Focussing on Physician Compensation is Dysfunctional

There are a large number of economists (and others), that simply believe that the reason healthcare is so expensive, is that doctors and nurses simply make too much money and need to be paid less for the services that they perform.

Not surprisingly, those who believe this are not incredibly popular with either physicians or nurses.

After all – telling people, professionals who have dedicated their lives to the industry, and are the suppliers of the vast majority of healthcare services, that they make too much money sends some very disengaging and negative messages. It sends the message that the work done is not valued. It sends the message that the suppliers of healthcare, themselves, personally, are responsible for the high-cost of healthcare and are responsible for the lack of financial sustainability of the system. It sends the message that the suppliers of healthcare (physicians and nurses) lack integrity and are out to fleece the public. It is a direct and very personal attack.

Worse than that, it likely works against the very things the healthcare system really does need – workforce engagement and innovation. It works against aligning the interests of those supplying healthcare with the interests of those in need of healthcare – the users of the healthcare system. It distracts from focussing on the things that really do matter and solving those problems collaboratively.

The things that really do matter are supplying enough healthcare services of a high-quality so that there is little or no unmet need (unnecessary disability, death and suffering) while constraining public expenditures to a financially sustainable level. That is the problem that needs the focus, adequately meeting the health needs of the population. That is the problem that needs to be solved – and solving it will require collaboration – and innovation. It will require physicians and nurses and patients and governments to shift their thinking away from the 1,000s of things that are essentially “red herrings”, things like physician compensation to the things that are actually worth focussing on.

Should the public care if a physician earns $1.5M per year or should they care that as a result of that $1.5 Million as much “health” as possible was bought. Which is a better investment? Paying 20 doctors each a $75,000 a year salary or one doctor $1.5M? It depends, are the doctors equivalent in skill or in productivity? Are the services provided to those who would benefit the most from the services? If the $1.5M doctor has innovated and delivers more health than the 20 other doctors combined, she or he might represent excellent value for money. The cost of a unit of health bought from the expensive doctor might be less than the cost of a unit of health bought from the group of 20 other doctors. Further, the “out-of-public-pocket” cost of Dr. A might be significantly less, as he would face a high rate of taxation on the income they earn.

Unfortunately, the way the system is currently structured, there is no incentive to maximize the amount of health (or conversely minimize the pain and suffering) that is bought with the money available. The price of procedures is standard – the fee for an office visit is the same regardless and there is no price flexibility to account for circumstances of either the physician or the patient. As a result a variety of worrying problems emerge. There are physicians who would like to be working – who might even consider working for less than the standard fee who are barred from doing so and go unemployed. There are patients in need of health services who have unmet needs – patients who might be willing to pay above the standard amount to get access to care - but they too are barred from doing so. There are no market mechanisms to assist in matching the supply of health services with the demand for health services.

Further, there is little incentive to go above and beyond or to provide services that truly meet the needs of the patients served. There is little incentive to provide enhanced services (aside from some personal motivation to do so) – services that set one provider apart from another or might even avoid the use of health services. Technically speaking, the provider who minimizes the use of health services by their patients, does so at the expense of their own income. Technically speaking, the provider who makes his office nicer, also does so at the expense of their own income. Technically speaking, the things that most enhance health for some individuals, might not even be health services – but might be problem solving (ie. Finding adequate housing).

Which speaks to the really, really big problem. The focus is not on maximizing health, or minimizing suffering. It’s about making the providers technicians rather than leaders and the patients throughputs rather than partners in health. The system is hierarchical not collaborative – it is resistant to change, and focussed on the wrong things.

Mrs. Sophie Gregoire-Trudeau Shared a Story with Me, So I Shared a Story with Her

Dear Mrs. Sophie Gregoire-Trudeau–

You sent me an email and shared with me a story about helping a new Canadian mother through a difficult birth – but how she was happy that her baby was going to be a Canadian. That you loved this story because it reminds you to “cherish your identity as a Canadian,” and “how lucky we are to live in a beautiful country, and share it with such generous and caring people.”

Can I share a story with you?

Let me share with you the story I’ve heard time and time again about new mothers giving birth to Canadians in Canada and being left with substantial medical bills. Let me share with you the story about new mothers giving birth at home or in hotel rooms out of fear of the substantial medical bills a hospital birth will leave them with. Let me share with you the story of those mothers enduring substantial pain because they fear the cost of an epidural. Let me share with you the story of mothers foregoing prenatal care because of its cost. Let me share with you the story about how we neglect the prenatal and birthing care needs of those women. Let me share with you the story of how these women and their infants face a 7 fold increase in infant and maternal complications, including death.

Who are these women who are uninsured? These women are the wives and partners of Canadians who are waiting for their permanent residency to be approved so that they can be eligible for Canadian health insurance. These women are refugees. These women are temporary workers and visitors to Canada whose visas have expired. Some of these women are future Canadians. These women are mothers to Canadians – Canadian babies who are denied free access to care they need while in utero and during birth because their Canadian parent happens to be their father instead of their mother or because their mother is newly arrived in our country. These are Canadians whose parents face substantial medical bills due to their births, bills that might have deep impact on their family’s ability to provide during their early years.

I hate this story, this story that I’ve heard time and time again. I hate that it reminds me of how we currently deny access to the best possible beginning to the most vulnerable Canadians – newborn babies. I hate that it demonstrates a lack of compassion, a lack of caring and a lack of generosity. Your email asked me for a donation to the Liberal Party – in support of its bid to become the next governing party.

I want to see a government elected that shares progressive values. I want to see a government that cares for the most vulnerable citizens – newborn babies. I want to live in a county where all mothers can put the best interests of their children first without fearing the financial repercussions of accessing appropriate medical care during pregnancy and childbirth. Will the Liberal Party of Canada do that? Will they commit to providing free access to medical care for all pregnant and birthing mothers in Canada, even those who are uninsured? Will they step up to the plate and demonstrate leadership, caring and compassion on this issue?

Before I consider donating, I’d like to know the Liberal Party of Canada’s position on this issue and what steps it plans on taking should it be elected to ensure the health and well-being of all new born Canadians and their mothers.

Sincerely,

Janice Williams

Background Stories and Information:

http://thetyee.ca/News/2014/03/21/Uninsured-Moms/

http://www.cbc.ca/news/canada/british-columbia/red-tape-leaves-expectant-b-c-mom-with-no-medicare-1.2638068

http://www.ncmn.ca/Resources/Documents/Plenary%20_1%20-%20CTAC%20Paul%20Caulford%20Sept%2026%202013.pdf

http://www.citynews.ca/2013/02/16/hamilton-mans-fight-for-maternity-care-for-wife-exposes-gap-in-canadian-system/

Transformative Change: The Carter Decision

This past week the Supreme Court of Canada unanimously decided that the provisions of the Criminal Code that prohibited assisted suicide were unconstitutional and should be struck, giving the federal government and the provinces a year to enact legislation with respect to assisted death. The impact of this decision should not be underestimated - as much of what was articulated has implications for not just how people approach death, but also for the healthcare system, the legal system, and cases that have yet to be decided in the years to come. Make no mistake, the Carter decision is a profound decision that is a landmark of profound changes in the years ahead.

