Yesterday the good news came that the missing MLA from the Nunavut legislature, Pauloosie Keyootak, his 16-year-old son, and his 47-year-old nephew, were all found alive more than a week after being lost in Baffin Island's unforgiving tundra. For days searchers had scanned some 15,000 sq kilometers of snowy, barren landscape in high winds and -35 C weather, with spotters in airplanes and helicopters and others in snowmobiles on the ground.

 For me a wonderful tidbit in the happy conclusion is that it was spotters in a Twin Otter who found them, way off the trio's intended course.

I love the Twin Otter, aka the pickup truck of the sky.  

 This past summer I spent 17 days flying all over the high arctic to celebrate the iconic plane's 50th anniversary. I was with a team from Victoria's Viking Air, the company that has successfully brought the plane back into production after de Havilland stopped producing it in the late 1980s. The trip was homage to the places that made the Twin Otter famous, where it built its reputation as a workhorse and the most hardy, reliable STOL plane in the sky.

Many friends have asked, puzzled, "Why were you on that trip again?" Let's just say it was a confluence of luck and circumstance, an adventure of a life-time that I could not turn down, even if it was far outside my usual day job as a health care communications consultant.

Over the 17 days we flew to Yellowknife, Cambridge Bay, Resolute, Pond Inlet, back to Resolute, back to Yellowknife, Whitehorse, Inuvik, Fort Good Hope, and Norman Wells. Fog kept us out of Gjoa Haven, Tuktoyaktuk, and Sachs Harbour.

 My title was "Ground Lead," which meant I was in the advance plane, a faster Beechcraft King Air turboprop that arrived first in our locations.  I'd put out treats for the kids, and set up a display of colourful flags and banners and a table with a wing rib for locals to sign. A wing rib is an inner supportive strut that gives the wing strength, lightness and lift. We had some 20 ribs with us, all destined to be installed in the 100th Series 400 Twin Otter plane, which should be under construction any day now at Viking's Sidney plant.

 In some places the crowds were small but eager. In Pond Inlet, the lineup waiting to meet us snaked out the building. I, the crowds, and a documentary film crew traveling with us, would all be ready when the slower Twin Otter made a dramatic entrance in the sky, landing on the strip to applause from the locals. The dignitaries (the Viking Air President and the company owners) would disembark from the Twin Otter and the celebration would begin with speeches, commemorative gifts and the wing rib signing.

I was amazed how much people loved signing the wing rib—it had real meaning to put their name on something they valued that would soon be flying the skies. "You will go up in history," I would quip at each location and locals would laugh, pleased. The best part was hearing the Twin Otter stories of the people who signed. 

Many had a personal connection why they had come to the airport to greet the plane and sign the rib. A midwife told me of the babies she had delivered, in mid air, transporting labouring Inuit women in the Twin. "Some of those deliveries were so scary because of the difficult labours, but I never once worried about the plane. I knew it would get us through." She described her favourite time, after the mom and babe had been happily transported back to their home community, when the pilots would fly home low along the landscape. "It was so beautiful and peaceful." 

Geologists told me of the prospecting they'd done with the Twin. Pilots told me of the fun they'd had flying it, "There is nothing like that baby on skis," said one. Others joked how the Twin in the north "always smelled of kerosene and whale meat."

In Inuvik a young woman named Lanita Thrasher, who is one of the first female Inuit pilots, told me how the Twin Otter made her decide to learn to fly: "I was 13 and it was a very scary flight — very bad turbulence and bad weather. My mother and all the other women on the flight were crying, but the pilots were really calm. I decided I wanted to learn all about flying so I could be calm like them." 

In Cambridge Bay, Rick Ekpakohak told me how when he was 13 years old, in 1967, he and his 8-year-oldRick Ekpakohak and his wife Mary. He was rescued at age 13 by a Twin Otter  cousin got lost on the tundra while hunting with relatives in mid February. They were lost for almost three days. Legendary Cambridge Bay pilot Willy Laserich was out looking for them night and day in his Twin Otter. He found them, huddled by a rock on a high point of land. Ekpakohak told me Laserich flew over a few times, took a bright orange toque, put food and a note in it and dropped it from the plane so it landed near them. The note told them to go a location nearby where he could land. It was very rough ground, heaving with wind sculpted ice. Laserich got the plane down, rescued the boys, and was able to take off in near impossible conditions. "He gunned it, put the flaps down and it hopped into the air in a few feet," said Ekpakohak. "The Twin Otter saved my life." 

