Wednesday, October 22, 2014

On The Road to a Healthier, Happier Mrs. W

At the beginning of October, Mr. W and I went away on a mini-vacation. A welcomed get away to Seattle, where we indulged in sleep, and food, and drink, and shopping - and yet more food and drink. The shopping was needed in part because in the year since returning to work (economists are desk jockeys), my pants had grown tight and there were very few pairs that actually fit. I had hoped that a year after my return to work, that more of my pants would fit, rather than fewer. The scale confirmed what the pants were telling me - I was just 10 pounds lighter than I was when I was 9 months pregnant with my daughter, a full 15 pounds heavier than when I returned to work. I had joined the two-thirds of the population who are either overweight or obese in Canada - with a BMI squarely in the overweight category. I had also noticed that my blood pressure that was historically low/very-low had creeped up to normal levels over the past year (in years past it would be 95/50 - and was last clocked at 125/65).

I resolved that I had to do something different and the sooner I did, the sooner I'd be on a better path. Further, having had developed gestational diabetes with my daughter, and having a father and grand parents who have developed Type II diabetes - I know that I am at an elevated risk of developing Type II diabetes over the next decade.

I had all kinds of reasons to be out-of-shape. My work environment is stressful. The kids limit the amount of time I have to work out and get exercise. My husband does the cooking. I was mildly depressed. I'll get fit after I change jobs, or after Wyatt starts kindergarten and life is more accommodating of doing so.

I knew whatever I did had to be compatable with where I am at now, and that waiting for other circumstances to align to do something might come at a steep cost in terms of my health (if the last year had brought 15 pounds and a 30 point increase in blood pressure, where would I be in 5 years?). So I thought about what I could change to get to a healthier place and have been pursuing the following strategy for the past 17 days:

*I have abstained from drinking alcohol - I wasn't a "Big Drinker" before, but 5-7 glasses of wine/beer and the occasional Martini over the course of a week has a way of adding up. I have decided that when I reach my interim goal, I might reintroduce wine to my diet - which has been surprisingly motivating.

*I have eliminated creamer/milk from my coffee and have grown accustomed to drinking it black.

*I gave my husband a cooking holiday and have taken over most of the food preparation.

*I bought a FitBit($99) and installed its app (FREE) - initially I bought a black one, and three days later, just long enough to fall in love with it, it got lost. So my current FitBit (another $99) is grey/blue and in Sharpie I have written my phone number.

*I started weighing my food (bonus use for the kitchen scale we already have), and journaling what I ate via an app on my iPhone (MyFitnessPal - FREE). Because the app counts calories for me, can add calories for the activity tracked by my FitBit and sets a calorie goal for the day staying on track has been pretty easy. As a bonus - because of the nutritional information the app provides me I have a better understanding of where my diet falls short and the impact of small changes (like substituting baked yam fries for fries). I have found that I can eat a very large volume of food that is hunger satisfying within the calorie goal if I focus on eating non-starchy vegetables (most veggies are calorie cheap), some fruits (melons, apples and berries are also colorie miserly choices), and proteins, choosing whole grains (quinoa is now a staple), limiting dressings and sauces and avoiding refined flours and added sugars. Chocolate bars and desserts aren't "out-of-bounds" but when faced with the choice of having such a treat and feeling hungry later, I have changed the choice I make. I've said good-bye to the pain-au-chocolat, and have opted for Hazelnut Chocolate Chia pudding instead (125 mls of Chocolate Hazelnut Almond Milk mixed with 15 grams of chia seeds and allowed to set for 45 minutes). This has meant packing a lunch - and has had the pleasant bonus of avoiding the $10-12 lunch expenditure each day.

*I got a FitBit Aria ($130) - a wifi scale that links up with the FitBit App and MyFitnessPal and allows for tracking trends over time. As a bit of a surprise, the Aria also lets you spy on non-registered users of your scale (guest users)...

*I committed to 10,000 steps a day (a walk at lunch time usually is enough to get there) and a Boot Camp (45 minutes, 3 days a week - cost $120 for 4 weeks/12 sessions).

Seventeen days (and $450)in, and I'm starting to notice more energy, better mood, looser pants, more money (as spending on booze and lunches has been slashed - I anticipate the sunk costs will be recouped in less than 3 months as I estimate a $25 saving in food costs and $20 saving in booze costs per week - $180 per month) and have dropped nearly 5 pounds. I'm looking forward to a more enjoyable ski season and am hoping that most of the changes that have been made can be sustainable over the longer term.

Thursday, October 16, 2014

The Category is: Early Twenty-Somethings

Today’s post is a bit of a divergence – it has nothing to do with healthcare, maternity care, or my workplace. Today’s post is about our unexpected, hopefully short-term, houseguest.

On Friday, I got a phone call from my Aunt – who still lives in my hometown. Her eldest son (early twenties) has decided that it was time to leave the family home and moved out to the coast in June and has been living between the Victoria area and Salt Spring Island. He has been doing cash jobs (general labour stuff) and crashing at acquaintances. In July he was involved in a car accident, and briefly went back to Alberta for medical care, but returned to the coast in September.

“Are you around this weekend?” she asked.

