Ontario health care workers to gain more power

[monkey799]

Health-care workers to get broader powers

 

Pharmacists, nurses, other professionals will do some work of MDs

 

The Toronto Star

Sat 25 Apr 2009

Page: A10

Section: News

By: Tanya Talaga

 

Ontario is about to move ahead with plans to allow pharmacists, nurse practitioners and other health-care professionals to provide some services now performed by doctors, Premier Dalton McGuinty says. Pharmacists would, for instance, be able to extend prescription refills, one of a series of moves aimed at easing long waits for health care, said McGuinty.

 

The necessary legislative changes will be made "very soon," he said. "Our government plans to better utilize your skills and maximize your contributions," McGuinty told the annual general meeting of the Registered Nurses' Association of Ontario in Markham. "Families seeking health care will experience the difference."

 

The premier went on to give examples of how the changes should help shorten wait times and enhance access to care. "Instead of waiting in the emergency room to see a physician, you would have your fracture set by a nurse practitioner, who is qualified to do it ... and you'll be on your way home," he said. "People needing a prescription refill would be able to make one trip to a pharmacist instead of two trips: one to the doctor and then one to the pharmacist."

 

And if a patient has an injured knee, a physiotherapist could order an X-ray, McGuinty said. About 11 regulated health professionals will have expanded scopes of practice, including physiotherapists, dietitians, respiratory therapists, midwives and dentists, Health Minister David Caplan told the Star, adding the changes are "all about patient access to health care."

 

"It is about getting care sooner and faster," Caplan said in an interview. "A lot of this to me seems very common sense." Last November, the Ontario Health Professions Regulatory Advisory Council made a number of recommendations in a report to the health ministry supporting many of these changes.

 

But when that report was released last fall, parts of it, including its suggestion on expanding the roles of pharmacists, drew the ire of the Ontario Medical Association, which argued the practice would not be safe. But Dennis Darby, head of the Ontario Pharmacists' Association, said yesterday that a prescribing pharmacist could take the pressure off emergency rooms and doctors' offices. He welcomed the news that legislation is on its way. "It is all in the name of trying to take some of the pressure off an overburdened health system," Darby said.

[future_doc]

Health-care workers to get broader powers

 

Pharmacists, nurses, other professionals will do some work of MDs

 

The Toronto Star

Sat 25 Apr 2009

Page: A10

Section: News

By: Tanya Talaga

 

Ontario is about to move ahead with plans to allow pharmacists, nurse practitioners and other health-care professionals to provide some services now performed by doctors, Premier Dalton McGuinty says. Pharmacists would, for instance, be able to extend prescription refills, one of a series of moves aimed at easing long waits for health care, said McGuinty.

 

The necessary legislative changes will be made "very soon," he said. "Our government plans to better utilize your skills and maximize your contributions," McGuinty told the annual general meeting of the Registered Nurses' Association of Ontario in Markham. "Families seeking health care will experience the difference."

 

The premier went on to give examples of how the changes should help shorten wait times and enhance access to care. "Instead of waiting in the emergency room to see a physician, you would have your fracture set by a nurse practitioner, who is qualified to do it ... and you'll be on your way home," he said. "People needing a prescription refill would be able to make one trip to a pharmacist instead of two trips: one to the doctor and then one to the pharmacist."

 

And if a patient has an injured knee, a physiotherapist could order an X-ray, McGuinty said. About 11 regulated health professionals will have expanded scopes of practice, including physiotherapists, dietitians, respiratory therapists, midwives and dentists, Health Minister David Caplan told the Star, adding the changes are "all about patient access to health care."

 

"It is about getting care sooner and faster," Caplan said in an interview. "A lot of this to me seems very common sense." Last November, the Ontario Health Professions Regulatory Advisory Council made a number of recommendations in a report to the health ministry supporting many of these changes.

 

But when that report was released last fall, parts of it, including its suggestion on expanding the roles of pharmacists, drew the ire of the Ontario Medical Association, which argued the practice would not be safe. But Dennis Darby, head of the Ontario Pharmacists' Association, said yesterday that a prescribing pharmacist could take the pressure off emergency rooms and doctors' offices. He welcomed the news that legislation is on its way. "It is all in the name of trying to take some of the pressure off an overburdened health system," Darby said.

