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13 Responses to Home

  1. heinz mayr says:

    hi dr peng . i read your article on safer narcotic prescribing in canadian doctors magazine and was surprised that you did not even mention methadone clincs . i worked as gp for 32 years and now for the last 8 years have been working with opiate addicts at a methadone clinic in london ontario .i would be glad to discuss what we do and how we are trying to deal with this problem,on the phone ,in person or on line.

    • drpeng says:

      Thank you for your comments.

      I am restricted to 700 words. On this subject I could probably write 7000.

      I am very much in favour of the harm reduction/methadone program. In fact I would go one further and would like to know what ever happened to the Naomi Project.

      Unfortunately it is very difficult to get a patient on to the methadone programme. There is also pressure from the coroner, and hence from the college, to address this problem.

      I do not think there is going to be any one single answer.

      I do not think I’ve ever seen any single problem causing more stress in primary care physicians than this one.

  2. SIMON MCBRIDE says:

    Good day, further to your article in the recent Canadian doctors magazine I’m shocked and surprised that you would fall victim to the same faulty reasoning that the government likes to perpetuate. Namely, we want doctors to be free to do more of what doctors do best. This euphemism is what has caused the increasing loss of what it means to be a physician. The title “Doctor” has been given away to all and sundry including for example doctor of Audiology, which one can apply and receive from the United States simply through a paper work application. With physician assistants and nurse practitioners, the role of a physician is being lost in the community. When you say that this will take some of the pressure off for example walk-in clinics, and this will allow Physicians to “get away from the office”, . sorry, I think you are losing track of the idea that that is our income. If you took Dental fillings and Cavities away from a dentist you would see their income drop sharply, and no dentist wants to spend an entire day simply doing very complex root canal surgery which will be few and far between and will not pay as much nor fill in the day, as doing the occasional cavity. It is just frighteningly obvious to me and many of my colleagues that this agenda of dividing and conquering physicians by having others eat away at their available skill-set doing “more and more of what a physician would do”, is just another way of devaluing positions and dropping our income. Sadly yes it all comes down to a takeaway dollar at the end of the day. We may be altruistic but we would appreciate very much being properly paid for doing a full job. Effectively by having nurse practitioners, pharmacists, physician assistants, all these other people doing more and more of what we used to do, you are leaving us with virtually nothing but the complex, difficult, neurasthenic patients, along with palliative care and other groups, which are very complicated to deal with and which are not remunerated in any sufficient way by the government.
    I think your main focus being the idea that there are insufficient numbers of primary care physicians or family doctors, is because the government simply will not remunerate properly a family physician for doing all that one would expect from a family physician. For this reason the government has effectively won. There will be less and less need for True Physicians. There will be more and more pharmacists, nurse practitioners, and physician assistants doing more and more of primary care and you will effectively get the lowest common denominator of care that you deserve and you pay for. This is how governments win in this situation.
    But really is a doctor in Ontario really only worth a $160,000 a year. I could work overtime at GM and make that much.
    You still have to pay that pharmacist to do more, at the expense of physicians’ income.
    Well done, Government. It looks like they’re doing something, when they are rearranging paycheques.
    Good day, Sir.

    • drpeng says:

      Thank you for your full and thoughtful response to my essay concerning pharmacists’ role in medical delivery.

      I think actually that you are bringing up several different issues which are only loosely interrelated.

      First of all we are all woefully underpaid and has been for a long time. Anybody who goes into medicine to make a fortune is going to be very disappointed. Here in British Columbia it is not just the government’s fault. The deep division between the specialists and family physicians has made a perfect wedge for the government to split the profession. Increases in fees are usually spread evenly by a fixed percentage across the board which means that the already higher paid will have a larger increase.

      In 2001 in British Columbia a binding arbitration award would really have helped family medicine but it was refused by the incoming provincial government and the British Columbia medical Association failed to challenge it legally. It took 17 years but eventually the teachers, who were similarly affected, were proven to be right and the government’s actions wrong and the numbers had to be restored.

      The subsequent award was renegotiated by the BCM A and replaced by chronic disease management and complex care management which involved duplication of testing and no end of paperwork–lots of paperwork–a useless waste of Dr.’s time. The idea being that good primary care of chronic diseases and complex care would reduce visits to the emergency department. 15 years later and is made not on bit of difference.

      Primary care needs to negotiate with the government separately from the specialists. Medicine has evolved so much that the old combined negotiations have to be thrown out. The fee guide needs to be completely rewritten.

      Most governments are relatively sympathetic to primary care but who are elbowed out of the way by the powerful specialists within most provincial medical Association.