As the technical manuals boast, the plane was designed for “high lift performance in marginal conditions.” I witnessed some of the Twin Otter's renowned capabilities first hand. Coming back from Pond Inlet to Resolute strong cross winds bedeviled the single landing strip. The King Air got in, but with the Twin Otter more than an hour behind us, the winds continued to build. "They may have to bail and go back to Pond, it is getting too dangerous," our King Air pilots said. We watched the Twin Otter approach in gale force crosswinds. It did a looping fly over and appeared to be turning around. "They're heading back to Pond," we thought. But no. Pilots Ariel Pettigrew and Sylvain Breault did another approach, this time sideways to the strip. They flew head into the strong wind, as slow as a hovering hummingbird, over the top of the airport. Astonishingly, they landed and stopped in the width of the narrow runway. We were jubilant on the apron.

A NAV Canada technician, Francois Gravel, caught it all on his cell phone."Holy Shit!" he says on the footage. "I’ve never seen nothing like that!"  Later, when he showed the clip to me, he said he was sure he was filming a plane crash. "I'd heard the Twin Otter could do that, but I'd never seen it done."

During our tour I rarely got to fly in the Twin Otter myself. So on the final day, when a volunteer was needed to join pilots Breault and Pettigrew and our mechanic on the slower Twin Otter flight back to Victoria, I happily complied.  The King Air left with 6 passengers and two  pilots the night before. The next morning, Saturday July 19, in a plane chock full of our gear and luggage, the two Twin Otter pilots, the mechanic and I left Norman Wells for the 10+ hour flight back to Victoria.

"On the first stretch, we have to go up over the mountains, but the weather is pretty bad, so we may have to go pretty high," said Breault showing me the route. Since the Twin is an unpressurized plane, anything over 13,000ft means we would need to use supplemental oxygen. 

We took off and began to climb, first through rain, then sleet. The mountains were 9,000 feet . We climbed 11,000 ft, 12,000 ft, 13,000 ft,  all the time in hard driving sleet and snow.  I looked out the window to see ice building up in thick layers on the wings and struts of the plane. It was two inches thick and building. Ice was flying off the propeller and hitting the plane skin and windows: ding, ding, ding, like pebbles on a metal can. I decided it was best not to look out the window. 

 Pilot Breault came back and put on the supplemental oxygen – tubes and a mustache-like bolus of plastic under my nose. He put a pulsimeter on my finger to measure whether I was getting enough oxygen and showed me how it increase the flow with a valve on the line.  “What happens if I don’t get enough?” I asked. “You’ll black out,” he said.

He seemed calm, matter of fact. I took my queue from him. I’d panic if they panicked. He and his partner Pettigrew have thousands of hours flying Twins.   As a pair they deliver brand new planes off the Viking production line to clients all over the world. They fly planes filled with bladders of fuel in the fuselage, like flying with a huge bomb. They have flown in everything. The highest altitude they'll take a Twin Otter is 22,000 ft. That is when a delivery route takes them over North Korea. “We have to go that high but it’s not fun that high,” said Pettigrew. 

 I could see them in the cockpit constantly refreshing the weather map, over and over, this green enormous mass of ugly precipitation all around.  “We are going to have to go higher to get out of this stuff,” said Breault — 14,000 ft, 15,000 ft. Still sleet was building up ice on the wings. I don’t know if it was thin air or pure terror, but I found it hard to breathe, 16,000 ft, 17,000 ft. The potato chip bags in our snack supply exploded. I put on my iPod, to classical music shuffle, hoping relaxing music might calm the quiet trapped panic I was feeling, but the songs didn’t help: Mozart Requiem, Brahms Requiem. Acck, try pop!! Up came Taylor Swift’s “Last time.”  Dylan’ “Knockin’ On Heaven’s Door." I'd laugh under less alarming circumstances. 

