The Appalling Treatment of Dr. Elaine Ma Is Hurting Health Care in Ontario

I’ve written about the horrific treatment that Dr. Elaine Ma has been subjected to by the bureaucrats at Ontario Health before. The situation is so ridiculous that it could be a story presented at the Theatre of the Absurd.

What happened?

Dr. Ma is a family physician from the Kingston area. During the Covid pandemic she realizes the need to immunize as many people as possible to protect the community. She organizes a number of outdoor mass vaccination clinics, which resulted in Kingston being one of the most heavily vaccinated areas of the province. For her efforts, she wins the very well deserved the praise of many, and an award from the Ontario College of Family Physicians.

There are two billing codes for providing Covid vaccinations. One for physicians who work in a vaccination clinic that someone else set up (e.g. public health). Another for those who set up the clinics themselves, and paid for staff/heating for outdoors/tents/internet etc. Since she paid for all of that, Dr. Ma bills the second code.

Dr. Elaine Ma

Fast forward a couple of years and the callous and unthinking bureaucrats at OHIP decide that she has billed the wrong code and demand she pay back $600,000. I won’t restate all the steps she went through to fight this. I will state that the reasons for them wanting the money paid back varied between the clinic being outdoors instead of indoors, medical students being involved and so on. But eventually the case winds up at Divisional Court.

On Dec 16, the court handed down a ruling supporting Dr. Ma. What I had failed to realize before is that the Ontario Health bureaucrats main argument appears to be that there were no extenuating circumstances during the time of the Vaccine Clinics that Dr. Ma set up. Yes, you read that correctly. The whole country was in the midst of a (hopefully) once in a lifetime pandemic. Canada was effectively shut down for business. People were not allowed to visit loved ones in hospital or nursing homes. Travel had ground to a halt. But, in the minds of the soulless and spiteful bureaucrats, none of this constituted “extenuating circumstances”.

Thankfully, Divisional Court Justices Matheson, Varpio and O’Brien were having none of this nonsense. They clearly stated the decision by bureaucrats that there were no extenuating circumstances was “unreasonable.” (I would have, and will, call that decision much worse things). The Justices pointed out the obvious. There was clearly a public health crisis at the time, and that many leaders, including politicians were calling on physicians to get the vaccinations done.

More importantly they stated something the OMA’s legal team really needs to take a deep dive into:

…”that the wording of section 17.5 does not limit relief to unpaid claims; it only requires the presence of extenuating circumstances. Since OHIP typically pays claims first and reviews them later, a restriction on unpaid claims would effectively nullify the provision. The court called this interpretation unreasonable.”

Currently OHIP pays physicians whenever they bill. Later, OHIP decides if it was reasonable or not, and if OHIP feels the situation is unreasonable, they demand the money back. The justices seem to be saying this process is not fair. Which has implications far beyond this one case. Obviously, this would not apply to clear cut cases of fraud. It is a much much needed kick to the slow, incompetent, and spiteful OHIP review process. I can’t possibly understand the potential future implications for this – but I suspect there will be many.

Finally, the justices let their displeasure be known by ordering OHIP to pay Dr. Ma $10,000 in court costs. This strongly suggests to me that they were peeved at the OHIP bureaucrats for taking it this far, and really didn’t think it should have gone there.

How is this hurting health care now?

Ontario is currently seeing an unprecedented surge in flu cases. Flu season has come early. The current variant appears to be extremely strong. It is circulating at “sky high” levels among young people. Three children (at least) have died. Hospitals have declared outbreaks and wards are closed. Visitation has stopped.

Sign on the door to the Medical Ward of my Hospital

You know what would really help? If only some people would come up with some innovative ways of getting their communities vaccinated against the flu. Yes this year’s flu shot is a bit of mismatch for the current strain, but it still provides some protection and keeps you from getting really ill.

Or how about an innovative idea for where to safely look after patients like was done during the Covid crisis. My friend Dr. Bryan Recoskie set up a unique 18 bed ward in our local Legion, to look after non-covid patients while the hospital wards were shut with covid positive patients.

Dr. Bryan Recoskie

And yet, I don’t see any of that happening right now. Don’t get me wrong, doctors continue to go to work. We continue to care for the sick and continue to comfort those in need. We continue to do our best in these trying circumstances.

But I can’t find any evidence (please correct me if I’m wrong) – of where people are doing unique out of the box things to try and mitigate the currently unfolding nightmare. Given the potential exists that IF you try something unique, you may wind up undergoing two years of pure hell by bitter, ruthless and depraved bureaucrats – can you blame people for not trying?

