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ana_safavi

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  1. In America, becoming a doctor can prove fatal By Amitha Kalaichandran M.D. March 15, 2019 TODAY, 30,000 medical students across the United States learned where they would be heading next year. Each student opened an email or an envelope; inside was the name of the residency program where they’d been accepted. For many residents, the revelation was a source of joy. For others, relief that they had matched at all. But for some, it could be the beginning of a nightmare. In America, becoming a doctor can prove fatal. Suicide is estimated to be the second leading cause of death among medical residents, after cancer. (In contrast, the leading cause of death in the general population for that age group — 25 to 40 — is trauma.) Suicide statistics for young doctors are difficult to track because many deaths go unreported as such. But we know that 300 to 400 American doctors complete suicide each year, twice the rate of the general population. Just last May, thousands of medical residents across the country took a moment one evening to reflect on the suicide of an unnamed psychiatry resident at NYU Langone Medical Center. While NYU Langone provided a statement, no further details were given about the resident’s age, exactly where she worked, or where she was found. Her death seemed inexplicable; her life erased with no clear rationale. Within a few months, two more women in the New York City medical community would take their lives. Perhaps it was the long work hours, we in the medical community thought. Or maybe a difficult breakup. Maybe the women were depressed and hadn’t received adequate treatment. Then again, maybe it was something else that many of us were all too familiar with. A few weeks after the NYU resident’s death, physician suicide expert Pamela Wible asked a question many of us had been discussing in private: Could it have been bullying? Wible disclosed some of the letters she had received from a resident at the same hospital suggesting the victim had been emotionally abused by her supervisors. If so, it wouldn’t be the first time a resident had been bullied to death. THERE’S NO QUESTION that bullying is endemic in medical education. One study revealed that about half of residents and fellows in the U.S. reported being bullied, most often by their attending physicians. Canadian researchers found that 78 percent of residents surveyed reported being bullied and harassed in their training, often by attendings or program directors. And residents aren’t the only victims at risk; patient care may also suffer. Studies have shown that if a resident is distracted by the additional cognitive load of bullying and mobbing, he or she is more likely to commit errors. General patient care can also be negatively affected; bullied trainees may be less empathetic because they’re consistently in fight or flight mode and may fail to communicate as effectively with their own patients. Search “bullying in residency” and you’ll get thousands of hits, from heart-wrenching blog posts to short opinion articles to forums on sites like **DELETED** or Quora where residents anonymously share their experiences and advise targets. There are tales of discriminatory remarks. There are performance reviews in which attending physicians detail fabricated incidents that the residents can’t refute. There are verbal threats, intimidation, and over-monitoring of patient care. “I was very badly bullied by my Professor in my residency program,” wrote one resident on Quora. “I tolerated it for the simple reason I thought I was in the wrong. I was made to feel guilty though I had been correct.” The most shared Humans of New York Instagram photo of 2018 was a photo of an unidentified medical resident who said: “On the first day of rotations, my attending physician told me: ‘I’m an asshole, but I’ll make you a better doctor.’ He made fun of me in front of other students. He put me down in front of patients. He’d threaten to kick me out every day. . . after going through hell, I just don’t care anymore.” The post has nearly half a million likes. STORIES OF ABUSE abound. Daniel (not his real name) was a perky and bright medical student who moved from a small town to a larger city to pursue a primary care residency. Naturally curious, dynamic, and passionate about the social issues affecting his patients, Daniel noticed that his goals — social justice and medicine — didn’t align with the program’s values. He struggled to continue his work in child advocacy, which he had begun in medical school and which the interviewers had assured him they would support. Nevertheless, he adjusted and made close friends. In his second year, Daniel started a high-pressure rotation in neonatology and that’s when things began to spiral. It was his first time in that demanding environment; his peers had previously completed electives and were used to both the medicine and the intensity. Daniel tried his best to catch up, reading for hours each evening. But he always felt like he was struggling. What’s worse, his background reading put him directly in his supervisors’ crosshairs: Instead of embracing Daniel’s independent research as a sign of intellectual curiosity, his superiors accused him of questioning their expertise. No matter how much Daniel worked, he was constantly, and publicly, berated by one particular attending if his management plan wasn’t exactly what she would have chosen, even if it aligned with another staff member’s from the week prior. The feedback was punitive and demeaning. Daniel found himself crying almost nightly. “The repeated episodes of public shaming shattered my confidence and forced me into silence,” he told me. “I felt the staff wanted to break my spirit, not build up my abilities. . . to manage our patients effectively.” After hanging on for another few months, Daniel quit medicine altogether, forfeiting his four years of undergraduate pre-medical studies, four years of medical school, and two years of residency. That amounted to hundreds of thousands of dollars invested in his formal education, and years working towards a goal of caring for patients. “I had never, and have never since, experienced such a toxic, destructive, and demoralizing environment,” he says. THERE IS VERY little research on bullying in medicine because, ironically, few medical programs are willing to participate in research studies. They may, rightfully, be concerned about the findings. But we do know that the bullying tactics in medicine are identical to other industries. It takes many forms: intimidation; threats of career ruin; belittling; undermining; unjustified criticism; spreading gossip about the resident; work interference or sabotage; blocking promotions or opportunities at other clinical sites; setting trainees against one another which can include complying with bullying actions. The list goes on. But the stakes are often higher in medicine than in other sectors. Friday’s Match Day assigns trainees to a specific program, ostensibly trapping them into a potentially impossible situation. Once matched, a resident becomes bound to that program until their training is complete. If they experience debilitating bullying, residents are contractually obliged to stay, even though research shows that this is the second most common reason for seeking a transfer. Like Daniel, Lara found herself bullied when she joined the Intensive Care Unit (ICU) as a second-year resident. The behavior began one day when she accidentally presented the wrong patient to her supervising attending