 

This is a welcome step in the right direction. The healthcare system is overburdened and the public requiring attention within the system will be the winners. I see the OMA attempted unsucessfully to protect their vested selfish interests.

 

This is a small but important step for reorganization of our helathcare system.

 

Nurse practioners are important to our system, provide a valuable role and take the load off the physician while attending to the needs of patients. The training takes less time than that of physicians, is done at considerable less cost and their pay is less than physicians. It is a win/win situation.

 

Congratulations to the Premier for having the guts to make these valuable and needed changes.

[Retsage]

Only idiot premeds would argue for other professions to take over their field.

 

Pharmacists should not be prescribing.

[Guest Shim]

Only idiot premeds would argue for other professions to take over their field.

 

Pharmacists should not be prescribing.

 

Be an intelligent premed and explain why.

[A-Stark]

It really depends what they're prescribing. Beta blockers? 1% hydrocortisone? Well, ok... Oxycodone? No friggin' way. I imagine this won't apply to narcotics and it's certainly inappropriate for antibiotics.

[Jochi1543]

Only idiot premeds would argue for other professions to take over their field.

 

Pharmacists should not be prescribing.

 

Scopes of practice have consistently expanded without any damage to the work of a physician. If anything, it's allowed physicians to focus on the more challenging cases - and allow lives to be saved in the process. Take EMS, for example (picked this because I'm more familiar with EMS than other allied health professions). It used to be that all you needed was a taxi and a First Aid certificate. Today, an advanced care paramedic has near 150 drugs in her scope (varies widely among provinces, but this is the case in AB). They can suture a wound, pace a failing heart, intubate, stop a seizure, prevent death from a drug overdose, you name it. Think of all the lives that have been saved thanks to this. Even at the primary paramedic scope - it used to be that if you had a diabetic patient (that's even if you could figure out they were diabetic, because monitoring BGL was not always in our scope), all you could do was bring them to the ER, where the medical team had to do the BGL, start an IV, give D50, check BGL again,, etc. Today, all this will be done before the patient even gets to the ER, saving a ton of time for them that can be spent on something much more challenging.

[future_doc]

Pharmacists should not be prescribing.

 

Presumably, there are strict guidelines in place as to the limitations of the pharmacists increased powers.

 

And if there are abuses or unforeseen circumstances that create problems these will be addressed.

[future_doc]

Scopes of practice have consistently expanded without any damage to the work of a physician. If anything, it's allowed physicians to focus on the more challenging cases - and allow lives to be saved in the process. Take EMS

 

Jochi1543 makes excellent points.

 

This is not about prtoecting the turf of the physician, rather about protecting the public safely with limited resources. And physians can be put to better use while the interests of the public are served.

 

As volunteer EMS first responder to 911 calls, our service gets there within 3 minutes. We are not paid. The firemen and others are paid and felt we had encroached on their turf, there were political fights behind the scenes and in the open that went up to the provincial legislature, and ultimately we continue to serve.

 

It is not about power and authority, just doing the best for patients.

[n00b]

Obviously, no MDs or MDs-to-be would be in favour of this lol

[future_doc]

Obviously, no MDs or MDs-to-be would be in favour of this lol

 

I would suggest that there was a spirited debate within the medical profession, other professions within the healthcare field and those representing the interests of the citizens(voters) in our overburdened healthcare system and somehow, consensus was reached. as a future MD, I favour these improvements.

[n00b]

you would only favour it if it had no impact on your patient flow. if it decreased the number of people you saw, you'd be all up in arms

[Satsuma]

I think as long as each profession that gets these expanded roles is willing to take on the full responsibility of their act, then probably is a workable situation. But if it falls on the physician ultimately, then that could be a bad situation.

 

So the PT who orders that xray should be able to to feel comfortable with the interpretation and be responsible if anything is missed.