      I am in the fortunate position where I am able to audit practices throughout the province and will often advise in the form of peer mentoring. The doctors who work in teams are happier. They have usually elected for an alternative payment and they can then work at their pace and enjoy. They can pass off to nurse practitioners our physician assistants chores and tasks which they do not like to do. If I were never to to give another allergy injection or syringe other ear that would be fine by me. I can think to 1 or 2 practices here where I would love to work because they have a full team and they are content and really are very productive in patient numbers and patient outcomes.

      I also envisage that family practice and medicine have evolved so much that in fact if we were rid of a lot of relatively minor chores, physicians could then have time to do more skillful work such as minor surgery, endoscopy, general practice and anaesthesia and have time and ability to undertake cognitive therapy. The services would have to be remuneration appropriately.

      So that is why I do not envisaged pharmacists, physician assistants and nurse practitioners as a threat.

      One of the “happy” physicians that I have met working in a team in the interior British Columbia uses a mantra “if it does not need a medical degree then I will not do it”. Interestingly, this same physician was telling me of the huge pay cut that he took in moving from Alberta to British Columbia.

      Again, thanks for your comments.

      Best wishes

  3. Jim Dickinson says:

    Dear Chris,
    I enjoy your regular columns, though I do not always agree with them. your comments about how Family Physicians have been totally out manouevred by specialists are spot on. The Canadian system where the medical associations decide the fees is crazy. The lunatics are in charge of the asylum. Or the rich in charge of the cheque-writing machine that Medicare has become.

    Your recent comment about EBM and guidelines is also appropriate. Many drug companies have simply adapted to the guideline process and trumped it, usually with the aid of yet more venal specialists, who take funds from the companies and then declare that their opinions are not altered in the slightest by those funds. As if the drug companies would keep doing it if it did not work for them.

    But I am afraid that I disagree with your comments about pelvic exams and pap testing in young women. There is recent correspondence in the American journals pointing out that we could ask women to give informed consent to a pelvic exam, saying “This is the most uncomfortable part of the pap test, and there is no evidence it will do you any good and indeed may cause harm by finding false positive results that may be difficult to check out, but I want to do it to develop/maintain my skills in pelvic exam.” Few would consent.

    Similarly using a pap test to bring girls in to talk about sexually transmitted disease, safe sex and contraception is dishonest. Many will come in for those topics, sometimes more comfortably if they do not have to endure a pap test. We have to work on better ways of helping the others, but doing potentially harmful pap tests is not a good way. See our commentary in the CMAJ last week.

    So without consent we are committing sexual assault. What used to be called “rape.” So yes, we may be less skilled at doing pelvic exams: but they never had a high level of agreement, so we could never be very confident, especially in plumper women who are now much more common. So we may simply have to do ultrasounds on symptomatic women if we think we are feeling something on examination: but we do this anyway.

    Best wishes, and keep writing!

    Jim Dickinson

    Screening Pelvic Examinations. The Emperor’s New Clothes, Now in 3 Sizes?
    George F. Sawaya,MD JAMA Internal Medicine. Published online March 7, 2017

    James A. Dickinson, Gina Ogilvie, Dirk Van Niekerk, and Cathy Popadiuk
    Evidence that supports policies to delay cervical screening until after age 25 years
    CMAJ March 13, 2017 189:E380-E381; doi:10.1503/cmaj.160636

    • drpeng says:

      Thank you for your long and thoughtful response to my essay. I am glad that you appreciate most of them–but if I reach the point where everybody would agree with all that I write then I think I will quit. I love playing with words. The word processor makes what used to be a laborious process easy and enjoyable.

      I would, however, like to debate the benefits of the bimanual pelvic examination. Just as an interesting aside, one relatively young female physician that I was training for peer assessment was critical of the assessed physician for not undertaking a bimanual and rectal examination. Regardless of age she felt that this was indicated. She did admit that she had a relative who died relatively young of rectal cancer. This is, of course, an extreme example of one physician’s opinion.

      I am confident that I could now say that I have never undertaken a pelvic examination without explicit consent from the patient. It would be like driving without putting a seatbelt on.

      I am surprised at how ill-informed many woman are concerning the Pap test and what it is for. I always explain what I am doing and get consent to screen for chlamydia and gonorrhea. Over the years many patients come to my office saying that they had a Pap test at a walk-in clinic where in fact it was a speculum examination looking for STDs.