and fellow residents during rounds. She caught herself and immediately apologized, but the staff member went on the attack, berating her for violating patient confidentiality and accusing her of incompetence. Feeling defeated and cornered, Lara could say nothing and accept the abuse, or say something and risk being labelled unprofessional. She chose to stay quiet. Within a few days, nearly all of Lara’s supervisors began to act as adversaries. They seemed to be waiting for her to make mistakes so that they could point them out. Lara knew that these physicians — who were all female — regularly met in private to review her performance and behavior. From the consistency of their language, she began to worry that they were conspiring against her. During Lara’s mid-rotation performance review, her superiors told her that they had observed incidents which Lara felt had been either grossly misinterpreted or simply fabricated. When she tried to defend herself, backing up her claims with documentation, she was branded as “unprofessional” and “unable to take feedback.” One of her ICU attendings even suggested that Lara quit medicine. Then the nightmares began — dreams that mirrored real life. Even in sleep, the ICU and the abusive attendings haunted her. The program director suggested that Lara might have an underlying psychiatric disorder and referred her to a physician health support program for an in-depth psychiatric assessment. Lara had never had a mental health condition prior to residency, but was diagnosed with workplace-induced anxiety, which required therapy. Soon she was on probation; she was told that this decision had nothing to do with the diagnosis and everything to do with her “poor performance.” But one possible outcome of probation was dismissal. Were Lara’s superiors setting her up? TO A CERTAIN EXTENT, medical education rewards obedience, and that’s precisely what makes it ripe for abuse. Medical ethicist Ajay Major notes that attendings may celebrate “ethical and professional chameleons” — those residents who rarely oppose their superiors. In this climate of fealty and cloying respect for authority, many residents view their advanced medical training in part as an introduction to medicine’s “hidden curriculum.” Their success depends on understanding and playing by these rules. And within the system, attendings generally have all the power, while trainees rarely are given a safe way to defend themselves when they feel wrongfully attacked. Even 360-degree evaluation systems, intended to provide more objective feedback, can be manipulated in hospitals to target individuals. As one commentator on a popular survey by Doximity wrote: “I was constantly threatened. I would be put on probation when I disagreed with the attending’s assessment and evaluation.” Typically, bullies twist concepts, such as professionalism, to shame residents who express divergent viewpoints, and Lara certainly experienced that. Even witnesses of abuse fear reprisal because there are few, if any, mechanisms for reporting. “When this happens, a real culture of fear is present,” says Howard Liu, an academic psychiatrist from the University of Nebraska, “People feel like they can’t tell the truth.” Bullying may also be deeply ingrained in medical tradition. William Bynum, a family physician based out of Duke University, researches shame and intergenerational trauma in medical education. “It’s possible that those doing the bullying were bullied and shamed themselves, and they then channel that unresolved conflict onto others, especially those at lower levels of the hierarchy,” he says. That’s why high performers like Daniel can be deemed a threat to attendings who feel insecure about their own position and abilities. LARA HAD BEEN mobbed — a form of bullying that encompasses groupthink and collusion among leadership. She knew that if she stayed at her hospital, she would very likely be fired, as the probation period relied on repeating a rotation in that abusive ICU. Fortunately, as part of her mental health accommodation, she was permitted to complete that rotation at another institution. In the new setting, her performance was deemed excellent, so she continued to progress and will finish her training next year. Lara (not her real name) was one of the lucky ones. Bullied residents have turned to substance use; some become so severely depressed, like Daniel, that they quit their program. Even witnesses to negative acts such as mobbing can experience psychological effects, reflected in high turnover. And of course, there is the specter of suicide. In 2017, the World Medical Association issued a statement about the need to address bullying and harassment in medicine. The American Medical Association, British Medical Association, Royal Australasian College of Surgeons, and the Canadian Medical Association followed suit. Regulatory bodies in the U.S. and Canada are beginning to refine how bullying should affect accreditation, and permit individual physician complaints if they experience mobbing, bullying, or harassment — much as a patient would — as the behavior violates established codes of professional and ethical conduct. Some American institutions have responded by changing the match system. In Texas, for instance, through the “FITXBEST” initiative, surgical programs are foregoing the match system to help circumvent the factors that would set someone up to be a target. Staff interviewers are trained to recognize their unconscious biases, while focusing on questions that shed light onto the learning style, goals, and personality of the candidate to determine fit and their anticipated level of support in the training culture. Residents are also stepping up to protect each other. The trainee-led website Scutwork.com acts like the “Glassdoor” of residency programs. The hope is that with enough feedback it should paint a fair picture of programs across North America and nudge the most problematic ones to change. And finally, there’s a new anti-bullying movement: TimesUp Healthcare. In a Lancet editorial last month, the leaders of this group outlined a roadmap for hospitals and training programs to address mistreatment. They recommended incorporating bystander and civility training, sanctioning perpetrators, improving reporting mechanisms, and being transparent about the number of complaints and lawsuits. For trainees, transparency will help them avoid so-called malignant programs, while also motivating these programs to change so they don’t deter applicants. BY THE TIME you read this, another doctor in North America will likely have completed suicide. This person may be a resident, someone in his or her late-20s, with a decade of expensive schooling and training behind them, and countless hopes and dreams ahead. Several hundred more will have thought about taking their lives. As a physician, I have had to acknowledge that those who I’ve most admired haven’t always behaved ethically. They haven’t always had their trainees’ best interests at heart. Power and perceived threats to egos are unseen and sinister forces; respected leaders, in turn, have failed to model integrity. But above all, the greatest irony is that in the relentless pursuit to heal the sick, many doctors have put the next generation of physicians in harm’s way. If you or someone you know is having suicidal thoughts, there are resources available to help. The National Suicide Prevention Hotline number is: 1-800-273-8255. The Samaritans Suicide Prevention Hotline is 877-870-4673. Amitha Kalaichandran, M.H.S., M.D., is a resident physician, epidemiologist, and writer, based in Ottawa, Canada.
  2. ana_safavi