The legislation and regulations that provinces and the federal government develop to govern assisted death will determine who is permitted to assist in a death, the circumstances that must be met, and whether or not it is to be publicly funded as an insured service. The only requirement is that whatever legislation and regulations that are developed conform to the requirements of the constitution, or risk being struck down in the course of time.

It is difficult to predict how accessible or how popular assisted death will be - however, it is not difficult to predict that the removal of the ban on assisted death is a big shift in the landscape, and will likely be a transformative change in and of itself, and might be the start of a set of substantial and transformative changes. The decision was an affirmation of patient autonomy - an affirmation of a competent, adult individual's right to decide what happens with their body and to make medical decisions for themselves, even when the consequence of those decisions is certain death. To endure the suffering associated with many devastating diseases and the end of life will no longer be an obligation thrust upon victims, but rather a choice that is made by the individual after consideration of their own needs and circumstances. It is a shift away from a kind of paternalism towards individual autonomy, towards respect for what is an incredibly personal experience.

It is also a shift towards a more sustainable health system (as of this week all forecasts of demand for health resource use should be considered obsolete). Upwards of 25 percent of all health expenditures are made within the final 12 months of life - the provision of palliative care services, residential care services, and home care services have been widely acknowledged to face considerable challenges in the years ahead. The availability of assisted death will alleviate demand and reduce the amount of resources spent on the final months of life. Those electing assisted death, may enable those electing to endure better access to palliative care and other resources. Further, those electing assisted death might be able to choose between spending their wealth on longterm care or preserving it for their estate. However, given the strong incentives that both the government (as sole provider of health services) and perhaps individual's own family's may have in encouraging assisted death - it will be of tantamount importance to enshrine protections against being coerced into accessing assisted death services. Indeed, assisted death will not only be a new area of medical practice, but also a new area of legal practice.

Further, there are profound implications for future litigation concerning the health system. Specifically, the litigation that is currently underway in the Cambie case in British Columbia. If it is unconstitutional for there to be an outright ban on assisted death, how is it constitutional for there to be an outright ban on privately purchasing access to health services that enhance quality of life? If failing to provide access to death, infringes upon security of person and an individual's right to autonomy - then surely relegating people to waitlists or denying access to health services altogether must also be an infringement on Charter Rights. It would be sadly ironic, if assisted death is determined to be a "medically necessary" health service and insured by the provinces, that those who have fought hard for the right to die with dignity might suffer the indignity and the frustration of that right by finding themselves imprisoned by the shortcomings of the healthcare system.

Her Name Was Veronika

Maybe it was an accident.

Maybe she went to the bridge to think, to reflect – and while she was there, maybe she started to fall asleep, having been sleep deprived for a little too long, maybe she just nodded off; falling to the waters below – not intending to be there.

Or maybe there were other reasons, and one thing led to another, which led to her being in the frigid waters with her seven-month-old son. That led to her death, and his clinging to a life that has only just begun – his father keeping vigil while grieving her death.

The Coroner’s office is investigating.

The question that needs to be answered is: What needed to happen, that did not happen? What needed to happen, that would have led to some other reality? The reality in which a boy has his mother, a father has his wife, and they get through the now – the incredibly exhausting present of having a very small child. The different reality where a small child is not fighting for a life that has only just begun – a life that now will bear no resemblance to what could have and should have been.

What needed to happen, that did not happen?

Would a solid night's sleep and a shower have made a difference?

Would less judgement about whatever choices had been made, made a difference?

Would simply knowing who to call, and where to go have changed the outcome?

This is an unnecessary and tragic loss of life – and should renew the call for Canada to do better. Over a year ago, Kirsten Patrick, then deputy editor of the Canadian Medical Association Journal pointed out that in other countries maternal deaths are analyzed on a case by case basis to identify contributing factors, and that such an approach does not happen in Canada.

Will this mother’s death serve the only purpose it can? Will it be looked at and analyzed – to determine what needed to happen that did not happen, to determine how we could possibly do better?

Will this baby, and this father – who now have suffered her loss be adequately supported going forward?

Are we doing enough right now? Really?

Moms matter. This mom mattered. Her loss is tragic, regardless of the underlying cause.

BC Provincial Policy Intended to Ensure Quality Care Likely to Erode Quality in BC

There’s a pretty big policy change on the horizon of the healthcare system in British Columbia. One that most patients are probably not remotely aware of, that is likely to have sizeable, and foreseeable, albeit unintended consequences that might well result in achieving the opposite of what was intended. One that might make our already access strained system, even more painful, one in which both patients and the providers being impacted may not have been adequately consulted, and one that is likely not as evidence driven as it should be.

In the wake of a health-system scandal in 2011 involving 4 radiologists in British Columbia, where 12 British Columbians had their treatment delayed or were misdiagnosed and three of those patients died, where thousands of diagnostic images were suspect, British Columbia sought to improve the system by which doctors are licensed, credentialed and given privileges in order to safeguard patients. The policy response included the Provincial Privileging Standards Project an overview of which can be found here. With a blog about the project being established here. The stated goal of the Provincial Privileging Project was to create discipline specific privileging dictionaries along with criteria required to apply for and maintain those privileges for all medical staff disciplines in the province. Not a goal I'd choose for a major policy project, but it is certainly attainable.

The dictionaries would establish the set of procedures and activities a doctor would be permitted to perform based on that physician’s credentials (degrees and post-graduate training already completed), currency (the level of current experience the practitioner has in the activity), and context (the ability of the facility in which the doctor practices to support the procedures and activities). My understanding of how the dictionaries have been developed is that 28 expert “panels” have been established for each specialty with each panel consisting of two or more senior practitioners in each specialty who have delineated all of the activities undertaken in each specialty and have established “core activities” and “non-core activities” for each specialty along with the amount of recent experience in the procedures and in general practice that the expert panel felt would be required to maintain competence in undertaking the services. The physician would be required to request and demonstrate that they meet the qualifications to acquire privileges, and if they were lacking in any area there would need to be a “conversation” about it.

Providers have publicly voiced concern over the pending policy change as illustrated by a recent article in the BC Medical Journal. Provider’s are concerned that the currency standards that have been established have not been shown to demonstrate competency or procedural safety based on sound evidence and that the new dictionaries will ultimately lead to a loss of access to medical services.

In response to the criticism raised the champions of the project replied in a subsequent article . The reply to the concern expressed is that providers are being unjustifiably fearful of the policy change, that failure to meet a standard in the dictionary will merely merit a “collegial” discussion, that they understand that there is a difference between currency and competency and that there was wide consultation with 56 expert panels being established along with collaboration with administrators, and that they recognize that the dictionaries will need to be updated on an ongoing basis.

This policy change is fueled by the best of intentions (to safeguard patients) – however, patients and providers are right to question whether or not the policy will safeguard patients (at all) and to consider the full impact the policy may have on the healthcare system. Was consultation broad enough? Are the standards evidence based or are they arbitrary? What will happen to access to medical services as a result? What is the cost of this new tool and its maintenance and are there other policy tools that are likely to be more effective and less costly? And perhaps most importantly, will quality of care that patients receive actually improve?