“Well, sort of yes and sort of no – we will be around Friday but not until after 9 as we have a Thanksgiving dinner to go to, and we have the other two kids this weekend and were planning on being away Sunday night to go to a Thanksgiving dinner in Lake Cowichan.” I replied. It was going to be a busy weekend with a full-house. The dinner in Lake Cowichan was later cancelled.

“Well, would it be at all possible for Sam* to stay with you guys this weekend. I am kind of desperate, he has nowhere else to go.” Rock meet hard place.

The thing is, it’s not just Sam, but Sam and his dog “Jayla”*- a completely sweet purebred English Bulldog, but a dog none-the-less. The thing is, when it is just us our house is pretty full as we are trying to sleep train the toddler & preschooler and doing so is immensely easier when they can sleep in separate rooms and when the older kids are with us, there really is no spare room. The thing is between my job, my other job and my husband’s job and the kids – we were already red-lining. Having guests is one thing, having an unemployed early twenty-something, young man and his dog stay with next to no notice is quite another. Particularly, an early twenty-something young man who I barely know – I moved to the coast nearly 18 years ago now and my cousin might not yet have been in school when I did so. I have seen him all of a handful of times in the years since – and, had sparingly kept in touch with his mother. But he is family, it is Thanksgiving, and there was nowhere else for him to go.

“I guess so.” I replied.

So on Friday night my cousin (tattooed and pierced) and his dog arrived, after we had retired for the night, he parked his defunct Moped and trailer in our carport. We left a towel and some soap on his bed, and a note directing him and Jayla to the shower. I awoke the next morning unable to find my laptop – he had taken it from the dining room table and it was open beside him as he slept. I found myself mildly annoyed.

He slept late on Saturday. When he woke, and we spoke it was clear – my cousin had no work, no home, no money, no reliable transportation and no plan. He offered to make-do and crash at a friend’s house for the rest of the weekend, we offered for him to stay as he was already settled even though it would mean having my step-daughter bunk with her little siblings. The last thing we want is for our place to be a revolving door for my cousin, and we are hoping that when his stay with us is over, he will only be an invited guest (for dinner or the like) from time to time.

On Saturday, we took his resume (it clearly needed formatting and editing) and formatted and edited it – “So what year did you graduate high school?” I asked.

“I didn’t graduate, I need Science 12. Dumb, I know.” He replied.

I could not help but think, who in 2014, does not finish at least high school? Victoria is a University town, so there’s no shortage of young people looking for work. The lack of high school would put my cousin at a strict disadvantage.

“So do you have any other training? Like Food Safe or Serving it Right, or anything really?” I asked.

“No” – he replied succinctly.

“You might want to consider getting your GED or doing the course by correspondence as a high school diploma would really open some doors.” – I continued, half knowing that at some point, probably years down the road that he will need to come to that conclusion himself, and that no amount of well-intended “advice” will convince him at this time.

The resume done and emailed to him, I was hoping to find him actively scouring the internet for work. Nope, he was cruising Facebook. I was irritated.

I did a load of his wash (it is doubtful that our laundry machine has ever had such a challenge before, and in a house with toddlers and a dog, that is saying something).

On Sunday he again slept late – my husband waking him and reminding him that people without jobs and homes should not be sleeping in and asking him help with some chores around the house. He happily and diligently helped with the chores. He then tried to get his moped to work – switching the fuel in it and playing with the wires. He and his parents bought it the week before and needed to get it running, which it was, but since then had yet again had a mechanical failure. The back brake was also not operational. The Moped is 40 years old – and for the time being should not be considered reliable (or safe for that matter) transportation.

“Do you have a helmet?” I asked.

“No” he replied .

“You know you’ll probably get a ticket for riding it without a helmet.” I added – while thinking, you know, without a helmet if you only wind up with a ticket and not a brain injury, you would be lucky.

“I know – almost got a ticket the other day.”

It seeming clear that finding work quickly would be wishful thinking without some help, it is also clear that steady work and the money that comes with it are likely pre-requisites to finding a place that Sam can call home. Further, finding a home for Sam, is an absolutely priority – if not for Sam, for myself and our family - so my husband forwarded the revised resume to an acquaintance of his who runs a temporary labour company for blue collar workers. Luckily, the acquaintance was able to find work at a construction site that started on Tuesday. So far, he has worked hard and diligently and it is looking likely that the crew he is working on might employ him directly. At least with work and a legitimate paycheque, his chances of finding a roof over his head would be greatly improved.

Wednesday morning I went to give my cousin a ride to his co-worker’s to car pool (as was discussed the night before), as we had planned the night before only to find his room empty, his hard hat on his bed and his work boots on the floor. No note was to be found.

I texted him – and he explained that he went to his colleagues place earlier and would rent his equipment for the day. I let him know that not doing what you say you are going to do earns no brownie points around our house. I found myself, again, irritated.

So at least my cousin had work. But still, no home and he seemed to be making only cursory efforts at finding a home. It is Thursday – and I think he has only looked at less than a handful of places (maybe 3). On Tuesday I sent him a dozen links to listings. Yesterday, I started emailing and texting a few on his behalf. Today, I wrote an accommodations wanted ad on his behalf. If by the end of the weekend there is no headway on the home-front (Victoria’s rental market is insanely tight and having a dog in tow does not make it any easier), I will be requiring him to apply to a program directed to housing otherwise homeless youth and helping them with life skills.