      I think it is criminal to undertake a pelvic examination without a careful explanation. When I do one I explain what I am doing the whole time. I remark upon on the external genital skin looking for dermatitis and condylomatas. I explain what I am looking at in the vagina mucosa and how we should look like the inner mucous membrane of the mouth. I describe the size of the uterus and whether is anteverted and retroverted. If it is retroverted I tell the patient not to be alarmed if they get the occasional deep dyspareunia. Also if they are trying for pregnancy they should lie prone at night for the first trimester and slightly longer. I then explain how I am taking the Pap test and ask the patient to pass me the brush or spatula. That way they become involved in the process. As I am finishing the examination I estimate the size of the pelvis and I am usually able to reassure the patient that further parturition should be uncomplicated. Any patient who has had one or more pregnancies I get them to strain down and to do a Keagle exercises to make sure they are doing it appropriately and encourage them to practice that. I always precede a pelvic examination with an abdominal examination. Just to gently lead into the invasive procedure. I think to check the mobility of enough normal uteri would help in examination for infertility and PID.

      I quite often explain to the patient the concept of body integrity. There is innate self defensive behaviour or reflex that the body will not allow penetration willingly or easily. This is why many people find it traumatic to attend the dentist. Otolaryngology debriding and auditory canal can be stressful. Rectal examination induces more anxiety than really the physical discomfort should. A needle penetrating the skin can induce vasovagal symptoms in some people. A knife or a spear penetrating the skin is best avoided. Once the patient knows that their anxiety is appropriate they will find a procedure less stressful and embarrassing as well.

      I have had many very positive comments following the pelvic examination. Patients like to know what is “going on down there”. In spite of the early sex education and the ready availability of information on the Internet our younger generations are still abysmally ignorant of many sexual functions.

      That probably sounds terribly paternalistic. It probably is. It almost certainly is. It is, however, a formula which seems to have worked successfully over my 35 years and more of family practice.

      I very much appreciate your feedback. I was unable to find your paper in the CMAJ and will try the medical library tomorrow. Unless, please, you would be able to forward me a copy of this.

  4. John McLeod says:

    Reply to Where Have All the GP’s Gone?

    Dear Dr. Pengilly, I read your article “Where Have All The GP’S Gone” in “Just for Canadian Doctors”, the summer 2017 issue. Please consider my ideas on this subject.

    I graduated from the University of Alberta Medical School in 1974. I completed my Family Practice Residency in 1976. I was a full service Family Physician, including obstetrics, for 24 years. The first 5 years were in rural Alberta and the subsequent 18 years were in urban practice in British Columbia.

    Many changes occurred in my 24 years of Family Practice. For instance, male physician obstetrical demand fell as female physicians began practising. This was not bad, but it was a change that was disappointing to some. The onset of walk-in clinics was especially difficult for family practice as the easy patients were skimmed off. This affected my office, as overhead rose and the average complexity of full service family practice cases increased. Subsequent to this my office partner became overloaded with complex physical and emotional cases and she left family practice. When she left I could get no relief. I looked for local physician groups to join but none were available. At that time the Hospitalist program was starting. I closed my office and have been a full time hospitalist, for over 16 years now. This is my 40th year of medical practice.

    I would like to tell you where I think “All the GP’s Have Gone”, when it comes to hospital medicine. The GP’s have followed the patients, and the patients have left the building. In other words many of the patients that we GP’s used to treat, in hospital, are no longer treated in hospital. For instance, we have about the same number of hospital beds in Burnaby that we did in 1982 when I started family practice here. This is despite a large population increase. Burnaby’s population has grown by 60%, from 136,494 in 1981 to 223,218 in 2011.

    Most of the patients GP’s used to care for in hospital are gone. For instance, please note the following examples:

    1. Many general hospitals no longer have a pediatric ward. Croup is treated with racemic epinephrine in the ambulance and the child is observed in the ER and then, in most cases, sent home without admission. There are not as many viral respiratory infections needing admission. There is not the numbers of diarrhoea cases needing hospital admission etc. The overall need for family physicians to care for hospitalized children has dropped dramatically

    2. We used to keep mothers and their newborns for 5 days, no ifs, ands or buts. Now the newborn goes home very quickly, with mom, and homecare nursing follows as needed.

    3. Hernia operations used to come in the day before to get a shave prep, and then, after surgery, would stay in hospital until they could walk better. In our day surgical patients are not in hospital long, either pre- or post-op.

    4. The ER used to hold family practice patients in the ER until the family physician would come at the end of the office day. This became an onerous system for ER physicians and they proved to be the biggest advocates, in Burnaby, for the Hospitalist program. There is no time or space to work-up and hold patients for family physicians, in a busy ER that is trying to discharge patients within a few hours.

    What I am trying to say, from my perspective, is that family physicians left the hospital because the patient numbers, per physician, dropped substantially over the past 35 years. Also, the few patients left in hospital are not sufficient for a physician to want to provide 24/7 on-call coverage. As well, the few patients, that a family physician might still have in hospital, would likely be complex elderly that are very sick, and often have conditions that worsen while in hospital and need immediate care, that cannot wait until the end of the office day.