At 18,000 ft we finally broke through the heavy precipitation into clear blue sky. The relief was palpable all around.  The ice fell off. We flew for about an hour at this high altitude. My hands swelled up, rings tight on my fingers, dull headache.  Then it was time to descend, back down through the ugly black cloud of sleet and snow. We iced up again; ding, ding ding on the fuselage. I closed my eyes. When we landed safely, I felt drained but exhilarated. 

“Was that as bad as I thought it was?” I asked Breault and Pettigrew once we were safely on the ground in Watson Lake. 

“It wasn’t pleasant,” said Pettigrew. “We wanted to get out of it.”

 “Was all that ice dangerous?”

 “The Twin Otter can take about 5,000 lbs of ice on its wings before having trouble.”

 “How much did we have?”

 “Hmm, maybe 2,000-3,000lbs. But we had a really heavy cargo load. So we wanted to get out of that weather.”

 The rest of the flight from Watson Lake to Smithers to Victoria was phenomenally beautiful. We flew at about 1000 ft, or lower, over the rolling Chilcotin, past the Lillooet Ice fields and stunning Mount Waddington, out Bute Inlet, over Desolation Sound and the Gulf Islands. At times we were flying so low it was as if we could see what people were reading on their Gulf Island decks. They’d look up and wave.

We arrived back into Victoria at 6:30 pm. That day I had the full Twin Otter experience, from a white knuckle, bad weather nightmare to the glorious soaring of blue sky flight.

And when I step back on the ground I thought, I really do love this plane.

-30-

.   

Recently, Justin Trudeau and his wife Sophie Gregoire have come under fire for having two nannies on the payroll of the Prime Minister's staff. Here is what life might be like if they had to arrange sitters for evening childcare. 

"Honey, we've got that state dinner with the Thai Delegation next Thursday, have you lined up Emily?

 "Well, I called her but she has an exam. So then I tried Sarah, but she's getting her wisdom teeth pulled that morning." 

"How about Jessica? The kids love Jessica."|

 "Jessica? You said 'Never again!' for Jessica after she tried to sneak her boyfriend past security!..."

 "Oh yeah ...right....What about Hannah?"

 "Well, we really need someone who drives, because Xavier has judo after school and needs to be picked up."

 "My mom could pick up Xavier. She could stay with them over dinner. The whole night is too much for her, but then Hannah could do it for the rest of the evening....Mom would love that."

"We're using your Mom way too much. I know she likes it, but then my mom gets feeling all left out and I never hear the end of it. Every time she calls she says, in that way of hers, 'I wish I could be closer. I see on Facebook that Margaret is doing this and that with the kids.' I honestly don't need that right now. "

"Well, Xavier could miss judo.  Then we could get Hannah."

"He loves judo! And I don't want him to miss any more. He really needs it right now. We've had so much change and upheaval.  And, besides,  I don't want Hannah..."

"What's wrong with Hannah?" 

"She always leaves a mess and I think she spends more time texting friends then interacting with the kids. "

 "Hannah's great. I like her."

 "Of course you do,  she flirts outrageously with you!  'Mr. Hottie Prime Minister'  And you lap it up!  Just watch it,  buster! I've been thinking of setting up a Teddy-cam."

 "Oh for godsakes ...Okay,  so we won't use Hannah. ...

 The next day.

"We still don't have a sitter? Why don't you call Catherine McKenna, she's got three young kids, maybe she has some names..."

Sophie calls.

"Hey Catherine, it's Sophie..... Oh just great thanks,  how 'bout you? Ready for Christmas?.... No, me neither. .. Well that's what we get for going to Paris to fix climate change so close to the holidays, eh? (light-hearted laugh).

"Look, I won't keep you, I know you're really busy with the whole Environment portfolio.  We've got this state dinner with the Thai delegation next Thursday.... Oh, you're going, too? Of course!... Look we've gone through our list and no one's available....Have you got any names? .... Oh yeah? .. Uh huh....Sounds interesting....

Writes down a name and number.

Have you used her? .... No? Well okay....  Thanks so much. Hey, hope to see you at yoga! Bye Bye."

"Okay, so Catherine says the ambassador of Madagascar has a teenage daughter who's keen to do some sitting so she can get out of the house. ...She's fluently bilingual, so that's great. Catherine doesn't know anybody who's used her yet, but she was talking to another mom at Rockland Kindergym last week and got her name and cell. Maybe we should give her a try....?

"Well if you think so..."