Don’t get me wrong, my cousin is a sweet kid, as is his dog, he seems to be reasonably hard-working, has an outgoing personality and he does not smoke – he gets on with the kids, however, he is still an early twenty-something with all that comes with that territory. Including all kinds of things that not being an early twenty-something and being an entirely different kind of early twenty-something when I was – I am likely to find at a minimum irritating. He needs to be an early twenty-something somewhere else, and the less I know about it, probably the better – as it is entirely likely, that withholding judgement on the choices he makes might be beyond my capacity.

On that note – know of an available and affordable suite or somebody looking for a roommate in the Greater Victoria area (even a sublet would be fine)? Please drop me a line or two...please.

*Sam – not their real names, pseudonyms are being used.

Friday, October 10, 2014

Get it, Got it, Good

It's easy to see judgement of the choices women make - often by other women. Look no further than the mommy wars. Look no further than the question whether or not women should have the right to a cesarean section. Look at the right to access an abortion.

Sometimes the judgement is downright militant. There seems to be a need - not only to control our own lives, but then to extend that control to others. A need to have our own choices reflected back in the choice of others. A need to pressure others to make the same choice.

The pro-lifers with placards outside of women's health clinics are bullies - seeking to shame women away from their choice. The lactivists who seek to shame women into breastfeeding. Those who look to those who work outside of the home with disdain - and those who look to those who stay home with an equal amount of disdain. All of them are bullies.

It is not healthy.

It is an act of seeing through other women, rather than seeing women through.

Today, Malala Yousafzai became the youngest winner of a nobel peace prize - she is quoted as saying "A girl has the power to go forward in her life and she is not only a mother. She is not only a sister. She is not only a wife, but a girl should have an identity." Malala gets it.

A while ago, Suzie Barston and Kim Simon started the #ISupportYou movement. Suzie and Kim get it.

Similarly, Dr. Walker Karraa, founded Stigmama to start to peel away the many layers of stigma associated with mental illness, particularly among mothers. Dr. Karraa, gets it.

In her speech to the UN on the need for men to also be feminist, Emma Watson demonstrated that she gets it.

Lastly, in my own home town, I came accross another woman who seems to get it. Celtie Lou - gets it.

They get that we need to see women as people, fully people: nothing less. They get that we need to be secure enough in our own choices to allow other women to make their own choices even when they are different from our won. They get that we need to support and empower women - understand what the real needs are, and then work to meet those needs. We need to respect each other. We need to see each other through, rather than seeing through each other. What's more, is that these women understand that it's not enough to just get it - and what is remarkable and amazing, is these women understand the need to help others get it too. They are doing good work.

Imagine for a moment the world, if more women got it. If more people got it. Truly got it. Imagine the communities, imagine the mountains that could be climbed and the challenges that could be overcome.

Now ask yourself, what can you do to help others get it? Go do that. It is good work.

Tuesday, October 7, 2014

Small Steps in the Right Direction

This past week, something critical to the functional health of the BC Ministry of Health as a workplace, happened. Something that might signal a real turning point and a shift towards rebuilding the organization from the cultural damage that resulted from what was for many of those involved, an entirely disproportionate and inappropriate reaction to the circumstance.

Minister Lake, and Deputy Minister Stephen Brown issued an apology to the family of Mr. McIsaac. Further, there has been a committment to reviewing what happened in 2012 to learn from it and to revise policies and procedures to ensure that a similar situation will be handled better and more appropriately in the future.

Mr. McIsaac, was a co-op student who, 3 days from the end of his work term was fired from his position at the ministry along with 6 other staff. Subsequently, an investigation (which cost no less than $3.4 million) determined that there was not actually an breach in data security and largerly cleared the staff in question.

It is not easy to take responsibility for a mistake - particularly a mistake that happened as the result of another person's actions or inactions. The minister and deputy minister that were heading the ministry in 2012 have since moved on. As individuals, the current minister and deputy minister are not to blame for what happened in 2012. However, it demonstrates real leadership to recognize the responsibility the organization has for what happened in 2012, to recognize the need to learn from what happened, and to take steps to repair the damage that was done.

The events of the past week, are small steps in the right direction. It is unfortunate that such steps were not taken proactively - happening only after a very public appeal from the family for an apology. However, there is an opportunity to be proactive about the next steps that are taken - and for the sake of the Ministry, and the family of Mr. McIsaac and the others involved in the scandal, I hope the next steps continue in the right direction and adequately address what still needs to be done.

Monday, September 29, 2014

On Poking the Bear

On occasion, I have blogged about my workplace – about the frustration and angst of being where I am at. In short, I have “poked the bear”, I don’t know if “the bear” reads my blog – the bear might, parts of the bear probably do. I have also “poked the bear” more directly, via a book review in the divisional newsletter and the intranet and to that end, the bear has responded somewhat in mixed ways. Granted, the direct pokes are perhaps a little more diplomatic than some of what can be found on this blog. To date the bear hasn’t taken a swipe at me, although I have at times thought that it might.

However, my experience has sold me on the power of writing, and more broadly on the power of blogging and other social media (twitter, facebook) to affect change (both personal and social). It was not until I started pouring my thoughts and ideas out in a way that others might read and respond to that the challenges I was facing started to become surmountable in real and tangible ways. It is a way of speaking the name that should not be spoken; a way of peeling back the fa├žade of a challenge to identify and explore what is beneath the surface and from there to think about how that challenge might then be overcome. The beautiful thing about blogging, about allowing those who read my blog to respond either via comments or through email – is that the door is then open for collaboration.