Disturbingly, it appears that patients have not been included in the development of this policy. Disturbingly, it appears that including a few members of the specialties involved is considered “broad consultation”. Disturbingly, it appears that the standards that have been set are arbitrary in that every practice and procedure is to be included in the dictionary, whether or not there is clear evidence that volume of service delivery or experience has any clear link to quality or safety. Disturbingly it appears as though concerns with the policy are being brushed off as merely fearing change.

This policy will not improve transparency or shared decision making between patients and care providers. This policy will not improve the recourse patients have when they experience medical error. This policy will not encourage innovation in the delivery of medical services. This policy will not identify providers that have patients that experience qualitatively or quantitatively bad care – it will not monitor clinical performance. By and large this policy appears as though it likely will reduce the number of providers that are available to provide services to the public and will increase the amount of bureaucracy in the system. It appears that patients might well be told they can’t have access to a medical service at all, rather than have access to the service provided by someone who is overwhelmingly likely to be able to provide the service safely.

Quality care and public confidence is critical to the system, but we’d be foolish to think that the “Provincial Privileging Program” is going to effectively advance quality in the British Columbia healthcare system. Policies that are implemented with patient safety and patient confidence being the goal should be robust and subject to scrutiny by providers and patients. Knee-jerk responses to critical lapses in the provision of quality care should be avoided as they may be very expensive responses that fail to meet the goals that matter. If you think access to care in British Columbia is bad now, just wait, things could get substantially worse.

The Great Tale of How I met Mr. W - But is it Prize Winning?

I submitted the tale of how I met my husband to a contest with the Vancouver Observer and it made it to the top 5 - it'd be fun if it won - so I'd like to ask my readers to check it out and vote at the following link on Facebook.

Little in the Canadian Healthcare System Fosters Patient Centred Care

To be blunt, there is little about the Canadian healthcare system and how it works that fosters and encourages patient centred care, and there is much about it that stymies efforts to develop and deliver truly patient (or family) centered care. Much of how the system works is even in direct conflict with improving health outcomes. As a result, we have a system that is relatively expensive, while performing poorly particularly with respect to measures of access to healthcare services.

This might seem to be a harsh criticism of a system that is held in high regard by many Canadians (many of whom are actually non-users of the system, and so may hold beliefs about it that are in stark contrast to the realities faced by actual patients). However, there are a number of critical ways in which the system hinders the development and delivery of patient centred care.

A patient centred system would be accountable to patients for the services that are delivered. The reality is that there is little meaningful accountability. Currently, the only avenue for patients to be compensated for harm caused by the medical system (either by medical error or negligence) is to pursue a medical malpractice claim. Sadly, doing so is often a tale of David and Goliath, where the harm caused by the error or negligence must be very significant and the evidence exceptionally clear in order to merit the substantial resources needed to pursue the claim. In part this is because of a medical protective association that seeks to aggressively defend every claim that is made, and as a result many meritorious claims are never pursued and many patients never receive compensation for the harm that they have suffered. Absent compensation for harm caused, the other avenues for accountability include the Patient Care Quality Offices, the Colleges of Physicians and Surgeons across the country, the media and patient advocacy groups. Sadly, as a result of their limited powers to remedy the harms caused, many patients with poor experiences never have their voices heard as the cost of doing so simply exceeds the expected benefits. In the Canadian system patients are not even routinely surveyed about their experiences of care and outcomes. As a result, there is likely a large under reporting of poor experiences of care or outcomes. A no-fault compensation system similar to what exists in New Zealand would be a meaningful step in the direction of patient centeredness.

A patient centred system would reward care that meets the needs of patients and penalize care that fails to meet the needs of patients. The reality is that the doctor who makes a patient make 3 appointments (one for each issue needing to be addressed) gets paid more than the doctor who accommodates a patient’s need to have your appointments consolidated or who spends a bit more time with a patient to ensure questions are adequately answered, or who provides access to information before the appointment so that the patient can come prepared. The reality is the doctor who forces his or her patients to come into the office has an advantage over the one who is open to being available via email or phone to address minor concerns. The reality is that there is no incentive for a doctor to go above and beyond – because at the end of the day they will be paid exactly the same (or worse) as their colleague who does the bare minimum. Further, given the relative scarcity of doctors, patients who are dissatisfied with their care are often trapped between a rock and a hard place, where the choice is a doctor with whom they are dissatisfied with or no doctor at all. There is no reason for doctors to actually care about whether or not their patients are happy (except for the intrinsic desire to deliver good service) or to solicit feedback from patients about the care that was received. There is no reason for doctors to be innovative in order to set themselves apart from their competition. At the end of the day the doctor who delivers the most services (regardless of the quality of services delivered) takes home the fattest paycheque. There might even be a disincentive to actually improve the health of patients, as healthy patients do not see doctors and absent service use, there is no pay. Further, many doctors are in a conflict between serving the interests of their patients and serving the interests of the broader healthcare system.

A patient centred system would be transparent. Medical records in this country are often held for ransom (it is not uncommon for doctors’ offices to charge fees to patients if and when they change doctors to transfer the file to the new care provider). Test results and referral letters are rarely communicated or shared directly with patients absent an office visit. Few patients have care and control of their medical information. In order to gain access to information about our bodies, a referral for tests or imaging is needed. Data about the system is often hoarded and the metrics that are publically available are carefully scrutinized to limit the amount of potential political fallout that might result from their publication. Patients are largely kept in the dark about things that critically impact their lives such as hospital policies and practices or even the expected amount of time that they will wait before gaining access to the care that they need.

A patient centred system would be truly comprehensive and co-ordinated. A lot has changed since medicare started – including the options for treatment of many conditions. Pharmacological care, dental care and optometric care are all excluded from the publicly funded system. Not to mention many para-medical services including those provided by psychologists, massage therapists, physiotherapists, chiropractors, nutritionists, and others. Further there is limited communication between different care providers and navigating the system as a whole is often a daunting task for patients.

A patient centred system would respect patient choice and patient autonomy and recognize that different people value different things. There remains a culture of paternalism in medical care. As an example the approach to maternal request caesarean in Canada – where many Canadian women have difficulty accessing the care they desire. As another example, the prohibition against the purchase of medically necessary care means that the supply of care and access to care is regulated regardless of patient preferences.

There is considerable reason to believe that a system (similar to that in many European countries) that allowed for privately funded medically necessary healthcare services in addition to more comprehensive publicly funded healthcare services would be more patient centred than the current system.

However, absent significant changes and considerable courage on the policy front – patient centred care in Canada will happen in spite of the system because of those driven by a higher purpose to make the lives of others better rather than because of it.

