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Did Toronto MD take anti-poverty tactic too far?

Toronto doctor Roland Wong has for years approved every Special Diet Allowance application that patients receiving social assistance ask him to. Those forms, he says, are crucial tools to provide a little bit of extra income to families struggling to make ends meet, to buy healthier food and purchase dental care.

The College of Physicians and Surgeons of Ontario, the medical profession's regulatory body, sees it differently. Dr Wong now stands accused of being "incompetent" and having "failed to maintain the standard of practice of the profession" because he has been signing the applications without first confirming that patients have the food allergies or dietary restrictions that the Special Diet Allowance is intended to help with.

The allowance program has been a controversial one. Anti-poverty activists saw the program as a way to "take back" the money they felt the government should have provided to the poor, as the left-leaning Canadian newspaper The Dominion explained in 2006: essentially, physicians rationalized that even if patients didn't actually have medical conditions requiring the diet yet, living in poverty put them at risk of developing those conditions if they didn't eat better. More recently, disputes over which medical conditions necessitate the extra funding and accusations of discrimination against some patients led to a case before the provincial Human Rights Tribunal, and some changes to the way the program was administered. (You can consult the current regulations governing the program here.)

The complaint against Dr Wong was filed with the College by a local politician, and its roots may be partly financial. The province's auditor general's office last week released its annual report, which included the finding that the special dietary allowance program now costs 12 times what it did 9 years ago, as The Globe and Mail reported Wednesday in that paper's story on Dr Wong. (The Globe also published an extended interview with Dr Wong.)

The auditor general's report (PDF) found many requests were paid "under questionable circumstances" and placed responsibility for the cost increase on a "campaign by advocacy groups critical of Ontario works allowance amounts," which presumably includes prominently the Ontario Coalition Against Poverty, with whom Dr Wong has been involved. For example, the report notes that one family of 10 was identified in which all 10 members were receiving special dietary allowances, for a total of $29,700 in tax-fee aid per year.

The report also describes a doctor suspected of gaming the system, who sounds very much like he may be Dr Wong, or perhaps another doctor operating with similar goals:

In light of the significant increase in special dietary allowance expenditures, one of the service managers that we visited took the initiative to review more than 1,000 of its clients receiving the allowance. It found that one of the 318 health-care practitioners who approved the 1,000 applications reviewed was responsible for approving almost 20% of them. As well, that same practitioner, a general practitioner, diagnosed, on average, nine medical conditions per applicant, compared to an average of about two per applicant diagnosed by other health-care professionals. Furthermore, this doctor diagnosed Celiac disease in 99% of the applications, which we feel is unreasonably high given that the nationwide incidence of this disease is estimated at 1% of the population.
Besides what appears to be the College's concern about the government's concern about the cost of the program, there may another issue at hand. In regulatory-speak, Dr Wong's alleged transgression of simply signing off on the requests translates to "failure to take proper histories and failure to perform appropriate medical examinations, including diagnostic testing."

Consider for a moment that an application for the Special Diet Allowance represents an opportunity for the province to ensure that people on social assistance are screened by a physician. If it turns out Dr Wong was not only signing off without confirming patients' dietary restrictions but that he was also signing off without really examining the patients -- well, he might find himself in serious trouble.

Dr Wong is scheduled to appear at a hearing next Thursday to determine whether his medical licence should be suspended until his case his heard. A group of concerned physicians and professors, led by U of T assistant professor of family and community medicine Dr Gary Bloch, will be sending an open letter to College registrar Dr Rocco Gerace tomorrow to express their support for Dr Wong to retain his licence while the case progresses. "We cannot conceive of harm or injury to patients that might arise from the continuing ability of Dr. Wong to practice medicine," says a draft of the letter.

Update, Jan. 14: The College has decided not to suspend Dr Wong's licence before any decision is made on his case.

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8 comments:

  1. Anonymous10 December, 2009 9:14 AM

    Dr. Wong is trully a real good doctor in Canada!