 

I recall in earlier threads about the pharmacists...it seemed like there was talk about them changing prescriptions or renewing and then sending a note to the MD to say what was done. Well that to me is not such a good situation. Since it would seem that ultimately it is up to the physician to then decide if that is ok or if changes need to be made...without seeing the pt and likely without any billing for that time.

 

In terms of paramedics alot of their acts are delegated. Meaning the physician at the base hospital is ultimately responsible for the acts performed by the paramedics in the field. Now as an MD who would potentially be responsible for the acts of paramedics I have never met, sort of felt uneasy when I found that out. But at least there is constant communication between the paramedics and the base hospital...and the pt ultimately ends up at the hospital and is seem by the physician...it is like one continuum of care.

 

Not sure in the cases of the pharmacist prescribing, or the PT ordering xrays or the nurse reducing fractures, there will be that continuum of care. Whenever I hear of these suggestions of expanding scope of other health care professionals...it often seems alot like fragmenting care, to me.

[NLengr]

The article says pharmacists will be able to EXTEND prescription refills, not prescribe new drugs. Two very different things. Also, I believe some provinces have a limit on how many/how long extensions can be made.

 

It's two very different situations. For example, it's one thing to extend a OCP prescription for an extra month because the girl didn't know she was going to run out. Most physicians would probably not care to much about that.

 

It's a vastly different thing to start giving out NEW prescriptions to patients or extending them indefinitely. Pharmacists don't have near the training that physicians do to work up, investigate and diagnose new illness or assess efficiency of ongoing prescriptions. That brings up legitimate safety concerns by most physicians.

[future_doc]

you would only favour it if it had no impact on your patient flow. if it decreased the number of people you saw, you'd be all up in arms

 

There is a shortage of physicians as it is. Patient flow would not be interupted, rather we would be able to take take of more pressing health concerns.

 

The Physician to Population Ratio is:

 

USA 272 physicians per 100,000 population

Canada 210

UK 250

France 340

Germany 350,

 

so there are not enough doctors in Canada, in Ontario. By protecting the best interests of our (future) patients, our best interests are being served. We cannot have dual loyalty to both ourselves and patients at the same time - it is called conflict of interest. I know primary care physicians in one large city who are unethical while playing and robbing the system, they see patients like they were serving burgers and their only interest in their own financial bottom line. They miss serious patient problems and let the occasional patient die (one such patient was a relative of mine). These doctors should get caught and drummed out of the profession.

[A-Stark]

Pharmacists should not be prescribing in general. It's not their role or their job or part of their training. Doing some training as a student pharmacist in the community pharmacy (i.e. running the cash register at the pharmacy counter) doesn't cut it.

 

I just saw an ad for naturopathic "doctors" on TV. Naturally (no pun intended), it featured the usual images of nature combined with nature sounds and some vague testimonial playing up the the non-pharmaceutical approach. As my pharmacology lecture this afternoon reiterated, the following are common myths:

 

1) Natural Health Products are natural and not really "drugs"

(many drugs are derived from antural products, e.g. digitalis, morphine, atropine)

2) Natural Health Products cannot harm, only help

(active agents with risks, and drug interactions)

3) Natural Health Products have been used for centuries, therefore they must be safe

(one source of evidence; need MCTs)

 

So, to follow along these lines, what are the evidence-based justifications for expanded scope of practice for pharmacists, NPs, and PTs? Future_doc, instead of bashing the "selfish" MD associations for supposedly engaging in turf wars, I'd ask that you consider some actual arguments why these developments make sense. Advantages *and* disadvantages, please.

[A-Stark]

The article says pharmacists will be able to EXTEND prescription refills, not prescribe new drugs. Two very different things. Also, I believe some provinces have a limit on how many/how long extensions can be made.

 

It's two very different situations. For example, it's one thing to extend a OCP prescription for an extra month because the girl didn't know she was going to run out. Most physicians would probably not care to much about that.

 

It's a vastly different thing to start giving out NEW prescriptions to patients or extending them indefinitely. Pharmacists don't have near the training that physicians do to work up, investigate and diagnose new illness or assess efficiency of ongoing prescriptions. That brings up legitimate safety concerns by most physicians.