The McNeil Report - Condition Critical at the BC Ministry of Health

Health is a mission critical portfolio in government - it consumes two out of every five tax dollars spent in the province of British Columbia and faces incredible challenges in the years ahead as increased demand for health services taxes the resources available to meet those demands. It is not trite to say that in order to have a health system that meets the needs of those living in this province, the organization that is responsible for leading the entire healthcare system can not be dysfunctional. Organizational failure at the Ministry of Health will have critical consequences with respect to the Ministry's ability to meet the demands of its mandate. Even an organization that is marginally functional will result in tremendous opportunity costs moving forward. The Ministry needs to be an organization that exemplifies high performance - it needs to demonstrate the kind of culture and workplace that delivers exceptional results for the resources that it has at its disposal. It needs to be a place that attracts (and retains) the best and brightest - a place where that talent is recognized and used to its full potential. A place where people are supported to be their best.

As such, anyone who reads Marcia McNeil's report into the 2012 firings at the Ministry of Health should be deeply concerned and worried about the organizational health (or lack there of) of the Ministry - and the scars that remain from those events. Anyone who reads that report, should be asking themselves about the current state of the organization and its culture. Should be asking about the critical work that needs to be done to repair and rebuild to get the organization from where it is at (after an honest assessment about where that may be), to the place where it needs to be.

The McNeil report paints an awful picture of an organization that lacks integrity. It paints a picture of an organization that prematurely comes to conclusions and then goes on a hunt for the evidence to support those conclusions. It paints a picture of an organization that intimidates those who work for it. It paints a picture of an organization that will do anything to appease the public, even at the expense of its own people and its ability to do the work it must do. It paints the picture of an organization that is reluctant reflect on its own actions and take actions to repair the damage. It paints a picture of an organization, where people point the finger at other people, rather than be held accountable for what was done. It paints the picture of an organization with a culture of "fear and anxiety".

Now ask yourself, is that the kind of organization that is going to attract and retain the best and brightest? Is that an organization that is going to empower its people to do what needs to be done - to speak up when something needs to be said? Is that an organization capable of handling conflict? Is that an organization that will drive engagement? Is that an organization that is going to be high-performance? Is that an organization that exemplifies leadership?

The McNeil report has been criticized for being too narrow in scope - for failing to answer the critical questions of who made the decision to terminate and why. It is true that there are a lot of questions that remain unanswered (questions that deserve answers and an independent inquiry). However, the picture that is painted by the report should not be ignored for what it does show is a horrifying scene of an organization that is in need of drastic intervention, an organization that is in critical condition.

Sometimes a long, hard look in the mirror and an honest assessment about where things are at is all that is needed to start on the road to a better place. Sometimes much more is needed.

From Flubber to Firm - Hopes for 2015

I had hoped that by this time I would be preparing to venture on a new chapter in my life career wise. That I would be aligning who I am with what I do. That my plans for the months ahead would be more concrete - and that I would be excited about the work that was to come in the months ahead.

It is not that steps have not been made, they most certainly have - but that rather than the concrete I had hoped for, I have flubber (for those who do not know, flubber is a Newtonian solid made of school glue and a mixture of water and Borax, in short homemade silly putty). I have to accept that getting to a place where I do good work, that matters (and for which I am paid adequately) - is more of a process. I have to accept that going from where I am at, to where I ultimately want to be will take more. More time. More blog posts. More learning. More relationship building. More thought. More patience.

As such, I have been trying to make the most of where I am at. Identifying the bits and pieces at work that I can work towards changing (and working towards those changes), giving voice to what might otherwise go unheard, and doing good work, even when there are significant barriers to doing so. I know that in the long run, I likely will not remain where I am at - and hopefully by next New Years I will be several steps closer to where I want to be in my career (or perhaps will have made that next step a reality). I am also hopeful that when I leave where I am at - that maybe as a result of the things I do between now and then that I will have contributed to rebuilding a better workplace than the one that welcomed my return from maternity leave in September 2013.

What 2014 has brought is clarity - a clarity of purpose, and clarity around what the next chapter of my work life might look like. Clarity around the things I need in order to be satisfied with the work I do. Clarity around the things that seem to be causing me dissatisfaction.

So as I look forward to 2015, I am still excited about the work in the months ahead (work outside of work, and work at work to rebuild a better workplace). I will spend 2015 doing the more that needs to be done and perhaps when 2015 draws to a close, I will be starting that new chapter in my life career wise. A chapter that aligns who I am with what I do, a chapter filled with purpose, a chapter focussed on doing good work that matters, that makes the time spent working time that is well spent.

On Dr. Danielle Martin's 3 Big Ideas

I actually think that Dr. Martin and I might have a lot in common. We are both passionate about healthcare. We both believe that Canada’s public health care system could do a lot better when it comes to serving the needs of Canadians who rely on it. We both believe that timely access to medical care should not be reliant on a person’s wealth. We both believe that social determinants of health (things like income, education and housing) drive health outcomes and the use of the healthcare system – and that by addressing those issues significant improvements in the health and well-being of Canadians could be realized. We are both young women with well-informed opinions (hers developed in the context of being a physician and my own developed as a result of being a health economist and first hand experiences as a patient) and a willingness to debate those opinions publicly.

Dr. Martin believes that a single-payer system that has a monopoly on medically necessary care is critical. Further, she believes the system could be salvaged if just 3 big ideas were implemented – National Public Drug Coverage, Less is More, and a Guaranteed Income Supplement.

In contrast – I have come to the conclusion that the single-payer system and how it is structured is a very big part of the problems that seem endemic to our system and that no idea is “Big Enough” to salvage it, and absent structural change that the most promising “Big Ideas” are simply not feasible. I believe there’s a reason why every other first-world country in the world with a universal public health system that out performs Canada’s also has a parallel private system that also provides medically necessary care. Single-payer is simply one of those ideas (like communism) that is nice in theory, but in practice and in the context of a complex reality fails to deliver the best outcomes and leaves many suffering the very real consequences of the system’s inadequacies.

Dr. Danielle’s first “Big Idea” is National Public Drug Coverage for the top 20 drugs used to treat chronic conditions in Canada. It is nothing short of shameful that Canada does not include pharmaceuticals as part of its public health system – particularly given that pharmaceutical therapy has become the cornerstone of effective medical care for many conditions. It is also shameful that the approach to pharmaceutical policy in Canada is a provincial/federal/territorial patchwork quilt. It is true that bulk buying the most common drugs would save the system money, and that providing access to those drugs would likely improve adherence among those for whom cost is the primary reason for lack of treatment adherence. National coverage of the top 20 pharmaceuticals would be a good start.

However, that is all this particular “Big Idea” is; a start. It is nowhere near big enough to actually remedy the larger problems and the larger reality that Canada’s health system is a patchwork quilt of practice and policy that is far from comprehensive. The fact that Canada runs more than a dozen different health systems (each province and territory effectively administering its own system, plus the systems run to address the needs of first nations, prisoners, members of the military, etc.) – is a massive waste of resources in and of itself. Further, while the lack of pharmaceutical coverage is lamentable, other big voids include the absence of coverage for dentistry and the services of many para-health professionals (psychologists, chiropractors, massage therapists, physiotherapists, etc.) and the absence of comprehensive coverage for long-term care. If we want a public health care system that is truly functional and comprehensive – the multitude of public systems would be collapsed into a single federal entity, and the system would be expanded to be truly comprehensive in nature to include pharmaceuticals, the services of para-professionals, and long-term care.

