tell them that is dangerous because it risks a complaint. If a patient is being abusive, the doctors often take it because standing up to the patient risks a complaint.
I don't fully know what the solution here is. We can't toss every complaint as a doctor being curt could also be a doctor being racist. How do you know without investigating? There already is a non formal complaint process that in under used. Perhaps this needs to be made more prominent. Perhaps centralizing this system and having an internal routing system to direct some complaints into the non formal system could help. There could also potentially be an ombudsperson that could formally dismiss some complaints before they reach the doctor or the legal process. We could also work towards taking the administrative burden off the doctors. If a complaint comes in, doctors need to pull charts, review notes, and try to remember what happened. Maybe that could be offloaded to a central admin. Patient complaints are handled as a system to protect patients from doctors so any changes need to start on the patient side of the system.
- Actual consequences for abusive patients.
I think this one is straight forward. Patients are increasingly abusive towards doctors and nurses. There needs to be actual consequences for this up to criminal charges and they need to be pursued.
If a doctor or nurse is spat at, that should be a criminal charge. It is already defined as assault and the federal government recently made the charges for assaulting medical staff more severe but that is useless if the charges aren't pushed for. Doctors and nurses often accept it is part of the job. Someone needs to stand up for them and push the charges. The police are also part of this. They will refuse to file charges because the patient was distressed or intoxicated. These are things for courts to decide, not police. Police should proceed with the charges.
If a patient yells and is verbally abusive to nurses and doctors, and the patient isn't critical, staff should be allowed to defer service. In some ways they can but then we go back to the medical complaint problem. Deferring service invites a complaint so often doctors put up with the abuse to avoid a complaint.
Family doctors should have more path ways to firing patients that are abusive. They do have pathways, but unless violence is involved, the system is slow and favours the patient. This often leads to doctors continuing to interact with their abuser.
I am quite biased here as I hate the idea of my wife being abused by patients at work. If I had it my way, I would fully publish these abusers names in the media. Heck, I would make it into a social media channel and profit off it. That isn't ethical though, so we need processes in place to ethically deal with patients that are continuously abusive to doctors. This goes for the patient's family as well, if not more so. The families are often the worst ones.
Anyway, those are my random thoughts. They are biased, obviously, to someone that cares deeply for an individual in the medical field, but also towards her colleagues and others in similar positions. Patient advocates, nurse unions, and government bureaucrats probably see thing a differently. That is okay. Their input is valued as well. So take my post for what it is. A biased view from a husband of a doctor with his hear to the ground, no filter, and the willingness to post this publically.
*Edit... If you respond in a non-constructive manner, I am blocking you. I don't owe you a response or a conversation. Disagreeing with me is fine. Someone already disagreed with me on my opinion about NPs. Great. I respect and appreciate that response. It was very constructive. If the first thing they say is just laughing or insults, there is nothing to be had by discussing the topic further with you. I am just moving on with my day.