I recognize that my current situation is not sustainable in the long-run; that it results in a longing for something more. The writing is clearly on the wall. The culture as it has evolved, and who I am are not compatible and a consequence of that has been profound disengagement. Writing is my coping mechanism – and beyond that it is a tool to affect change, it builds a path from where I have been, to where I am at, to where I will be.

So I recognize that I might be “poking the bear” – but when I think of the alternative, of keeping the part of me that might best benefit from building new roads and bridges private – it seems as though it is a reasonable risk to take. Further, I have learned that skeletons in closets haunt their owners, whereas those on display have tremendous tuition value. Because of blogging, my closet is bare – and paths to a better future are being built

Tuesday, September 23, 2014

A Canada without Compassion Comes at a Tremendous Cost

The capacity for compassion, the ability to see each other through, rather than to see through each other is perhaps the one thing that sets Canada apart from many other nations in the world. It is a culture of being there for one another – of lending a hand-up when times are rough, and of sharing in success when times are good. It is a culture of true leadership. For decades, compassion has shaped Canada’s public policy at all levels of government, municipal, provincial and federal. For decades, Canada has been a leader in health and social policy – Canada has demonstrated the power of compassion to overcome the most significant of challenges.

As such, as a Canadian – the move away from compassion as a core value, as a way of being, should be seen as being deeply disturbing. It should be seen as a move away from a culture that has enabled many great successes, towards a strategy of every man, woman and child for themselves, a strategy that will ultimately lead to a Canada that is far less than what it is capable of doing and being. The loss of compassion among Canadians, and particularly among those who are our leaders is nothing short of heartbreaking.

The underfunding of public systems of health and education, and an unwavering focus on the second dumbest idea ever – “Taxpayer Value”, is at its core a demonstration of a lack of compassion for others and in particular a lack of compassion for those who work in the public service and those who rely on the services it provides. High-quality, high-performing public health and public education systems need to be a priority and they need to be based on a compassionate view of those they employ and those they serve – they need to embody the hand-up that they are capable of being.

Is it compassionate to have wait times that effectively deny access to care in order to manage budgets and at the same time prohibit people from their own resources to expedite their care to mitigate the costs of their illness and or disability?

Is it compassionate to deny access to adequate compensation to those harmed by medical error?

Is it compassionate to have students who are the most in need of resources the least able to access the resources needed – is it compassionate to fund every student in every school district similarly, when the availability and effectiveness of PACs varies substantially?

Is it compassionate to treat the children of Canadian mothers and foreign fathers differently from the children of Canadian fathers and foreign mothers with respect to their access to healthcare?

A Canada without compassion, is a cold and heartless country – a country that turns its back on tremendous potential and as a result pays a huge opportunity cost. A Canada without compassion, will struggle – as those in their time of need are abandoned, and in turn, those previously abandoned turn their backs on the needs of others. A Canada without compassion will be unable to overcome the challenges it confronts – it will condemn some of its citizens to poverty, others to pain and disability. It will fail to enable and empower its citizens to contribute what they are capable of, in favour of ensuring that those who are lucky enough to avoid adversity will keep a little more money in their pockets.

Sadly, I feel that stories, like that of this Ottawa family – are about to be more common place, and sadder yet, the comments that follow it seem to reflect a loss of compassion among Canadians that is nothing short of heartbreaking.

Sunday, September 14, 2014

Alternate Level of Care - Not a Silver Bullet to Fix Healthcare Woes

Alternate level of care (ALC) patients are often the scapegoats to what ails the healthcare system. They are accused of being overly expensive bed blockers who use up more resources than they need and prevent somebody who needs a higher level care from accessing those services.

I would argue that the system does not adequately understand the issue of alternate level of care patients, that alternate level of care patients might not use as many resources as they are accused of using, and that if the system addressed the problem of ALC it does not follow that access to healthcare, and in particular a reduction in wait times to care would follow.

First, the system does not adequately understand the issue of alternate level of care patients. It should be noted that all patients who are not "acute care" patients are "alternate level of care" patients. This would include patients who are admitted and waiting for a procedure (pre-procedure ALC), as well as patients who are "well enough" to be discharged but cannot be discharged because of inadequate post-discharge care environments. The problem of pre-procedure ALC is not the same as the problem of post-procedure ALC but rarely are the two kinds of ALC looked at separately. Typically, when people think of "bed blockers", they are thinking of patients who are adequately recovered from their illness or surgery to be discharged but cannot be discharged because they still require some level of care, or their home environment is inappropriate. Some of these patients will not need a permanent placement in a long-term care home, but rather need a place where they can recover further before returning home or are waiting for home care or informal care providers to be available to provide for their needs. At any rate, the needs and reasons that those patients are ALC needs to be better understood before leaping to the conclusion that building more long-term care facilities is the solution to the problem.