Dr. Danielle Martin’s second “Big Idea” is less is more. This idea is aimed at limiting the number of tests and procedures that are of questionable value or duplicative in nature. In retrospect there are a lot of things that happen in the health system that prove to be of little value, in retrospect there are things that are done that perhaps should not be done. In a perfect world – and even in this imperfect world, it is hard not to say that doing some things less would save the system money and not result in worse outcomes, in some cases, doing less might even result in better outcomes (for example the prescription of unnecessary antibiotics that lead to resistant strains of bacteria). This idea is alluring in its simplicity and echoes the environmental movement to reduce, reuse, and recycle in order to stretch what is available to the limit of its potential.

However, the idea of “Less is More” is deserving of scrutiny, particularly in healthcare. Born out of “Less is More”, are care protocols that exhaust conservative options first, denial or delay of access to diagnostic testing and denial or delay of access to treatment. The first thing to understand, is that healthcare decisions are not made retrospectively. There is no “way-back” machine to turn back time and make a different choice if the choice made proves to have been the wrong one – and for some the “less is more” will exact a terrible human toll. Further, patients are a diverse group of individuals with a diverse range of preferences and a diverse tolerance of risk. Not all patients want to wander through the conservative options first. Not all patients are going to be satisfied with denial and delay of access diagnostics or treatment. “Less is More” as a philosophy has the potential to deprive patients of informed choice and decision making with respect to their own bodies and has the potential of moving the system further away from being patient centred. Too many patients in Canada have already borne the brunt of “Less is More”, of having doctors put the needs of the system ahead of the needs of the patient – and absent any alternative route for patients to access, seems like an unjust infringement of rights that should be contested.

Dr. Danielle’s third big idea is a guaranteed income supplement. Poverty is highly correlated with levels of poor health. If you do not have an adequate income, you may not eat an adequate diet, you may not have access to adequate housing, you may not be able to make investments in your own skills to improve your chances in the labour market. Dr. Danielle’s answer is a straight-up hand out to the poor. She proposes that the tax system be used to directly transfer wealth, and that doing so will address the ills that poverty causes. Doing so will make the problems of inadequate housing, inadequate education and inadequate nutrition simply disappear.

However, this is another idea that is deserving of scrutiny and more than cursory thought. Simply giving money to the poor is attractive in its simplicity. It is what is done every time you walk down the street and give the panhandlers change. However, it neglects the reality that poverty is a symptom of underlying problems, many of which are not solved by a hand-out and for some, money may make those problems worse (in the case of addictions). It is also a bit of a “cop-out”, instead of trying to understand and address the causes of poverty and impacts on those impoverished, society buys itself out of the responsibility to be compassionate, the responsibility to give the impoverished a hand-up rather than a mere-hand out. Further, doing so would negatively distort individual decisions with respect to the development of skills, participation in the labour force, and other life choices. If the cost of making poor decisions is lowered, inevitably more poor decisions may be made. Further, it may generate even greater levels of disdain for those who are impoverished – particularly as significant tax increases on those who have made “good decisions” would be used to subsidize a share of the poor who are poor as a direct result of “bad decisions”. Merely giving money does not translate into better housing, better nutrition, better education and social integration. Canada needs to do the hard work in this area and truly get a handle on understanding poverty and its underlying causes as the solution is unlikely to be a mere hand-out. After all, it’d be a shame to spend all that money, and still have to contend with the results of inadequate nutrition, inadequate housing, inadequate education, and inadequate social integration – when that money could have been used to provide better nutrition, better housing, better education, and better social support. Good medicine is treating the underlying causes of disease and disorder, rather than ameliorating only the symptoms.

Big ideas are most definitely needed if we are going to get to a place where a truly comprehensive, universal public health system that meets the needs of Canadians is to be achieved, the biggest of which is the acceptance of the idea that it does not need to be a single-payer monopoly on medically necessary care.

Unintended Consequences: Information Resources Squandered

Freedom of Information and Protection of Privacy (FOIPPA) legislation was not intended to hamstring data scientists and policy workers. It was not intended to cause a culture of fear that inhibits the pursuit of knowledge in the public’s interest. It was not intended to cause the sharing of data and information to grind to a near halt. It was not intended to squander resources to ensure adherence to the letter of the law. It was not intended to result in the gutting of capacity to do valuable research on the efficacy and safety of drugs.

Yet, those are the very real unintended consequences – consequences that are difficult to cope with and understand unless you have attempted to grapple with them first hand.

When it comes to data and government’s use of data – many in British Columbia and Canada are in the dark about how it works and why it critically matters. Many are incredibly fearful of the use of their personal information, and the words “Data Privacy Breech” often elicit a tremendous fear of identity theft. Further, personal medical information is sensitive information that needs to be kept confidential as it has the potential to negatively impact an individual’s personal life. Protection of privacy and the mitigation of risks associated with sensitive personal information needs to be a priority. Those trusted with access to that information have a responsibility and a duty not to violate the privacy of individuals by accessing information to satisfy “personal curiosities” as was recently the case in Vancouver Island Health Authority (http://www.timescolonist.com/news/local/curiosity-of-island-health-employees-led-to-privacy-breach-probe-reveals-1.1622518#) or to sell that information for personal gain as was the case in Ontario a little while ago when a Rouge Valley Centenary Hospital clerk sold the information of birthing mothers to financial companies (http://www.thestar.com/news/crime/2014/11/24/hospital_clerk_charged_with_misusing_records_after_confidential_patient_files_were_sold.html).

The collection of data (either directly or indirectly), use and disclosure of that information are all governed by FOIPPA legislation – collection, use or disclosure that does not meet the needs of the legislation are subject to significant sanctions including termination of employment, substantial fines or even jail time.

So what does that mean?

It means that every time Ministry A wishes to link individual record level data with Ministry B or to share information with the health authorities, there has to be a Privacy Impact Assessment (PIA) and an Information Sharing Agreement in place. As a result significant resources are used to undertake Privacy Impact Assessments and to draft Information Sharing Agreements. As a result, far less information sharing between different organizations that are publicly funded occurs than what might be optimal, simply because sharing data is an onerous activity. As an example, consider a program that is being tailored to improve upon the health status of “at-risk” families. It is suspected that families who receive welfare, families who are newly arrived, families who have a history of domestic violence, families who have low income are “at-risk” of poor health outcomes. However, much of the needed information is not collected by the Ministry of Health – but is collected through a variety of other ministries and organizations including Revenue Canada, the Ministry of Justice, the Department of Corrections, the Ministry of Social Development, the Ministry of Children and Families, etc.. Much of that information was not collected with the purpose of evaluating or developing health policies or programs. As such, even though “the Government” collects the information, it might be severely limited in the sharing of that information and its use and at a minimum would need to undertake a Privacy Impact Assessment and enter into one or more Information Sharing Agreements. If it is an outside researcher needing the information there would significant costs (thousands of dollars) and delays in the production of information. This would need to happen not just once, but for every project that requires information to be shared between ministries or outside researchers – and every project would have to specify the use and disclosure of the information collected.