"Well, she has a car with diplomatic plates so parking outside of judo won't be a problem. That can be such a nightmare at 5:30 pm.

Calls number

"Hello is this Hanitra? It's Sophie Gregoire, the prime minister's wife.....Well, thank you, yes,  we were very pleased with the election results.

"Look, I hear through some Rockland Moms that you do some babysitting... You do? Great! Are you free next Thursday night?  

"Well that's fantastic..... We'd need you at 5pm. You'd have to put Ella-Grace and Hadrien in your car —we'll leave the car seats out.  Then you'd go pickup of Xavi from judo at 5:30. The cook will have dinner all prepared, but you'd have to eat with the kids. Is that okay? ... Oh that's just wonderful. We'd likely be home before 1 am.

"You're double time after midnight?  No, no,  that's just fine, makes sense on a school night. Look I'll  let security know your coming and they will buzz you in at the gate. And I'll text you the address for the judo .... Great. See you Thursday. Bye-Bye."

(Big sigh) "Okay, that's got next Thursday covered.....Now when's that dinner with the Obamas?

-30-

I have been a freelance magazine writer for 20 years and was the managing editor at a Victoria BC magazine for five. I am offering this insider information about how to be a successful freelance writer to help struggling writers everywhere.  And I am doing it to help beleaguered editors receive higher quality pitches from writers with more skill and less ego.

Part Two: The Art of the Pitch

Editors want the classic three to four paragraph pitch. It is not because we are stodgy old farts, it is because we don’t know you and we are taking a HUGE risk if we assign to a writer we don’t know. We are keeping two to three pages of our precious magazine open for someone who must be able to come through with a story that is accurate, well-researched, well-written and right for our magazine. If we make a mistake and back the wrong writer with the wrong idea, we are hooped. We don’t have a lot of inventory. The better the pitch, the more confident we feel about taking a risk.

How to write a winning pitch

1. Open with how it might open in our mag. (This shows us you know our style and what will fly in our pages.)

2. The second paragraph details what the story is all about— what it will cover, who it will interview and what style it will be ( profile, investigative feature) (This tells us you have a good handle on the subject matter and have a general workable approach for the story.) Be succinct: make it visual, so we can “see” the characters, the place, the scene.

3. The third paragraph tell us why the story is right for the magazine and its readers. Why our audience? Why now? Why do we care? (This tells us you know our audience and why they will read this.) Ask yourself, would you read it?

4. The fourth paragraph tells us why you are the person to write it. Summarize your experience, give us a brief précis of your CV or expertise, your publishing track record, your clips. If you haven’t yet got a magazine track record, still let us why you are a good risk for this story. (This tells us we can rely on you to come through with the story, that you are a good risk for us and we are not going to be left with a gaping hole in our magazine or a piece of dreck.)

How to send the pitch

Send the pitch as an email, with “Pitch” and a short description in the subject line (e.g Pitch -- Profile of Joe Smith.) Put the four paragraph pitch both in the body of the email and as an attachment in a Word document. Some editors want it in the email, some as an attachment. Give it to them both ways. (Or better yet, give it to them the way they have asked for it on their website or in The Writer's Market.)

 One pitch per email. Sometimes writers pile in three or four pitches in one email. Editors need to file pitches into the best months or by priorities (we are not going to assign three stories to one writer in one month. That is too many eggs in one risky basket.) Or we like two and hate two, so we want to kill off the two we hate and file the two we like. So keep them separate. You may make three pitches at once, but keep them all in separate emails so the editor can read and decide quickly and file accordingly.

How to follow up

It is important to follow up on a pitch, but do it in a way that does not piss the editor off. Here are a few tips:

• Follow up nicely in about two weeks: Editors are very busy. In the monthly publishing cycle we can be dealing with any number of fires. If I have been so busy not to have read and filed your pitch, it can get buried under emails. (An editor can get 200+ emails a day.) If I don’t know your name, if you didn’t put pitch in the subject line, I may never find it again. If you don’t hear, it may be that the editor has not rejected it, or even read it, but has no way to find it in the huge volume of material we get. Email and say: “About 2 weeks ago, I sent you this pitch (and send the pitch again) and I wondered if you had time to consider it. Let me know if there is anything more you need.” Be nice!! Be understanding, be patient, but be persistent. We like persistence. It is a good quality in a journalist.