 

Fair enough. But I trust you can see the problem with extending prescriptions for narcotics. Those might be excluded though.

[classA]

There is a reason why MD's are educated for 13 years after high school. Medicine is complicated. Each patient responds uniquely to different diseases and drugs. I would not trust a pharmacist, nurse, physiotherapist or anyone else over a doctor. Signing a bill into law doesn’t vamp up a pharmacists or nurses education anywhere close to an MD's.

It’s funny how McGuinty says this is in the public’s best interest. OPEN UP YOUR EYES PEOPLE HES TRYING TO CUT COSTS!!!!! He doesn’t care how qualified any of those who will receive new authority are, he’s just trying to save a buck and disguise it as an improvement to health care. Don’t be a sucker and take the bait.

[Alex2]

There is a reason why MD's are educated for 13 years after high school. (...)

So we can say that if the prime minister want more doctors, it will take 13 years to start getting results. What he can do to help now is to give more power to other health professionals. There is just no other way. Doctors cannot take more overtime, they cannot give less time by patient if they don't give chores to other people, etc.

[sethy]

As somebody who is currently finishing my training to be an allied health professional (PT), I have had the opportunity to follow the development of the extended scope proposals for the past couple of years. I know for a fact that several (I don't know the details for all of the professions) of the professional associations and colleges have been pushing for this extended scope for a long time now and have had to plan and re-plan how they will work to educate their clinicians to safely fulfill their responsibilities. New grads will not be able to suddenly do things that they are not trained to do. Rather, some sort of additional courses/qualifications will have to be completed. The associations and colleges are not going to let their members easily screw this up - everybody has worked too hard to finally get their scopes extended.

 

As for comments such as "I would not trust a pharmacist, nurse, physiotherapist or anyone else over a doctor", please consider that a physician's knowledge is not all-encompassing. As a quick example, family docs get a total of somewhere around 10 weeks of mandatory training in musculoskeletal education during med school/residency. Physiotherapists receive between 16 and 20 months of MSK education. If I have a MSK injury there are only 3 people I would consider seeing: a physio - who can assess me in 24-72 hours, or an orthopedic surgeon - who can assess me in 3-6 months, or a physiatrist - if anybody actually knew where I could find one.

 

Edit: One more comment from the physio perspective. I don't really understand the concern about physios interpreting xrays. While it is obviously a good idea to be able to interpret the tests that you are ordering, ultimately they will be doing the exact same thing that a GP will be doing - namely, reading the radiologist's interpretation. There is one major difference though - a physio can actually perform a proper physical exam to decide whether the imaging matches the clinical presentation.

[future_doc]

what are the evidence-based justifications for expanded scope of practice for pharmacists, NPs, and PTs? Future_doc, instead of bashing the "selfish" MD associations for supposedly engaging in turf wars, I'd ask that you consider some actual arguments why these developments make sense. Advantages *and* disadvantages, please.

 

I do not have any 'evidence-based' arguments nor is it my mandate to reinvent the wheel. I would presume there is not solid evidence to justify the implementation of such a plan, rather it is the consensus of all interest groups, including the medical association and the public that this move forward while being carefully monitored.

 

The advantages of this plan are those set out in the Article and the potential disadvantages (unlikely) can be tragic in a worst scenario. It is an honest attempt by government in consultation of all interested parties and taking into account risk:reward factors to make a better use of limited resources of manpower, health facilities and money so as to give better and faster service to patients and allow physicians to use their time to best advantage. Change carries with it its own risks and it is a matter for the power structure to decide whether the risks are worthwhile. As patients' lives are involved, the public has been consulted and approved.

 

Regarding turf wars, I know of such matters in another province where a powerful medical association influenced the province to change certain of their rules regarding how patients are dealt with by one specialty group. The immediate effect was to restrict timely treatment to patients and to cut off the feet of many practitioners in this specialty who had to close offices (while continuing to pay rent) because of the rules. There was a financial windfall from this change that benefited powerful members of this medical association in their own practice.