Second, on the issue of cost it is erroneous to assume that the "average cost" of a hospital day is the appropriate cost to attribute to an ALC patient. The average cost of a hospital day is an aggregate number that reflects the costs of "high needs" patients and "low needs" patients - it is all of the costs of hospitals divided by all of the hospital days. The mere existence of a patient in a hospital does not attract spending on that patient. It is absolutely ridiculous to think that an ALC patient is as resource intense as a patient who is within the first 48 hours post-surgery, or who is acutely ill, yet - declaring that an ALC patient costs the same as these other patients is often what happens in the hand-wringing over ALC. If it takes 5 nurses to care for 20 acutely ill patients, those same 5 nurses might be able to care for 50 "alternate level of care" patients, or perhaps nurse aides are adequate to address their needs. Further, it may be desirable to have some "less resource" intensive patients in the mix as it provides for a bit of a break. Do we really want a system where nurses are working at the limits of their capacity, all the time? What might that mean for rates of medical error? What might that mean for rates of nurse burnout? What might that mean for rates of occupational injuries among nurses? It is even imaginable that having these patients in hospital might be the most efficient way to address their needs under some circumstances. In short - do not expect resolving the ALC problem to save as much money as is often estimated. If the ALC problem were adequately addressed we would see the average cost per patient day increase, not decrease.

Lastly, because governments set health budgets, even if the beds were available in hospital - it is a heroic assumption to think that the number of procedures performed would increase by any substantial amount. To the extent that money is actually saved and could be reallocated to provide access to care, some additional surgeries might be performed. However, the increase in access is likely to be far less than what is often imagined - just because a bed or an OR is available in the public system does not mean that it will be used. Unless governments are willing to spend more on healthcare, they will simply reduce the number of beds "staffed and in operation" or will close OR's to manage budgets.

Wednesday, September 10, 2014

One Year From Now: First School Days

A Year From now my daughter will be heading to her first days of kindergarten - she will start her academic journey. As a parent, I know she already has some tremendous advantages, and that if she needs any help along the way that we will do what we can and what needs to be done to ensure that she is able to reach her potential. Our plan was to send our children to public school, at least for their elementary years. We have every confidence in the curriculum. We have every confidence in the ability of public school teachers to inspire learning - we know that there are many dedicated individuals who work tirelessly every school day and every other day to not only do their job, but to do it well. We appreciate the diversity in public school classrooms and feel that it is a benefit to our children.

However, the dispute between the BCTF and the Government, now has me asking some questions about the school system, about how it works, and about how it might be in a state of dysfunction going forward. It has me questioning whether or not the public school system is "healthy" - if it is a place where teachers feel they can innovate and practice to the fullest of their abilities? A place where all students have their needs met? It has me questioning the statistics that the "outcomes are the best in the world" and wondering if those statistics are subject to a kind of statistical slight of hand. Not that the statistics are wrong, just that they fail to tell the full story or have been subjected to cherry-picking. I am wondering about the culture of the public school system - about the relationship between those who teach and those who manage the system.

And I am left with a sense of trepidation and dread.

I fully support a universally accessible, public education system that performs well and meets the needs of the students it serves - but, I have a hard time coming to the conclusion that the system in British Columbia is where it needs to be in order to be a system that performs well, and meets the needs of the students it serves. A system where there is little gap between what the people who work in the system are capable of and what they actually achieve. I am very worried, that given the rhetoric and propaganda, the posturing, and the statistics - that what should be, is and will be, very different from what my daughter and son will actually experience if they go to public school.

First, I have serious concerns about the adequacy of funding in the school system. I know on a per-capita basis student funding has increased at a rate that is slightly ahead of inflation. However, that statistic hides a lot of details and in isolation actually says very little about whether or not that level of funding is "adequate". It fails to take into consideration changes in the composition of the population being served. Are there more high-needs students being served? Are there more students who are facing food insecurity or home instability? How has technology changed, is the system expected to deliver the same things it did 10 years ago, using the same tools? A proxy for adequacy is to look at the funding in other jurisdictions (again a lot of nuances, but in a pinch it will do) - and in British Columbia public school funding as 2010/11 was about $750 less per student per year than the Canadian average. Further, there is some argument to be made that funding all public schools equally at a per student level leaves a lot to be desired in the way of equity as schools in "better-off" neighbourhoods may have a much easier time suplementing their budgets than schools in economically disadvantaged areas. As a result, public funding might be adequate in some areas and inadequate in other areas. However, unlike in health, there is little measurement of the supplemental spending, the private spending, in education.

Second, in terms of outcomes and what is measured, again there are a lot of nuances and considerations to be made. The catchment school that my children would attend, has good outcomes. It also is in a very middle to upper middle class neighbourhood. Consequently, the students who attend might not be grappling with some of the challenges to learning that other students face. There might not be as many who are learning english as a second language. There might not be as many who face food insecurity. There might not be as many in adequate housing. There might be more students with parents who hold post-secondary credentials. There might be less unemployment. There might not be as many with absentee parents. There might not be as many who struggle with the tab for school supplies or field trips. There might be more parents willing to engage tutors to imporve academic performance. The students might be more likely to have a regular family doctor and to have thier health needs met. There might be more parents willing to chip in to fill the gaps in the budget for class room supplies. There might be fewer students waiting for psych-ed assessments simply because their parents have expedited access by paying out of pocket. As a result, the funding that follows students as having special learning needs might be more likely to be available, simply because a greater share of those students will have been identified. (I do not believe the government publically reports how many students are on the wait list for psych-ed assessments and what their average wait time is). In short, the outcomes observed are not entirely a result of what was done within the context of the school system.