• If they get back to you and reject the pitch, thank them for their consideration, ask if there was anything that you could have done to make it better, and very soon (a week or two) send another completely different pitch. (Don’t keep pitching a story that was rejected, unless you have a different angle or are fixing up and presenting more of what they said they needed.)

• If you don’t hear, or they don’t outright reject the pitch, follow up a month later – freshen the pitch if new information has come in (the interview subject is up for an award, a new book will be released.)

• And follow up again. Even write something on spec to show your talents. (But be damn sure it is good.) A bad spec article will close doors. A good one will open doors. If you think they are not giving you a chance and you really can do it, show us you can. But make it fantastic. No factual errors, no name errors, no typos, make it a story we can see in our magazine.

•  Pleasant persistence will eventually be rewarded because it shows you are dogged and we want that in a writer.  So we will finally give in and take a chance on you, if not on one of your ideas, on one that we have kicking around that we are looking for someone to do. For writers new to us it will likely be a brief.

• Do not pitch the same story to another magazine in the same market at the same time. This will seriously harm, if not destroy, your reputation. If you want to take it elsewhere and the editor has not yet responded, ask (nicely!) whether they have decided so that the idea can be released. This will often make the editor decide. Do not say that you have another magazine interested in the idea as that will tell us you sent the idea to another magazine while we were considering it. That is very bad form.

• If your story is rejected, do not take it personally, Many reasons keep editors from buying stories, including a lack of money to do so, lack of space in the magazine. The story is not your baby and it may not be fantastic just because you wrote it. At all times in this process, “get over yourself.”

Next up, Part Three: Writing the story.

I have been a freelance magazine writer for 20 years and was the managing editor at a Victoria BC magazine for five. I am offering this insider information about how to be a successful freelance writer to help struggling writers everywhere.  And I am doing it to help beleaguered editors receive higher quality pitches from writers with more skill and less ego.

Part One: Before you pitch

Study the magazine

• Get as many back copies as you can. Read the departments, note how many features they have, see which ones have regular designated writers, which ones seem open to freelancers. What is the tone, the timing, the balance of articles?
• Check out the magazine's website. Writers’ guidelines or back copies are often posted on their site. Books like The Writers Market also detail the magazine's requirements and pitch processes. The Writer's Market  is also online now for a subscription fee. See writersmarket.com
• Check the masthead and find out which person is the assigning editor, but these days it may just be the editor in chief or managing editor. If you have not found pitch information on the magazine's website or in The Writer's Market...email that editor for writers’ guidelines and pitch cycles – but keep email short and to the point and don’t send your resume yet. The editors only want to know about you if you have a story to pitch.  Just ask about how to pitch to the magazine and what sort of pitches the editor is looking for, how and when the editor would like to get them. (After you have made sure that info is NOT on the website.) Some editors take pitches monthly, some quarterly, some just annually. Ask if they will consider spec submissions. Find out how far in advance you need to pitch for seasonal stories. It could be six months to a year ahead.
• Try to go back at least two to three years. Libraries will often have back copies. You do not want to pitch an idea they have already done. You will be forgiven if it was more than 18 months ago, but if it was within the last year, we know you have not looked at our magazine. We will frown and be disappointed with you. If it is an idea that we already have in the hopper but not yet published we will think you are prescient and in tune with our needs.
• Who is the magazine's audience, the demographic? Then think about all the ways to interest them that fall within that audience. Magazines differ from newspapers: this kind of writing must not only be newsy, it must also be a pleasant experience for the reader to take the time to read it. Magazines are also a visual medium. What will your story look like illustrated, or with photos and/or graphics?