    PARO Insurance - pre-existing/new condition?

    Are you talking about medications? Or disability insurance?
  3. My program requires residents to evaluate every preceptor, rotation, teaching session, etc. Didn't make a difference, because the school never acted on it. It was just a box for them to check to get a Royal College accreditation they didn't rightfully deserve. The way to guard against malignant attendings is to set up a fund to help residents sue them in court for harassment. When they start having to pay financially for their abuse, they'll suddenly stop it, real quick. You'll see!
  4. If you're okay with being harassed as a condition of employment.
  5. ana_safavi

    2019 CaRMS unfilled spots

    I understand the premise. You don't understand the law. You suggested: "restrict IMG spots to CSAs --> CSAs have a much stronger legal ground to stand on compared to complete foreign grads" and then you further clarified: "But I'm suggesting a realistic solution that could pass in court." You are incorrect. The change you proposed, whether it's done via accreditation or any other means, would be immediately struck down in court, because it is against the law. More specifically, it is against the Canadian Human Rights Act and each province's respective Human Rights Code. Human Rights Codes are quasi-constitutional, and therefore necessarily supersede any statutory law that could be created in parliament.
  6. ana_safavi

    2019 CaRMS unfilled spots

    You are explicitly suggesting that we should discriminate against applicants based on their country of origin. This is not only, by definition, racism, it's also against the Ontario Human Rights Code. Favouring CSA applicants over other IMGs is LITERALLY AGAINST THE LAW. Because it is DISCRIMINATION BASED ON RACE. So yeah, at the minimum, I'd say you lack cultural competence.
  7. ana_safavi

    CBD = shorter residency?