Lastly, and perhaps my biggest area of concern - is the state of the relationship between those who manage the school system (government and administrators) and those who are on the front lines - the teachers. I have come to the conclusion that high-performing organizations are able to return exceptional results with the resources they have because they focus on two things: (1) empowering their staff to work to the fullest extent of their capabilities; and, (2) meeting the needs of their customers. There does not seem to be a whole lot of collaboration. There does not seem to be a whole lot of respect. There does not seem to be a lot of trust. There does not seem to be a focus on students and what they need from the education system (which might not be the same thing in all areas). There does not seem to be genuine leadership. There seems to be a lot of ideology, and a lot of frustration. That is not a recipe for innovation - that is not a recipe for "being the best" by any length of the imagination.

When I think of what the public school system should be capable of doing, particularly in a developed country with adequate resource to fund it, there is not a doubt in my mind that it would be more than adequate to meet the needs of my daughter or any other child in British Columbia. However, now less than a year from the time that my daughter will enter the "school system" - I sit very apprehensive. I suppose I could consider myself fortunate that if push came to shove, private school would be an option for us, but there again it disturbs me that the government would benefit from that decision with a substantial savings from not having to meet its full funding obligation with absolutely no requirement to redirect the money saved into the public system. Again, it seems wrong that there is an incentive for the government to encourage parents to opt out of the public system.

Tuesday, September 2, 2014

The Paradox of Taxpayer Value

Something awful happens when a business focuses its resources on achieving shareholder value. Things are done that improve the bottom line, but risk the long-run viability of the business. Before long, it’s a lean mean business machine that is unable to deliver because of high staff turn-over and abysmal customer satisfaction. Without the right staff, and without a demand for product, the writing is on the wall. It’s not that shareholder value is not important, it is – but rather that, the road to shareholder value is paved with having the right people to do the right things, and having a product or service that customers want, that meets their needs. Shareholder value is a happy side-effect to being successful in business, and paradoxically, when companies focus on shareholder value instead of the things that lead to business success, companies fail.

Despite clear indications that focusing on shareholder value leads to corporate dysfunction and failure – the parallel concept in government, “taxpayer value” has grown to be the dominant focus. The focus is on achieving the lowest possible tax rates – both corporate and individual. Unfortunately, a focus on “taxpayer value” will lead to the same dysfunction that it yields in the corporate world. There is reason to believe that the road to “taxpayer value” is paved by having the right people do the right things, and providing high-quality services that meet the needs of the public.

The relentless focus on “taxpayer value” has resulted in a situation where there is a lot of frustration – and seems to be leading to a situation where the government struggles to attract and retain the best and brightest and seems to be struggling to provide high-quality services that meet the needs of the public (particularly in the healthcare and education sectors). The government seems content with a command and control philosophy – even though, it seems that the world has shifted towards collaborate and innovate. I do not believe, absent a shift in thinking and a change in course, that this will end well.

If companies can shift their thinking and recognize that the road to shareholder value is paved by focussing on their human resources and their customers – why can’t government be capable of a parallel shift in thinking and recognize that the road to taxpayer value is paved with employee engagement and services that meet the needs of those who use them? There is nothing in particular about government that makes collaborate and innovate impossible - rather, all that is needed is the courage to do so, and the commitment to the public service and those it serves.

Sunday, August 31, 2014

Ethics and Single Payer Healthcare

Ethics can be described as the art of doing the right things for the right reasons. Recently, a family doctor (Dr. Brcic) writing for the Tyee claimed that private for-profit healthcare in BC had egregious ethics because the finances of for-profit care were obscure, accessibility of for-profit care was limited, and that individuals coping with pain and illness were vulnerable.

However, in claiming that the ethics of for-profit care are egregious, it would be a large error, an egregious one, to assume that the ethics of single-payer care are any better. Perhaps what is striking and often ignored are the numerous ways in which conflicts of interests and breaches of ethics occur because of the single payer system and how it is structured.

First, by prohibiting competition in the healthcare sector for medically necessary services and being the sole provider of those services, government is in a conflict of interest. It has a political interest in making it look like the system performs well. It has a financial interest in limiting the amount of money spent on services provided. It has both a political and financial interest in limiting accountability for medical error and system failures. It is fair to say that many measures of the system are cherry picked to demonstrate good performance or obscure poor performance. The system does not measure real wait times. The system does not measure care demanded but not received. The system takes credit, for things that are likely the result of other socio-economic changes. Holding the system to account for medical error, or even medical malpractice is notoriously difficult in Canada. Is it particularly ethical that a person wanting cosmetic surgery likely faces a much shorter wait time than a person in need of pelvic floor repair? Is it particularly ethical that a consumer who buys a faulty car likely has more recourse than a victim of medical error?

Second, by making doctors accountable for system sustainability it puts doctors in an unenviable position of being in a conflict of interest when it comes to the best interests of individual patients versus the best interests of the system. Doctors need to be able to focus on the needs of their patients without worrying about the needs of a system.