Come up with a great idea

Do your research to know that there really is a good story there that you can bring to life for that magazine's audience. Some don’ts:

• Don’t pitch a profile of some big celebrity if you have no idea whether the celebrity will consent. Don’t pitch an insider scoop on some industry, if you have not yet established insider status.
• Don’t pitch a topic. Pitch a theme and an angle. Be FOCUSED. Zero in on some new aspect of a story.
• Don’t pitch a story geared for parents of young children when your research shows the magazine demographic is 35+; or don’t pitch how to find deals at Value Village or stretch the food dollar when the magazine is aimed at the affluent reader. Don’t pitch a 3,000 word feature when the magazine’s longest feature is 1,500 words.
• Don’t pitch a whole new section of the magazine, or a series of articles (when the mag doesn’t do series) or that you write a new column. The magazine is not going to remake itself for you no matter how great the idea!! Mags have templates and structures. Pitch within the structure — different enough that we haven’t yet done it, but not so different that we can’t imagine doing it. Once we know and love you and we will do anything for you, then you can pitch the column, series or new section…
• Don’t pitch a story with a short time line. If you have done your research in point one, you will know how far in advance the magazine plans stories. Most national magazines work six to eight months ahead at least.  Local or city magazines work four to five months in advance.
•  But if you have a seasonal story that can be done now, that will stand up for publication a year from now do pitch it. Say: we can get colour, details and pictures right now and let us know why the story will stand up for a year. That is thinking ahead! We love that.
•  Don’t pitch the predictable. See things that others don’t see. Take a new angle. Find the hidden story. Tell us something about the region we cover that we have never heard before, something that is sitting there under our noses that we have never thought about.
• Don’t forget to talk about what kind of art might work, and let us know if you can take pictures. Most magazines will assign photographers, but some want research photos to help plan layout or to get photos in a pinch.

For new writers wanting to break in, the best “starter” articles are short briefs or quirky "evergreen” stories that can run anytime. Editors always need a few flex stories – stories that we can drop in if we suddenly get more pages or if another assigned story falls apart. If it is an evergreen we can take time to work with a new writer to polish it to get it right rather than assign a story with a strict time frame or seasonality that makes it unusable if it doesn’t run in that month.

Next up: The Art of the Pitch.

Just a few days after I published my last blog entry, lauding the new era of co-operation between doctors and government, Ruth Lavergne and Kim McGrail, researchers at the University of BC Centre for Health Services and Policy Research (CHSPR), published a commentary in the Globe and Mail that was highly critical of one of the key programs under these changes.

You can read their online commentary here, http://bit.ly/1yVovzH/ ,but the headline sums up their stance pretty succinctly:"Was BC's push for better primary care a $1-billion bust?" The article is based on their study, published in the May2014 Healthcare Policy, which examined 20 years of patterns of family doctors' fee-for-service billings in BC. They use this administrative data to come to the conclusion that patients have not been served by the program of incentive payments to GPs brought in under this joint doctors/government culture. You can read the abstract of their study here: http://www.longwoods.com/content/23782

"Isn't this at direct odds with your perspective, Anne?" I was asked in an email by one of my thoughtful blog readers.

It is, indeed. But I think their study has serious limitations, makes assumptions not backed up by their own or other research evidence, and comes to conclusions that cannot be made from their data. Moreover, they completely ignore patient health outcomes, which as I explained in the previous blog, was the unifying factor that got the perpetually-wrangling docs vs government to agree on a program in the first place. As I noted in the previous blog, I am working with these committees to explain their rationale and activities.

I am going to explain here why I think this study is weak and inconclusive. It is going to be a bit of a long entry, so bear with me. You can see whether or not you agree with me. I welcome debate and discussion.

First I will summarize what the authors did and what they say they found. They used administrative health data linking patients' anonymous personal health numbers to individual general practitioner's fee-for-service billing data, beginning from 1991/92 through to 2009/10.

They looked at what they called four main "conceptual" measures : access, coordination, continuity, and comprehensiveness. In essence that meant they looked at, from the billing data, where the care was provided (doctor's office, house call, hospital, nursing home) who it was provided by (one doctor or more than one over the year); what time of day it was provided (after hours or in office hours), and what was done (they looked at PAP screens, mental health, maternity care, glucose and lipid testing.)

They concluded that access, coordination, continuity had all continued to decline. Interestingly for comprehensiveness they found only the number of individual GPs doing maternity care had decreased during the study period, but the number of GPs doing mental health care, PAP screens, and preventive tests like glucose and lipid testing had actually increased — remember that, because I will come back to that at the end. They conclude in the Globe commentary that patients would be better served by putting BC doctors on salary.