    As with anything else the Royal College touches, this is a poorly-thought out disaster.
  8. ana_safavi

    CBD = shorter residency?

    Nope. It's just going to be used as an excuse to hold people back, that's all.
  9. ana_safavi

    2019 CaRMS unfilled spots

    I'm not fighting for "social" justice. I'm fighting for LEGAL justice. By suing med schools and the corrupt institutions that collude with them into the ground. And then, I'm going to change the law, so that they can't get away with it ever again. Anyway, sorry for derailing. If anyone wants advice, or just to vent about CaRMS, my DMs, as always, are open, and my cell is 519-859-9334. Stay strong, lovelies! <3
  10. ana_safavi

    2019 CaRMS unfilled spots

    Don't I know it. All the asshole attendings who harassed me (including sexually) were CMGs, trained in Canada, as are the leadership that is still trying to cover it up. Most were recent grads, too.
  11. ana_safavi

    2019 CaRMS unfilled spots

    LOL. If anyone lacks cultural competence, it's all the racist CMGs who discriminate against foreign-born doctors.
  12. ana_safavi

    2019 CaRMS unfilled spots

    Knowing uOttawa, it's got to be something shady. I'm guessing it's got something to do with this super sketchy policy of theirs: Process for vacant MOHLTC funded residency positions Application From time to time, the Ministry of Health and Long Term Care (MOHLTC) funded residency positions become vacant due to either transfer outside of the University of Ottawa, resignation, or the dismissal of a resident. Program Directors may fill the position with an admissible resident at the same level of training within the same specialty training program (including Family Medicine) as the vacant position within three (3) months of the position becoming vacant. If a position is not filled within the three (3) month period, it is released to the Vice-Dean of Postgraduate Medical Education (PGME), who has the discretion to fill it with a transfer request from an admissible resident - as defined below - who is currently enrolled in any of the accredited residency programs (i.e. any CMG or IMG enrolled in any program anywhere in Canada or USA). Requirements Admissible residents must be either: Canadian Medical Graduates (CMG); or International Medical Graduates (IMG) with Canadian citizenship or permanent resident status, currently registered in a postgraduate residency program in Canada or the USA.
  13. https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(19)30013-6/fulltext
  14. Ah, that makes a lot more sense...
  15. I LOVE this book: https://www.amazon.ca/Sapiras-Art-Science-Bedside-Diagnosis-ebook/dp/B007CMODQG/ref=sr_1_1?keywords=sapira&amp;qid=1550533436&amp;s=gateway&amp;sr=8-1
  16. Quick update. https://www.cbc.ca/news/canada/sudbury/northern-ontario-medical-school-sexual-harassment-year-later-1.5013847 Factors, indeed!
  17. Sadly, medicine as a profession, treats people with disabilities or mental health illness abysmally. If you choose to disclose your illness, or if anyone finds out, be prepared to hire a lawyer.
  18. For those who have not heard of this, PULSE 360 is a survey tool used by institutions for peers, supervisors, and allied health staff to anonymously evaluate physicians. PULSE also offers professionalism coaching for 'disruptive physicians.' As far as I am aware, PULSE is used only by medical schools -- Ottawa, McGill, NOSM - are there any others? The CPSO does request reports to be sent to them if it is part of a trainee's remediation plan, but I don't believe that the CPSO itself asks for PULSE assessments to be done. Please someone correct me if I am wrong about that last bit. Any thoughts, experiences, etc. with PULSE and/or other 360 tools? Or with Professionalism Coaching? Thoughts on the "disruptive physician" phenomenon in general? PM me or otherwise contact me via social media or private email if you want to speak confidentially instead.
  19. ana_safavi