Further, it means that once those charged with analysing the information have the data in hand – they are limited in the kinds of analysis and explorations that they may undertake. They are able to undertake the analysis for which they have been granted permission under the Privacy Impact Assessment and the Information Sharing Agreement (or via other legislation) only. Unfortunately, this often means that there is a tremendous opportunity cost that is incurred.

As an analogy, imagine for a moment, that a chef has been given the ingredients for a meal, but rather than enabling and empowering the chef to make the “best meal possible” with the ingredients that they have been given, the chef has also been given a precise recipe to follow and have been told that if they deviate from that recipe that they will be fired. If the chef wants to do something different with the ingredients that they have been given (and retain their job), the chef must first submit a revised recipe to their superior and only after that recipe has been approved by a joint board will the chef be allowed to make the revised dish – however, when the chef has suggested revisions to the recipe before, the suggestions are often dismissed out of hand either because of lack of time, or fear that the chef will produce something that is not palatable.

Imagine what that does for innovation?

Imagine what that does for job satisfaction?

Imagine how hard it would be to keep the best and brightest interested in public data?

Imagine the difference between what is done and what could be done?

Those who work with health data need to be empowered and enabled to make the most of the information resources that are available. They need to be free to explore the data and to make potentially profound discoveries about how the public can be served better. There needs to be a better way to protect the privacy and interests of individuals without sacrificing the potential to develop, implement and evaluate the policies and programs that are publicly funded.

Working with data is not just a science, it is also an art – and unless we are willing to enable and empower those who work with data to make the most out of the information resources available – the gap between what is and what could be will remain.

Focussing on the cost of health care won't make it sustainable

The sustainability of the health care system is a legitimate concern - worthy of attention and actions to ensure that it remains capable of meeting the health needs of the population in the decades to come.

Unfortunately, the conversation around sustainability as it relates to the healthcare system is often limited to the cost of providing healthcare. The focus is on saving the system money - almost by any means feasible. The focus is on demand management. The focus is on doing the things that will cost the least amount of money to do, or alternatively, choosing to save money by doing less, doing nothing or denying or delaying access.

There is no end of angst when people (some highly educated and informed) look at the historical patterns of health care use and growth in health care costs and apply current forecasts of population and forecasts of costs. The conclusion that things will go from bad to worse, is an easy conclusion to reach. If a person applies a pessimistic view to the trajectory of general levels of health and well-being (the consequences of less than optimal lifestyles) - a grey picture becomes darker still. However, it is folly to look at the future in this way - can you imagine if people viewed other industries similarly, with a view that how things are done will be the way that things will continue to be done and that demand would simply outstrip supply (note: such an approach does sound somewhat familiar with respect to worries about the food supply).

Almost paradoxically, by focussing on the money (on "taxpayer value"), on the cost of care - the sustainability of the system itself is being jeopardized, opportunities to advance the health and well-being of the population are being foregone, and things very likely will go from bad to worse.

By focussing on the money - policy makers put blinders on and are subject to thinking in the short-term, managing this year's budget and next year's budget - and perhaps if the government is newly elected maybe the budget 3 or 4 years down the road is taken into consideration. The ability to truly consider impacts for a generation or more is limited. The long-term view is abused to inspire "chicken-little" thinking. As such an investment in health that might take a decade (or more) to "pay-off" is likely to be foregone in favor of investments that have pay-offs in the short term. As such, short-term cuts to access become appealing because they improve the budget that is on the immediate horizon - the budget that becomes so central at the time of the next election. Cuts that impact a small group of people are chosen in order to please the majority of taxpayers with promises to keep expenditures "in-check". All the while, undertaking the business of healthcare, becomes ever more frustrating (and unsustainable) to both patients and providers, as innovation becomes an unintended casuality and provider burnout becomes an unintended side-effect of short-sighted cost-cutting.

However, consider for a moment, what might happen if the focus were to shift away from "taxpayer value" and towards a system intent on pleasing those who use it (patients), by doing what can reasonably be done to improve the health and well-being of patients. A system that truly values patients, and those who provide services to those patients. A system that is compassionate enough to understand that health needs often have soci-economic causes. Think about the kinds of wide-angle thinking that might be fostered - the kinds of innovation that might come to fruition.

If we desire a "sustainable health-system", the first step is fostering a shift in thinking and shift in focus, and to believe that "taxpayer value" will follow as a side-effect. I conceed, it is a radical leap to be made - but a critical one if true sustainability is the goal.

Perhaps, as some measure of evidence of the potential for this kind of shift, consider the results businesses have been able to achieve by making similar shifts. Consider the businesses that have shifted their thinking away from "shareholder value" towards delighting their customers - notable examples include WestJet, Telus, and Apple and in contrast, organizations who have refused to make similar shifts. Is there any real evidence that thinking a parallel shift in thought applied to public systems is foolish?

The Dawn

I will be blunt, in the year and a bit since I returned from maternity leave I have spent most of that year wanting to leave behind the place I have gone to work to for the past decade. I have spent most of that year frustrated and floundering. Most of that year stressed. Most of that year disengaged at best. Often quietly angry by the lack of what once was.

I have gone through 3 supervisors as a result of re-orgs in the past year.

The overall vacancy rate on our floor hovers around 30 percent (nearly 40 percent of all cubicles are empty and 10 percent of offices).

The vast majority of halls have remained as they have been for the past 10 years – barren expanses of cream.

The effects of the 2012 scandal continue to reverberate through the organization.

The scores of the Workplace Environment Survey had sunk to new lows and our branch, had gone from a group with some of the highest scores in the ministry to the group with the lowest scores in the ministry.

On a personal level, a good chunk of the time since my daughter was born has been a struggle (as illustrated by countless posts on this blog). As a result, it has required a great deal of effort simply to tread water, and to get back to a place where I feel that I can once again make headway on the things that I care about. For most of the past four years it was not possible to think about where I wanted to go, when as a consequence of what happened I was stuck on where I had been.

Then there was a dawn of sorts.

In the past 4 years I had not just “tread water”, I had not just kept my head above the level (although often times it had felt that, that was all I was intent on doing), I had made a difference. People had read my blog and for some what I had wrote resonated, for others I was allowed to help them achieve their goals or to better navigate the system, my perspective on the health system had shifted, my perspective on my work had change; I had built new bridges. I was once again at a place where I felt that I was able to not just “tread water” but to move forward in meaningful ways. I am at a place where I feel that I have learned a great deal of very important lessons, and that working to apply those lessons has a great deal of potential, even where I currently am at.

I could “abandon ship” – and indeed, if the right opportunity materialized, a position where the purpose of the position and my purpose and passions aligned, I would. However, in the interim, I could make where I am at, a better place. I could do what is feasible to align my work, my purpose and my passions. I could do things to improve upon the empty walls in the halls, I could do things to shift thinking, I could help others navigate towards being happier here (or elsewhere), I could make where I was at a place where at the very least, the little voice that says “This is not a place I want to be,” shifts, and says, “This could be a place where I’d want to be, if…” and then set about doing those things that will transform this place a little bit each day.