    Delete
  2. sharon10 December, 2009 9:28 AM

    Context:

    Is Dr. Wong confusing the population health perspective (in his role as medical officer of health ) in his role as family practitioner?

    { see Hamilton & Bhatti population health cube)

    Does he understand how one role demands SYSTEMS advocacy , while the other demands ISSUES advocacy?

    { see Sean O' Sullivan ( politician) doc entitled 'You've Got a Friend' }

    Does the politician understand the broader investment of the " diagonal approach" in community health provision which actually saves money?

    { www.who.int/social_determinants/resources/frenk.pdf }

    Will the academics involved in supporting the good doctor explain to the politician the cost containment of building a broader collaborative base ( dietitian or nutritionist + physician= client access to education, supplements and foodstuffs)where resulting documentation can be submitted by any client portal?

    Can the collaborative ( vs. punitive) approach encompass the current physician, politician, academics?

    Delete
  3. sharon10 December, 2009 9:54 AM

    P.S. If you read Frenk's report ( and check on how Harvard feels about it) you should be interested in discovering what " democratic financing" is.

    (To do this you will have to add a mathematician to your list of collaboratives)

    I tell you clearly that:
    if you:
    (a) identified a stable segment of the client population constantly requiring a supplement,
    (b) delivered it in a consistent pattern and
    (c)(key) coordinated it through technology ( based on a small fee)

    ....that your entire program would generate monies beyond your exponential imagination that would ultimately cover the costs of the entire program.

    Seriously folks........... wake up!

    Delete
  4. sharon10 December, 2009 12:44 PM

    RE: Situational ethics

    For many academics and university prepared professionals they have a decision-making process that is linked to a " tree" .
    At the top of the trunk is the question

    ' What should "I" do?'

    Branching out from the trunke are arms that present YES or NO directions to go in..... based on the criteria.
    This question ' what should "I" do ?' places that professional in a very "subjective" role at the top... which is then supposed to become " objective as you move down the tree.... ultimately translating into a "decision" at the root level..

    and..to continue the analogy....they become "rooted" to that decision.

    Sometimes the issue is not just the first question...sometimes it is found in selected indicators chosen....maybe indicators that could change that initial question to " 'what should I "do"?'

    For many ordinary folks voted into political positions( and often manipulated by mandarins to do their dirty work because they " come and go")...their learning process emerges from "law" and the underlying legislation that birthed it.

    A decision-making tree for someone who looks beyond their own perspective into the perspective of the " law" the top of "their" decision-making trees has this statement:

    " What I should do"

    Branches emerging from that trunk bring forward evidences and ethics that help them identify adherence to the " law" ..... or lack of it.

    Therefore the challenge is not the " perspective" of either discipline. The challenge is for both perspectives to travel back to the true " scientific" approach.

    What bases for scientific discovery do they both like?
    We all know the evidences of science-based
    medicine ( which sometimes simply settles for " evidence-based medicine" without checking the scientific theories behind it.

    Right now the "darling" scientist who personifies the right approach for a " civil society is Pasteur.

    Academics place his ethic in the upper right quadrant because it has : a " use-inspired basic science " approach:
    + potential real-world utility
    + desire to advance scientific understanding
    +basic -to-applied research as well as applied-to-basic
    +inclusive [ thrives with openness, collaboration and apomediation;) ]
    +symbiotic in funder relationships
    +sustained value

    Read Stokes

    I'll try to replace my photo on my website with a picture of a poster I made on this perspective ( poster #10 of 12)

    Delete
  5. sharon11 December, 2009 12:19 AM

    .... sorry...too many megabytes..... :(

    Delete
  6. Sam Solomon14 January, 2010 11:51 AM

    Update, Jan. 14: The College has decided not to suspend Dr Wong's licence before any decision is made on his case.

    Delete
  7. Anonymous23 January, 2010 7:21 PM

    I don't think that most Ontarians understand just how little money is actually given to people on social assistance. In most cases, it is barely enough to pay rent for a room. There is almost nothing left over for food, never mind nutritious food. I don't see anything wrong with the doctor in question doing whatever he can to see patients get fed.

    Delete
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