Third, a single-payer system often results in an arbitrary violation of an individual’s right to medical autonomy. Rather than a person being in charge of what is done, and when, the system determines which choices are available and controls access. If a service is medically necessary, an individual is at the mercy of the system and the system’s assessment of the importance of the condition and accessing treatment. The system assumes (wrongly) that all individuals affected by a condition are impacted in the same way and fails to adequately reflect the wide variety of circumstances that individuals contend with. Further, because of the political nature of a single payer health system, conditions that have a high degree of stigma, or that affect few individuals may have a difficult time jockeying for a fair share of the resources needed. Is it particularly ethical to withhold access to treatment options and care, when the resources are available (upwards of 16 percent of specialists in Canada are unemployed, and more are likely under-employed), simply because public tax money is unavailable, but private resources are available? Is it particularly ethical to deny an individual the right to make medical decisions for themselves, because those decisions do not conform to the decisions the average taxpayer would make?

It is perhaps important to remember that politicians are not always renowned for their ethics, and it is an egregious assumption to declare that doctors are willing to abandon their ethics in favor of profit in a private system.

Wednesday, August 27, 2014

The Fine Art of Feedback - A Lesson for Fraser Health

Feedback is a gift - those who provide it are being brave in doing so, they are providing an insight into not only want went wrong (or conversely well) but how to do better in the future. It's not easy to tell someone else or an organization that they failed you. When a person provides feedback, they do so in the hope that someone else will not be failed in the same way. They do so in the hope that by being open - by exposing themselves, that they can affect positive change. They do so in the hope that their words do not fall on deaf ears.

The easy thing to do, is to defend against the criticism. People and organizations receive feedback as a threat - a threat to their viewpoint. Further, it is difficult to admit that what was done or not done caused real harm to another person. It is difficult to admit that change is neccessary. Particularly difficult when the organization or individual is heavily invested in their point of view or way of doing things.

This past week, Fraser Health got the gift of feedback. The articles, on Today's Parent, and iVillage and comments on those articles are a treasure trove of information that can be used to do better - to provide quality care to all moms, to learn.

However, rather than take the gift as an opportunity to do better, to initiate changes to better serve moms, Fraser Health took the easy way out in their response. Which basically reads like - the choice is yours as long as your choice is the same one we'd make for you, which is to breastfeed, unless it's absolutely not a physical possibility.

So what's the problem?

The problem is that the health and well being of ALL women at a time of exceptional health vulnerability (not just physical health vulnerability, but also mental health vulnerability) needs to be supported. The problem is that a health authority can not just say that they are available to support the needs of those who make the choices they deem to be the 'right' choices. A health authority can not just substitute ideology for quality care and neglect the needs of those who either cannot or choose not to breast feed. The problem is that the right to do what one pleases with ones' own body is sacred and that those choices need to be made out of free will, not coercion.

The problem is that health care provision should never come with a big heaping helping of unjustified guilt and shame, as that generates stigma and undermines quality care.

So what would be the right response, in this situation? How could Fraser Health make the most of the gift of feedback that they've been given?

The right response would be to acknowledge that real harm has resulted from the policy - harm that Fraser Health is committed to remediating. The right response would be to include those who have been brave enough to call out Fraser Health in it's approach to new moms to develop a new approach to infant feeding. The right response would be to develop an infant feeding strategy that treats grown women, new mothers, like adults and respects their right to decide what to do with their own bodies. The right response would be to commit to support all women in the provision of quality healthcare during pregnancy, childbirth, and the year post-partum and to encourage feedback, and to use that feedback to do better.

Fraser Health via twitter has indicated that they are reviewing and would like to talk and has asked for my contact information.

I am hopeful they are now willing to listen, and will ultimately find their way to doing the right thing.

Tuesday, August 26, 2014

Infant Feeding Declarations: A Violation of Quality Care

Quality care begins with an unwavering commitment to meeting the needs of patients by providing informed consent and collaborating on care plans in a spirit of shared decision making. That means working with patients to understand what matters to them, it means providing the benefits and risks of the options available, and it means respecting their decisions. Stigmatizing certain decisions does nothing to promote health and well-being of any patient – including mothers.

As such, it is disturbing to see quality care take a back seat for some new mothers in British Columbia as health authorities fail to support all new moms in what is perhaps one of the most health challenging times of their lives. Specifically, the “Infant Feeding Declaration” that is being hoisted upon women is a reprehensible violation of the duty owed to these women as patients, a duty to provide the care that best meets the needs of mothers and their babies, a duty to provide informed consent, and a duty to foster shared decision making.

In the “Infant Feeding Declaration” women are told of the benefits of breastfeeding and the risks of formula feeding. Further, they are asked to make a promise about their future actions regardless of the circumstances they might ultimately face. Imagine being told that by feeding formula you are providing your child with less than the best start in life – and the additional guilt that is brought on by the feeling that you “broke a promise”. Imagine the stigma associated with even admitting that you happened to use formula.

How does any of that contribute to good care?

Frankly, Fraser Health, and any other health authority in British Columbia or elsewhere deserves to be told that treating patients in this way – new mothers, grown women- is wrong and needs to end. All mothers deserve support as they begin motherhood - all new mothers and their babies deserve informed consent and shared decision making. All new mothers deserve to feel that they can be honest about how they feed their children with their care providers – and that means health authorities should provide care and hold the judgement.

I encourage you to tweet (@FraserHealth) or email them and let them know you think they’ve gone to far. Demand better!