 

Doctors are good guys who mostly wish to serve their patients to the best of their ability. However, there exist those rotten apples, a small minority, whose agenda is not for the protection of patients as their priority, rather it is to play the system to their own financial gain.

[da_birdie]

Regarding turf wars, I know of such matters in another province where a powerful medical association influenced the province to change certain of their rules ...

 

Doctors are good guys who mostly wish to serve their patients to the best of their ability. However, there exist those rotten apples, a small minority, whose agenda is not for the protection of patients as their priority, rather it is to play the system to their own financial gain.

 

What about the powerful naturopathic association/health foods lobby in BC that influenced the province to change certain of their rules, despite the opposition from BCMA/CPSBC - which in the laypeople's eyes may be deemed as selfish, money-driven and turf-hogging?

 

Well, consider yourself fortunate that, for now, "naturopathic physicians" seem to be missing in the list of allied health professions expanding their scope in Ontario.

[Satsuma]

Edit: One more comment from the physio perspective. I don't really understand the concern about physios interpreting xrays. While it is obviously a good idea to be able to interpret the tests that you are ordering, ultimately they will be doing the exact same thing that a GP will be doing - namely, reading the radiologist's interpretation. There is one major difference though - a physio can actually perform a proper physical exam to decide whether the imaging matches the clinical presentation.

 

I would be careful of what you say. If all a PT will be doing is reading the radiologists interpretation of an xray...then they clearly should not be ordering that xray.

 

It is great that you have such respect for your own profession. It would be nice if you could have some respect for physicians including family physicians...who may have even done a fellowship in sports med.

[sethy]

I would be careful of what you say. If all a PT will be doing is reading the radiologists interpretation of an xray...then they clearly should not be ordering that xray.

 

It is great that you have such respect for your own profession. It would be nice if you could have some respect for physicians including family physicians...who may have even done a fellowship in sports med.

 

Sorry, I thought I was being careful by saying that physios would be using the radiologists interpretation in conjunction with a full assessment.

 

I have enough respect for family physicians that it is a career that I am hoping to pursue very soon. I am well aware of the incredibly important position that family doctors have within our healthcare system and am in no way trying to show them disrespect. I was responding to comments by previous posters regarding physios interpreting xrays and suggesting that physicians should be the most trusted of all health professionals.

 

The point about physicians with sports med fellowships is well made. Unfortunately, such professionals remain few and far between in most communities.

[tree999]

There is a reason why MD's are educated for 13 years after high school. Medicine is complicated. Each patient responds uniquely to different diseases and drugs. I would not trust a pharmacist, nurse, physiotherapist or anyone else over a doctor. Signing a bill into law doesn’t vamp up a pharmacists or nurses education anywhere close to an MD's.

It’s funny how McGuinty says this is in the public’s best interest. OPEN UP YOUR EYES PEOPLE HES TRYING TO CUT COSTS!!!!! He doesn’t care how qualified any of those who will receive new authority are, he’s just trying to save a buck and disguise it as an improvement to health care. Don’t be a sucker and take the bait.

I guess I'm just curious about this point. What exactly is wrong with trying to cut costs in the health care system? Current spending is unsustainable, and if it continues, there's no way to maintain our current single-payer public insurance system. Being cost-effective doesn't have to mean a sacrifice in quality or safety of care -- that's pretty narrow-minded. What about introducing an electronic patient record to reduce administrative costs associated with paper-based systems? Is that so bad? Changing the scope of practice of NPs and pharmacists is a long-time coming, and already exists to varying degrees in other provinces. There will continue to be other major changes in health care in the future in an effort to be more efficient, and I think anyone working in the health field has to be flexible and responsive to those changes.

[future_doc]

Increased use of technology, innovation, collaboration of professions in the healthcare field and cost costing measures are necessary, here to stay and certainly are not the end of the world. Every step along the way has been in the pipeline for quite some time and is taken only after consultations with advocacy groups representing all professions/points of views, including those representing the public interest.

 

As Tree999 says, "There will continue to be other major changes in health care in the future in an effort to be more efficient, and I think anyone working in the health field has to be flexible and responsive to those changes."