So 14 months after coming back from Maternity Leave, I’m finally, settling in, my boxes are unpacked and the cardboard has been taken to recycling and I’m making where I am at a place where I can do good work, that matters – a place where the difference between what is and what could be, gets a little smaller each day.

Ready. Set. Go. This is the starting line.

Cost versus Quality: Focus on What Matters

Money. It is a distraction from focusing on what matters. What happens when a business makes making a profit, it’s only reason for being? What happens when a government makes exceptionally low tax rates it’s only reason for being? In both cases, the organizations quickly forget why they exist in the first place and begin to make decisions that jeopardize and limit the potential of their organizations to do good (even great) work, that matters.

I’ll be blunt, saving the taxpayer an extra $100 or even $1,000 a year, is not going to motivate the kinds of public servants the province needs to innovate, to effectively run its programs and to deliver exceptional taxpayer value (services bought for the money spent). Similarly, making money for the shareholders of a business, likely will not be able to inspire employees to bring their “A” game to the office, day in and day out. A nameless, faceless shareholder or taxpayer simply fails to inspire and meet a deeper need for meaningful work. Even if those working are objectively paid well for the work that is done.

Meeting a deeper need for meaningful work is what enables people to go above and beyond, is what makes a difference between a job done well, and a job done exceptionally well. Finding passion and purpose in the work that is done, unleashes the potential to do not only good things, but, amazing things. People who have passion and purpose in the work they do, do not work 9 to 5, they work 24/7/365 because their work fills an intrinsic need beyond just paying the bills. A need to know that what a person has done matters, that it makes a meaningful difference to lives of others.

That’s not to say that the work that is done should be done without thinking about the financial impact of undertaking the work (resources are not unlimited), or that employees should be wasteful in their use of resources. Rather, it is to say, that in the long run focusing on what really matters is likely to yield much better outcomes.

Applying this thinking to the health system, think about the kind of system that results from focusing on the cost of care (taxpayer centered) versus the kind of system that results on focusing on the quality of care (patient centered).

If the costs of care become the focus, then what is in the best financial interest of the system becomes the priority when making a decision. In a system focused on cost, there is rationing of care. In a system focused on cost, there is a need to control information and decision-making, there is a need for “gatekeepers” and collateral damage becomes an acceptable cost of doing business. In a system where cost of care is what matters, even the needs of providers might be neglected. In a system focused on cost, it is not about what is possible, it is about what is affordable. A system focused on costs sacrifices the needs of both patients and those who provide services in order to appease the taxpayer – it sacrifices the great in favor of the mediocre.

If the costs of care are taken as a given (as much resources are used as are needed to meet needs), then the focus shifts to what is in the best interests of the patients and what is in the best interests of those delivering the services to patients. Information is no longer feared and hoarded. Innovation is embraced. There is no need for care rationing and there is a great incentive for shared decision-making. Further, the work becomes intrinsically meaningful as it becomes about making life better for others, and in particular about making life better for patients. The pursuit of better care and better outcomes becomes the goal. The possible is unleashed.

To highlight the difference between these two approaches, consider the work of Elizabeth Holmes and her company Theranos. In a system focused on costs of care, her work could be seen as a threat, as it opens the door to demands for health services that would otherwise be deferred or go unneeded. In a system focused on quality of care, her work becomes a tremendous opportunity to avoid bad outcomes from ever materializing in the first place. A system that might cost more, but might also deliver far more for the dollars spent.

So what matters, really?

The Continuing Saga of Sam

Last week, I wrote of our houseguest Sam*. My cousin – who has drifted out to the coast, and who it seems is adrift in life. After a week of somewhat anaemic searches for housing, going out Friday night, which led to a Saturday morning that had me discovering pee on my living room floor at 7 am – I went to my cousin’s room to find Jayla (who I let out), but no Sam. I texted my cousin:

“I just cleaned Jayla’s pee off of the floor – not cool.” I called my aunt, asking her to offer to my cousin to take Jayla until he could find a job and a home that would accommodate having a pet. She agreed to talk to my cousin.

My cousin responded more than an hour and a half later by text “Shit on my way home walking.”

At which point, I again went to look in on Jayla, and thought that the room smelled, to discover the source of the smell on the bedroom floor.

I texted my cousin again, with a picture of the offending matter (a rather large turd), “and now this”. To which he responded by text, “God dam,” “I’ll find a place to go tonight can I still do some work for you today or no?”.

My husband and I had discussed how we should respond to the situation, we texted back “Look, you and Jayla can stay tonight, but Jayla has to go by the end of day tomorrow, you can stay until the end of the month.”

The dog was making the housing search near impossible, and what was evident was that my cousin’s lifestyle seemed incompatible with being a responsible pet owner at this time. I was hoping, that perhaps if Jayla was not part of the current situation, that maybe my cousin would be able to do the things that need to be done – things like finding steady work and stable housing. More than anything I wanted my house back, my cousin had been there a week and the stress was starting to build in a number of ways.

At mid-day Sunday, Sam indicated he had found a place, a room that was available immediately in a Condo on a bus route and across from a mall with a middle-aged room mate who worked in the oil patch half the time and was okay with the Jayla. It had seemed as though a minor miracle had happened and that my cousin would soon (in the next 48 hours) be in a place of his own.

On Monday, I asked Sam what his plan for moving was and he said he was paying the rent and the damage deposit, getting keys cut and signing forms, and that he could move Tuesday.

Tuesday, I bought my cousin a moving out gift – a laundry basket filled with a set of towels, some pajama bottoms and a t-shirt, laundry soap, soap and personal grooming supplies. I printed a stack (30) of his resumes and the forms for the Medical Services Plan. He indicated his girlfriend, Mel* who he intended to move out with, was not well, and that he’d move out on Wednesday instead. The gift nearly brought Sam to tears.

Wednesday, I bought Jayla a dog license at lunch. A little after 6, I texted my cousin, “What’s your plan?”

To which he texted back, “Just out with Mels* for din din.” Mels, is his girlfriend, they’ve known each other for all of two months, and for some reason or another, think that it is a good idea to move in together. Not the choice, I’d make, but it’s not my choice to make.

I replied, “OK, do you want a ride to your new place with your stuff tonight?”

He replied “I’ll ask Mels now.”

And then there was nothing, for more than two hours at which I point I texted again, “What’s the plan?” and, fatefully, “Does Lola need to be let out?”

My cousin texted back, “Yes, just one last time,” and “Is it ok if I spend one last night I just feel unsafe without a lock on the door for my girl.” I had gotten the distinct impression, that despite my cousin’s wanting his girl to move in with him, that she did not share the same desire, but was perhaps unwilling to clearly communicate that with him.

I texted my cousin back with the picture of a throughly soiled bed.

“I’m too late – Lola has made a mess of your bed. We can pick up a lock for your door tonight.”