    #MeToo and Due Process

    There was an excellent article in the CMAJ a month ago about how to best handle harassment complaints by medical trainees. With #MeToo constantly in the news for a year now, it has made me think that as a society, we really need to come up with better ways of handling complaints of workplace sexual harassment. Right now, the employer/institution calls all of the shots, at the expense of the rights of both the victim and the harasser. If the institution wants to protect the harasser, they will cover everything up and punish the victim for coming forward. On the other hand, if the institution is already looking for some pretext to fire the harasser, they will use the victim to scapegoat the harasser. In the end, it is usually only the institution that wins in this rigged process. I wanted to draw attention to this particular paragraph from Lauren Vogel's article above: Bechard says third-party investigations may represent a viable option for balancing the rights of both the accuser and the accused. “The ability for objective review of allegations of sexual harassment would be helpful, while allowing for the anonymity of the complainant.” From the very start, I told my school that I would release the name of my harasser directly to the third party investigator only. I did this not to protect my own anonymity (that ship sailed went I went public), but rather to protect *his* anonymity. In my view, if the investigation determines that my allegations are unsubstantiated, then there is no reason for the school to ever know his identity. He can proceed with his reputation completely intact, with no threat to his career or marriage. If the third party investigator finds that my allegations are substantiated, then a limited summary of the findings can be released, as necessary, for disciplinary purposes. But, I am not convinced that a bunch of university administrators need to know the full details of the specific allegations (including sexually salacious details that would be personally embarrassing to my harasser, his colleagues, friends, family, and other witnesses) in order to fulfill their duty to maintain a safe training environment for medical learners. Perhaps this is a way that, as a society, we can balance an institution's duty to investigate complaints with both the complainant's and respondent's rights to a fair process, while preserving the privacy of all parties (including witnesses) to a greater extent than is typically afforded in an internal investigation (particularly at small institutions where rumours run rampant). So, I am proposing an alternate model for institutions to deal with complaints of sexual harassment, particularly when there is a significant power imbalance at play: The victim submits a brief summary of allegations to HR, but keeps the harasser's name anonymous. HR decides whether the allegations, if found to be true, would meet the definition of sexual harassment according to the law and workplace policies. If yes, HR hires a third party investigator, without knowing the identity of the harasser (this is crucial so that the decision to investigate internally vs. externally is not biased by how important or well liked the harasser is). Once the investigator has been hired, the victim submits the name of the harasser and the full details of the allegations (along with names of potential witnesses and any other supporting evidence) directly to the investigator only. The investigator shares the identity of the victim and the detailed allegations directly with the harasser (so that they can prepare a defence). The investigation should proceed as discreetly as possible. For example, the department head and university administrators need not even know that an investigation is taking place. At the end, the investigator decides whether the allegations are: substantiated, unsubstantiated, or false/malicious, and communicates their conclusion to the victim & harasser. (If either the victim or harasser contests the result, then the full report should be shared with both parties.) If the allegations are determined to be unsubstantiated, then it doesn't go any further. The investigator tells HR of the 'unsubstantiated' result, and the matter is closed. Nobody will ever know the identity of the alleged harasser other than the alleged victim. Only the alleged harasser and HR will ever know the identity of the alleged victim. If the allegations are determined to be false/malicious, the investigator tells HR of this result. HR discloses this finding, along with the victim's identity to the appropriate body for disciplinary proceedings for knowingly filing a false complaint. The identity fo the alleged harasser is never disclosed to anyone. If the allegations are determined to be substantiated, then the full report is given to the university's legal counsel (separate from the investigator) who will draft recommendations (i.e. is the conduct serious enough to merit termination; do any regulatory bodies need to be notified, etc). The person in charge of termination decisions will receive a copy of the recommendations, and the identity of the harasser, but not the identity of the victim. Separately, the victim and harasser may choose between themselves to proceed to mediation and/or to Court. The university should not in any way be involved in this aspect of the process. My hope is that with the above method, those in power will be less hostile to victims, as they will be less afraid of the repercussions of a false accusation, and less vulnerable to an employer-driven witch hunt as pretext to drive them out of the organization. In turn, hopefully victims will suffer fewer reprisals, trust that their complaints will be handled seriously and discreetly, and as a result they will be less afraid to report abuse. And while third-party investigations don't come cheap, a proper investigation saves the institution from a drawn out, expensive and very public fight in the court room and/or press. And it's not just unhappy victims that sue; harassers denied due process sue just as often. I welcome everybody's thoughts on this.
  20. ana_safavi