Here are my problems with the study:

1)It studies trends from 1991 through to 2010. The decline of primary care was well underway for more than a decade when the joint General Practice Services Committee (GPSC) was formed in 2003. The bulk of the GPSC incentives and the Practice Support Program that teaches doctors and staff both clinical and administrative skills on how to use the incentives started late 2007 and didn't gain force until 2008/9. Some incentives came in after 2010. How can the CHSPR study make blanket statements about success or failure based on 2 or 3 years of 18 years of trends data?

2.)There is no control group, or no comparison to what happened with GPs in other jurisdictions over the same time period. BC's changes applied across the board to all doctors, anywhere, but it was completely voluntary. CHSPR, by using billing codes cannot distinguish who was "on the program" and who was not. As with all programs there were early and late adopters. All these are in the same sample. They cannot show what might have happened to their data if no changes had been applied or a different model was taken in BC, in light of a huge decline in family practice across all Western nations.

3.)They make the assumption that seeing more than one doctor is bad for care (without showing its impact on patient outcomes.) We do know that going to walk in clinics, for a single issue and that doctor not being able to access the patient's full medical record, is not as good care as having a doctor know the whole patient history and seeing the full record. But in BC now many doctors are working in group practices, such as my GP. That means when I make an appointment at her office, if she is not available, I may see one of her associates but they all have access to my health record, my Rx history, my pap screen record etc. In the last year I have seen four doctors, all in my family doctor's office, all of which coordinated around my care. The CHSPR study of billing number patterns cannot distinguish group practice from walk in clinics, when an increasing number of GPs this past decade are working in group practices.

4.)They equate house calls, hospital care, and after hours care with patients having higher quality care and being seen in doctors' offices, during office hours, with patients having poorer quality care. Where is the evidence that house calls, hospitals and after hours is better care and being seen in the office is lower quality? BC has been focusing on managing chronic diseases, planning care and avoiding crises and hospitalizations. This data finding could equally mean that fewer patients are having crises. A doctor that does a house call takes more than five times as long —- keeping other patients who need care waiting. It is very inefficient. Does it lead to better care? We cannot say. It is likely better not to need a house call at all. BC has also introduced in 2010 incentives for telephone calls from GPs to patients at their home, which greatly reduces the need for house calls, which this study also did not pick up. How can they conclude patients are worse off now from this finding of location of care? They cannot. There is one finding, however, that concerns me: A 20-year steady decline in GPs visiting their long time patients in nursing homes. If we want GPs to support patients to the end of life, how we stop this trend should be examined.

5) They say patients are not being seen after hours by doctors and equate that patients are therefore being less well served. They cannot make that assumption in BC because if a doctor's practice or group practice has decided that they will regularly have one or more nights a week where they provide service into the evening, as many have done in the last 10 years, there is no fee code difference for time. There only is a fee code difference if the doc is called out on an emergency after regular hours. BC's changes are all aimed, again, at avoiding the crises and emergencies, and going to better managed care. It is better for doctors and better for patients to avoid those after hours emergency calls.

6)They don't look at system outcomes over the time frame. CIHI data shows that BC is now leading the country on a number of key health indicators of system performance:

• Ambulatory care sensitive conditions:  Since 2005 we have the lowest "ambulatory care sensitive conditions." This is a horribly obtuse term for acute and chronic diseases that with good primary care management outside of hospital (ambulatory care) leads to reduced or fewer hospitalizations. It is seen, world-wide, as a measure of an effective primary care system. So BC has the lowest hospitalization rates for diabetes, asthma, COPD, congestive heart failure, high blood pressure, vaccine-preventable conditions, pneumonia and gastroenteritis.  This is good.
• Avoidable mortality: BC has the lowest avoidable mortality in Canada, meaning we have the fewest people dying before 75. This is seen as a measure of the general health of the population — in BC we have the fewest smokers, the most exercisers, and the lowest rate of obesity, which really has nothing to do with our health system — but avoidable mortality is also seen as a general measure of overall health system performance.
• Avoidable mortality for treatable causes: BC has the lowest rate of death under age 75 once a disease is found. So if you are diagnosed with diabetes, or high blood pressure, BC's death rate is the lowest in Canada. This is an important marker of quality of health system performance. Could it be lower? Yup, particularly among the poor in BC. The wealthy in BC have among the best rates for this measure in the world. Our poor very much less so. But socio economic status (SES) has a huge impact on health outcomes. The next huge jump in health improvement is making sure the poor are as healthy as the wealthy. No one has cracked that yet, but systems like Scandinavia and Netherlands, which have less inequality in wealth, have less inequality in health outcomes. If you are interested in reading more about national health indicators, and the impact of SES on health , read the 2013 CIHI Health Indicators Report, available for download here: https://secure.cihi.ca/estore/productFamily.htm?locale=en&pf=PFC2195&lang=en
• Per capita spending on health by province. BC has the second lowest per capita spending on health, second only to Quebec. The Fraser Institute always uses this to say that BC is under spending, but our health indicators do not show this. In Quebec, the health indicators (near the bottom half) would suggest they may be under spending. In BC our lower per capita rate, coupled with better national health indicators noted above, would suggest that we are spending less money because we are keeping people healthier and out of hospital — which is what we want. That means we have a more cost efficient system. Could it be better? Yes compared to other countries.
• Per capita spending for physicians. Highest rates according to CIHI are in Alberta and Ontario ($986 and $942) and BC is in the lower half of the pack at $844. So this shows that what we have been spending on physicians this last decade is actually less than other provinces and not so out of line, despite the "$1-billion bust" headline. CHSPR's focus on $1 billion is taken of proportion to the overall costs. Health care is mind-blowingly expensive. Our provincial system is $17 billion a year, so $1 billion over 10 years actually works out (when you factor the various growth rates of expenditure) to about 2.6 % of the annual health budget. In BC the health system burns through $1.2 million ever hour, so in the time I wrote this blog close to $3million was spent in BC! Check out this CIHI report for national and provincial health expenditure data if you want more info:  https://secure.cihi.ca/free_products/NHEXTrendsReport_EN.pdf

7.) The authors suggest that Ontario's primary care reform has been more effective. Ontario underwent changes at the same time in BC, but that province now actually has three systems of primary care for doctors. In another blog post I am going to take a closer look at the pros and cons of Ontario, compared to what BC has done, because that is a huge and complex topic. I know that this blog post has been going on too long and, you dear reader, are getting tired.

8.) Comprehensiveness.  I told you to remember the finding that mental health care, Pap screen, lipid testing and glucose testing had all improved over the time frame of their study. This is a point the study completely dismisses, yet this is precisely what the incentives were geared towards. These are the kinds of actions that appear to have an impact on patient health outcomes.

9.) Maternity care: One last point, I promise. Fewer doctors doing maternity care is concerning, but that is a finding that is happening everywhere across North America and has been declining for decades. In BC, the maternity incentive HAS NOT focused on supporting solo doctors doing maternity care because that is not so good for patients and most doctors do not want to do this alone. Solo doctors can only do so many deliveries a year and we know the more you do the better you are. Rather, BC has focused more on providing incentives to support a group of doctors joining together in group practice to share maternity care, to which other GPs in the region refer their pregnant patients. You can read about the details of the "Maternity Network Initiative" here: http://www.gpscbc.ca/family-practice-incentive/maternity-network-initiative . Evidence shows this concentrated care is better for patient outcomes and better for doctors' lives, meaning more docs are willing to deliver under this kind of model. We still need to find more ways to provide good maternity coverage outside of population centres. That is a real challenge. But the CHSPR study, finding fewer individual doctors are doing maternity care, cannot jump to the conclusion the situation is worse for patients now than prior to the incentives.

In closing, BC is by no means perfect. We still have a ways to go. One huge task is to ensure that everyone who wants a family doctor has one. One very promising change since the BC program is that more new medical graduates are choosing family practice, up from the nadir of 23 % in 2002 before the changes took effect to 39% in 2014. More family doctors are in the BC system and that helps more patients find doctors. It is not solved, but believe me this is a focus of a whole bunch of activities.

I believe we have a much better chance of doing the changes we need in a culture of collaboration between doctors and government that asks the question "what is truly best for patient care?" We should never be afraid of looking at evaluations to see whether we are actually accomplishing that.

 I fear, however,  the damage that can be done to this fragile cooperative relationship with simplistic studies that claim patients aren't benefiting, that only doctors are, and that don't look at the big picture.

Thanks readers, for staying with me on this long post. Again, I welcome debate and discussion. I don't have the answers, but I do try to present things as clearly as I see them.