The message though, seemed not to connect, and my cousin texted again asking to stay one more night, to which I texted back, “Your dog has pissed and defecated on your bedding, there is no bedding on your bed and it will be at least 4 hours before it will be cleaned.” I was doubtful the bedding was anything less than ruined, thankful a waterproof mattress protector had saved the mattress, however, I was truly at my limit. I needed my house back.

The message finally seemed to get through, and he responded, “Omg I’m so sorry I’ll be home soon, I’ll pack my stuff.” He and Mels arrived by cab 20 minutes later – I calmly greeted them at the door and said I’d give them a ride to where they would stay that night. I placed a hook and eye lock I had found in the basement with his belongings. He gathered his stuff and we loaded it and Jayla into the car. I drove them to their friend’s place, he ordered Pizza on the way. I dropped them off and wished him well and drove home.

The next day, I texted my cousin and invited him for dinner on Sunday. I had felt somewhat bad about how the move out had gone, and wanted to let my cousin know that he was still welcome as a guest. On Saturday, I texted him further and indicated we could pay him for the work that he had already done, and that if he could come around two in the afternoon that there would be about two hours of work that could be done. He agreed.

Sunday came. Two o’clock came, and went. Then three. Then four, and then at half past four, my cousin showed up with Mels and Jayla in tow. My husband, tired of waiting for my cousin to arrive, had taken the kids out for a walk. He arrived back – and briefly exchanged niceties, asking if there was a reason Sam was late and could not text or call. Sam, being Sam, answered vaguely. It did not go over well. My husband, left to cool off at his office. My cousin, claimed to need to get keys from his landlord, but that he’d be back later. I started on dinner. Not knowing who was or was not going to be eating, I made dinner for four adults and two kids.

Sam later texted to say that he had gotten scammed on his place and was out both cash and a place to live. I advised him that my husband was willing to help, and that he should call the cops. Sam indicated that he did not want to bug us.

Dinner was ready at half past six. I ate alone with the kids.

This morning, I wrote Sam an email –

Sam –

I have no doubt that at the moment your life is not easy. The work that is available to you at this moment is not overly stable or secure, offers little in the way of benefits, and the pay is minimal. This past weekend we offered you a couple hours of work at $20/hour - and you show up 2.5 hours late with no prior text or warning that you intended to be late. You claim to have been scammed on your room - and are out both money and accommodations, and Mr. W has offered to assist you legally in that regard, but you do not want to "bug us". The reality is that at this moment your life as an adult is at ground zero. There is no easy road forward, the choices you make will either lead to an easier and more comfortable life that will afford stability and satisfaction; or, alternatively will lead to a life that is harder yet, plagued by poverty and insecurity and littered with regret.

Over the past couple of weeks, I have had an opportunity to get to know you and I see tremendous potential for you to make a good life for yourself that is filled with the love of family and friends and the rewards of hard work and dedication. You have an engaging personality, the kind of personality that makes friends easily and leads others to want to lend you a hand in helping you to achieve your goals. You are socially gifted. You are physically fit and capable of hard work. Further, you have the advantage of time – you are young enough to create nearly any future you want. At your core you are a good person who is capable of doing well in this world.

You have people who believe in your ability to do well and who are willing to help you help yourself in making a better life. You have people in your life who want to see you succeed – who want to help you up when you stumble and who want to cheer you on when you are doing well – do not take that for granted.

With that said, I would like to offer the following advice:

1. Do not get caught up on your past. Your past is the result of previous choices that were made, and the parts of your past that you regret offer up an opportunity for you to learn how to do better in the moment, and in the future. Let your past enable you to build a better future – do not let it condemn you to a life of struggle.

2. Do not get caught up on your shortcomings or the challenges that you are confronted with. Everyone has shortcomings and everyone is confronted by challenges in their lives. Those who succeed find ways to overcome their shortcomings, ways to compensate for their failings. Those who succeed carefully reflect on the areas of their lives in which they need to do better, and then undertake to improve or compensate in those areas. Further, there is no shame in seeking guidance on how to overcome your shortcomings.

3. Be accountable, to both yourself and others. Be aware of when you have failed either yourself or those in your life, acknowledge the failure and take steps to remedy it. Do not step away from your responsibility to either yourself or to others.

4. Value and respect your relationships with others – as they are, and always will be, your greatest asset and the source of much satisfaction in your life. Try to see others through to the degree possible and resist the urge to see through others. Do what you say you are going to do, and treat others with the kind of respect you'd expect to receive from others.

5. Look for and capitalize on opportunities that move you closer to the kind of life you want for yourself. With each choice you make, ask yourself if that choice moves you closer to or further away from the life you want for yourself in a month, a year or five years from now. With each relationship you have, ask yourself if that relationship moves you closer to or further away from the life you want for yourself – if a relationship is causing you to move further away from your goals, consider fixing it or moving on. If a choice is likely to move you further away from your goals, make a different choice.

6. Seek to be a role model. There will be those who will look up to you – who will see what you do, and the challenges you overcome – demonstrate the kind of life that you would want someone you love to lead. Lead the kind of life you would want your niece or nephew to lead, the kind of life you would want your son or daughter to lead.

7. Strive to rely on yourself and be confident in your ability to do so. Be aware of your attitude towards yourself and about your own capabilities. Seek to rid your vocabulary of the word “can’t” and instead focus on the “can”.

With that said – think about what you want for yourself in a year from now, and in five years from now and start moving towards it. We'd like to keep in touch with you and support you in making good life choices - but we will not support you in continuing to make poor life choices.

This is your life, now lead it.

Much love and kind regards,

The W Family

P.S. The following is a link to the Residential Tenancy Branch who may be able to assist you in your dispute regarding your room. http://www2.gov.bc.ca/gov/topic.page?id=3908F05C52AD49F29CCF9DC3FC0B4D25

Mr. W. has also offered his assistance - carefully consider whether or not you want to forego that.

P.P.S. Please find the following information on housing/shelters in Victoria - as much as we'd like to help you out further in the way of housing, we do not want to support you in continuing to make poor life decisions, and these programs may be better able to assist you.

Threshold Housing Society: http://thresholdhousing.ca/?page_id=1968 , shy@thresholdhousing.ca , and the referral form: http://thresholdhousing.ca/wp-content/uploads/2013/03/Form-for-Youth-Self-Referrals-without-agency-assistance.pdf

Out of the Rain Youth Shelter (pet friendly) http://www.outoftherainvictoria.ca/index.php

Our Place: http://www.ourplacesociety.com/

Coolaid Society: http://coolaid.org/our-services/

Again, as much as it may pain you to do so - seriously ask yourself whether or not your lifestyle at this time is compatible with having a dog - and whether or not you can adequately meet her needs. Having a dog is a choice - one that might be moving you further away from your goals, or alternatively adjust your lifestyle and place meeting her needs as a priority in your life.

P.P.P.S. We have a cheque for you for the work that you have done - let us know when you'd like to pick it up, or alternatively, if you'd prefer email money transfer, that too is doable.

*Names have been changed to protect identities.