    Doctor has sexual relations with patient

    Yeah, is this a recent phenomenon? Like, a trend brought on by all the celebrity dick pic leaks in the past few years? Or have men always been doing this?? Do you have any idea how awkward it is to work with a preceptor again, after he's even just talked to you about his penis? Like, if I really wanted to know about it or see it, I'd ask. Really. I promise.
  21. Have you thought of FM-anesthesia?
  22. Yeah, the main issue is that it can affect the capacity of a program to take on learners (i.e. not enough preceptors/patients to go around). This was more a problem in the past, when most programs were actually at capacity. They no longer are. Now, it's funding that is almost always the limiting factor in number of residency spots. I think I heard that the universities get exorbitant fees from the Saudi government, which (presumably) goes to supplement the learning experience for the CMGs in that program?
  23. "CaRMS also supports and enhances the Canadian medical education system through regular research collaboration with universities and other medical and governmental organizations. We are also pleased to accommodate data requests from stakeholders in the medical education community and other interested parties." https://www.carms.ca/en/about/services/research-and-data-services/ Do you think if I did a resident research project comparing the cost-effectiveness of CaRMS vs. NRMP, they would be pleased to accommodate my data request for their full set of audited financial statements? It would be an excellent CanMEDs learning activity. Specific competencies covered: LE 2.1 & 3.2; HA 2.3; SC 4.2 & 4.3; PF 1.4, 2.1 & 4.3
  24. ana_safavi

    Unmathched Human Rights Complaint

    From the same book, on negligent misrepresentation: Colleges and universities have also been held accountable to students in tort law for negligent misrepresentations in promotional or other similar material.168 In addition, universities have been found liable for breach of contract or negligent misrepresentation in cases when they have failed to offer courses or programs as advertised. In Chicoine v Ryerson Polytechnical Institute, a student convinced the Ontario Provincial Court that a case involving a course he claimed had not been taught as offered and advertised should proceed to trial.169 In Bell v St. Thomas University, the court held that a student had a contractual right to retake a course without conditions because a statement in the calendar permitted course repetitions without special permission.170When a program placed certain conditions upon the student’s repeating the course, the university was found to have breached the contract. In a 2000 Ontario Supreme Court case, a student successfully sued Lakehead University for negligent misrepresentation when it cancelled a program to which he had been admitted without informing him when it first became aware that the program would not be offered.171 Perhaps the most egregious case of this type was Olar v Laurentian University, which involved a student who had completed two years of study at Laurentian’s School of Engineering on the understanding that he would receive full credit for his courses at a number of other Ontario engineering schools, as was clearly stated in the university’s calendar, student guide, promotional materials, and website.172 While he was accepted into engineering at another university, he did not receive full credit for his courses and was required to take an extra year to complete his program. Because Olar had relied on Laurentian’s misrepresentations regarding the transferability of its engineering courses, he was awarded damages in excess of $120,000. Hickey-Button v Loyalist College of Applied Arts & Technology is similar in many respects. In this case, a group of students entered the nursing program at Loyalist College with the understanding, based on Loyalist’s promotional materials and other representations, that they could transfer to Queen’s University after two years to complete their nursing degree.173 When negotiations between Loyalist and Queen’s broke down, this option was not available, and the affected students successfully petitioned the court to be certified as a class in a class-action suit for breach of contract or negligent misrepresentation.174Crerar v Grande Prairie Regional College addressed the question of whether institutions could be held liable for the provision of erroneous oral advice.175 In this case, the Alberta Court of Queen’s Bench found that students have an obligation to verify the accuracy of oral advice given to them, rather than relying exclusively on such advice. I mean, you might as well go for both negligent misrepresentation and breach of contract, and see if either one of them sticks... I mean, it would be a class action. So the legal fees would be shared (and could be paid via fundraising). And although getting 4 years of tuition back doesn't make up for not matching...could you imagine if hundreds or thousands of unmatched applicants were awarded 4 years of tuition fees, all at once? That would be a fairly significant hit to the universities... Anyway, even if it failed, just the attempt to get it certified as a class action would likely draw enough media attention to drive a decent political lobbying effort for a legislative solution, which is what is ultimately needed here to fix the issue for future generations.
  25. One more! They have a GST number, and collect HST on all the fees they charge. Shouldn't the tax they remit show up as a line item somewhere? Or are the amounts listed in that financial statement net revenues?
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