    I read an article (I cannot recall the reference) some time ago, which noted that Internists in California used to spend 40% of their time in hospital and then it dropped to 10 %. Regardless, many medical disciplines, from pediatrics to plastic surgery to internal medicine and family practice etc., have fewer patients in hospital. Family physicians left the hospital because the types and numbers of patients in hospitals changed, not because the physicians lacked skills or motivation.

    I recall the head of the College of Family Physicians of Canada saying, at the National Conference about 20 years ago, that: “In times of change some people do better and some people do worse, and I made my mind up which group I wanted to be in”. The times of change are ongoing inside and outside of hospitals. I feel optimistic, for the young family practice residents we have with us, because they can decide which group they want to be in. They can create something special with their medical skills and their care of patients, whether inside or outside of hospitals.

    Warm Regards,
    John McLeod, BSc, MD, CCFP

  5. Daniel says:

    Dear Dr. Peng,

    The issue of effectively removing the medical corporation has ignited a spark underneath all physician, whether they be family physicians or specialists. Physicians are realizing that we have working conditions that are against the Employment Standards Act. The fee for service model has us running faster and faster on a wheel in cage. By placing a full tax burden on the medical corporation, the federal government is removing our ability to have a pension. The only answer is to eliminate the fee for service model. Physicians need to be paid a fair wage and given pension benefits. The health care system needs to provide physicians with an office space and assistants. If they need us to work more than 37.5 hours per week be it seeing patients, being on call or doing our EMR work, then they need to pay us overtime. We need to be paid a fair wage based on what other professional earn working in government. All other workers in Canada are treated in this manner. An unofficial pole I have taken reveals that hospital based physicians, whether GPs or specialists are working over 100 hours per week. It is the excessive work hours that results in a higher income for doctors and it is these very long hours which continue to prop up a fully public health care system. I would urge you to read Dr. Day’s twitter post for August 6, 2017. Doctors need to be paid fairly by the hour, for all their work hours and fee for service needs to be eliminated to have a truly fair system, which is fair to GPs and specialists,

    Many thanks,


  6. Brian garland says:

    I read your article in Canadian Doctors about the issues of MVA’s in Canada .

    Like you I abhored mildly injured entitled litigious patients.

    NZ May have some of the answers.

    I enclose a link.


    Dr. Brian Garland. NB.

  7. Hillel Finestone says:

    Hi Dr Pengilly,
    Your article “Reaponsible recoup” had good information but in my opinion was too simplistic. PTSD does exist, as does mild TBI and if our patient is a heavy duty truck mechanic he may have more trouble bouncing back from his injury than a doctor in similar circumstances. Yup, we need to encourage mobility but I would like to see appropriate services for our patients Eg psychology, workplace interventions, exercise therapy… that oft doesn’t happen..,

    • drpeng says:

      Thank you for your comments and I appreciate them. In the beginning part of the essay I did clearly state that I felt that the severely injured deserved fair and full compensation. I should have gone on to say that these serious claims can be held up or lost in the debris of unsubstantiated cases.

      It is interesting that my editor rarely comments concerning my essays but she did to this one saying very much as you did. Clearly that paragraph did not carry the impact that I wanted it to.

      Over the years I have treated many motor vehicle accidents patients and is interesting that when the patient is the one responsible for the accident how quickly they recover. I know of at least four patients who sincerely regretted getting involved with litigation. I have had some that have had serious injuries and for those I will fight like a tiger.

      With regard to recovery and symptoms, if motivation and determination to get better is strong enough then Mark McMorris is a good example. In spite of his multiple injuries he was determined to get back into the Olympics and it looks as though he has made it.

      Unfortunately with litigation there is not that driving utter determination to get better which would reduce the ultimate settlement.

      Anyway, thank you very much for your comments.

  8. BD says:

    I apologize for using this comment space. When I click on the comments button in the upper right-hand corner I’m getting the code view which I suspect will not accept my message.

    This is a reference to an article you wrote for the fall 2016 issue of “just for Canadian doctors” entitled “Physician shortage, With fewer general practitioners, doctors need to do some problem solving”.

    In this article you say “disincentives that had not already been disallowed by the courts (for example, compulsory retirement for physicians at age 75) were quickly withdrawn and incentives were then introduced at an escalating (and recently proven) ineffective rate.”

    This is my question: can you provide me with references to the court decisions which allowed physicians to work beyond age 75. Thanks for your help.

    • drpeng says:

      That is a good question and I do not have an answer. Most likely more information may be available in the archives of our local newspaper – the Times Colonist. Not very sophisticated research on my behalf. Best wishes

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