Monday, August 25, 2014

The Irony of Insisting That "Patients Must Demand Better Care"

Ever read the statistics on Malpractice suits in Canada? Maybe peruse the reports from the BC Patient Care Quality Office? Read up on the incidence of medical error? Maybe you have read the latest Commonwealth Fund report on healthcare in Canada – you know the one that places Canada second to dead last among OECD countries in terms of health system performance? Are you at all familiar with who the patients who use the health system actually are? Are you familiar with how the system is structured?

There are those who insist that patients are the ones who should be responsible for changing the healthcare system – that patients should demand better care. It is a shame that those who take this stance have not really given much thought to the reality of being a patient. It is a shame that they seem to have neglected that it is one thing to “Demand Better Care” and quite another to have the demand that is made, heard and then actually result in “Better Care”. It is a harsh truth that there are patients who have been “Demanding Better Care” – in whatever ways they can – but that many of these patients find that their demands are met with the same indifference that the demands of a toddler asking for a non-existent popsicle are met with.

It is all well and good to think that patients should have the ability to demand better care, and that those demands should result in meaningful and positive change. But the reality is that the system is designed in such a way, that the patients are the people ‘in the system’ whose voices are least likely to be heard but who are impacted most when the system fails.

Think about it – think about the resources at the disposal of the government. Think about the organization of doctors, nurses and healthcare providers. Think about the knowledge of “the system” that these other parties to the system have. Think about the levers available to affect change in the system – and exactly how few of them are available to patients. Now think about the reality of facing a health challenge – and then having the burden of “Demanding Better Care” hoisted upon your shoulders when you are at the mercy of the system.

As it currently stands, patients in Canada are in a position where they have tremendous potential to affect meaningful change, but until those who are in control of the system meaningfully empower patients to affect that change, they remain unable to do what they are being called upon to do.

Thursday, August 21, 2014

Imagine Being Unable to Read - Save Literacy Victoria!

This morning I was shocked to hear that the only free resource for adults with literacy challenges in Victoria is going to be closing its doors as of August 31 due to a lack of funding. This is a tragedy in the making - and if it can be averted, it should be.

Imagine for a moment what it would be like to try to cope in today's world without an adequate level of literacy. Imagine being unable to apply on the vast majority of jobs. Imagine being unable to read and understand the directions on your medication. Imagine being unable to understand the directions to prepare your food, or that of someone you love. Imagine being unable to access the assistance available to you because you cannot fill out the forms. Imagine trying to be able to vote, but being unable to understand the ballot.

Literacy is a functional, foundational skill that enables and empowers individuals to engage in today's world. Without literacy, the risks of unemployment, poverty, homelessness, and disability increase tremendously. By improving the levels of literacy to those most in need of assistance, the ability of individuals to help themselves is dramatically increased.

In 10 days, Victoria will lose one of its tools (and perhaps one of the most effective ones) in the fight against crime, disability and poverty.

I note that the Literacy Victoria has a donate button on its website - maybe if enough people take action, maybe tragedy can be averted.

News Story: Literacy Victoria website

Wednesday, August 20, 2014

Bad Evidence Drives Bad Decisions and Bad Policy

There is a saying: “Bad evidence drives bad decisions.” Unfortunately there appears to be growing mountains of bad evidence (or misinterpreted evidence) when it comes to maternity care, and that bad evidence is being fed into bad policy that then results in bad practice and ultimately moms and babies who suffer. Sadly, some of the bad evidence is likely a result of a backwards cycle of evidence and policy where by a policy is developed based on ideology or theory, and then evidence is sought out to support the policy or practice after the fact.

It’s a logic (and arguably ethics) fail of elephantine proportions.

A failure that has yet again been demonstrated in yet another study, widely reported by the BBC: – this time finding that breastfeeding cuts depression risk.

The first big red flag – the thing that should cause policy makers and their brethren pause for thought is the real finding of this study (as opposed to the trumpeted headline) – which is the following: There is a large increase in the risk of depression in women planning to breastfeed who are then unable to do so.

Think about that for a moment, women who successfully breastfeed, who manage to fulfill their objective are seen to have a lower risk of depression (50 percent decrease in risk), while those who plan on, but ultimately find that they cannot, for whatever reason – suffer a large increase in risk of post-natal depression. It is remarkably similar to a recent study that found that women who had births that were unlike the births that they had ‘planned’ were at increased risk for post-natal depression.

So what are the policy implications of this study?

In the news article, the conclusion is drawn that mothers should be encouraged to breastfeed and that there are so many benefits, and that more support to breastfeed is needed, but those who “fail” should be identified as being at risk and health visitors should keep an “eye” on those women.

So in short, the policy response to this study is to keep doing what is likely causing the observed relationship between breastfeeding and depression. Applaud and support the “good mothers” who breastfeed, and further stigmatize those who either choose not to or find that they are unable to breastfeed.

I am dumb founded at the sheer lack of insight as to what ought to be done in response to this study. It seems incredibly clear to me that the right policy response, is to build resilience among all expectant mothers as many might find that for whatever reason they are either not wanting to or not able to breastfeed and by supporting them in the choices that best meet their needs and those of their babies. That would mean toning down the incredible amount of pro-breastfeeding/anti-formula propaganda that mothers are exposed to. That means sending different messages about the meaning of being a “good mother” – messages that focus on outcomes, not process and contribute to a feeling of confidence in what is to many a challenging and difficult new role.