To quote a good friend of mine, “The damage has been done. Nobody is going to stick their necks out now.”

What should happen (but won’t):

First, under no circumstances should OHIP appeal the decision from Divisional Court. The mercilessly inhumane bureaucrats need back down. Second, Health Minister Sylvia Jones needs to do what she should have done a year ago – and direct the bureaucrats not to seek any recovery at all from Dr. Ma. It’s just the right and decent thing to do.

Finally, it would really help if Minister Jones issued a formal apology to Dr. Ma for how she has been treated by the bureaucrats. It’s not just the OHIP bureaucrats. Jones’ own communications director, Hannah Jensen claimed Dr. Ma had “pocketed the funds“, a statement that clearly suggested malfeasance.

Do that, and maybe, just maybe, physicians would once again feel comfortable coming up with out of the box solutions for crises that are occurring.

Maybe.

More on the OMA Elections

I don’t often reply to critiques of previous blogs. My opinions are my own, and disagreements are part of life. However, there were a couple of consistent themes in critiques to my last blog, OMA Manipulates Board Elections and Weakens Members Voices. I think it is worthwhile to address those.

Is “Relational Advocacy” a Concern?

The first theme was that it was distracting to express concern that people who work at the OMA would be inclined towards what’s been called relational advocacy. This would be to suggest that they may not be as aggressive as needed on some issues, due to concerns about implications for potential future career prospects with government. More than one person told me off about this.

In order to know for sure whether this is something to be aware of, or whether it’s just the rantings of a miserable grumpy old bugger, one would have to do an exhaustive search of people who went to work for government after working at the OMA. It would require extensive resources to search things like LinkedIn profiles, available public employment data bases, and the like.

It being 2025, I therefore had ChatGPT do the search. My initial ask was to see how many employees left the OMA to work for the Ontario government from 2000-2025. This turned up 12 verified people (I won’t print their names). Even I would admit that doesn’t seem like much of a concern.

I then realized I had done the search wrong. I should have asked how many OMA employees went on to work for the government OR any government funded agencies. Agencies like hospitals, Ontario Health at Home, Family Health Teams, Public Health etc etc .

The results of this much more comprehensive search? Up to 80 people. The software had to do a fair approximation due to not everyone having searchable info. (The OMA has about 300 employees).

Should we hold it against those people for seeking other employment? No. People should be able to make decisions in the best interests of their careers (you would too in their shoes). Should we suspect they are not working diligently on behalf of physicians while at the OMA. No, no, no, a thousand times no. The vast majority of employees there really are passionate about advocating for physicians and I’ve seen that firsthand. Should we question their integrity? Again, no, no, no, a million times no.

BUT – should the OMA Board at least be aware of the fact that up to a quarter of the employees may one day work for government (in some way or another)? Should the Board keep it in the back of their minds when reviewing strategy presented to them? Especially if it comes at a time when relationship with government is adversarial? Human nature is human nature….

To be fair, ChatGPT also helpfully suggested (without prompting) that up 220 physician leaders had roles in some capacity with the OMA and then moved on to government/government agencies during the same time period. So it’s not like we don’t need to re-think how we as physicians choose our own leaders either. Which brings me to the next point.

How Independent is Promeus?

The other main critique was that my assertion that the OMA staff would vet candidates for Board was off base. After all, the OMA has hired an “independent third party firm” called Promeus to screen candidates. Promeus would decide who was most suitable for Board positions, not the OMA staff.

Let’s get real here. The consultants will be told what the criteria are. Those of you who work in a hospital can relate to this. Do you know how when the CEO of your hospital is facing, say, a budget deficit or a revolt around some program? The CEO knows that he/she has to lay off nurses or cut a program or change leadership. But not wanting to be “the bad guy”, they hire a consulting firm. The consulting firm then “reviews the information”, helpfully provided by the CEO. The firm then recommends that a bunch of nurses get fired, or programs get cut. The CEO then says “based on the recommendation of the expert consultants we are going to….” (The CEO doesn’t say they would have done that anyway, but are glad to have someone else scape goat the decision for them).

Similarly, the criteria for what is “needed” will be provided by the OMA to Promeus. I don’t doubt for a minute that Promeus will do a good job of reviewing candidates and has experience doing this. But they will choose candidates based on the OMA criteria.

This kind of tactic is common in all organizations, both public and private. Those interested can look up Robin Hanson’s theory of young consultants or if you want a denser read, go look at Killing Strategy.

As an aside, a few people have contacted me saying they’ve been approached to run for Board. They are all strong leaders, and I respect them. But they are also people who have roles in government funded organizations.

The counter argument will be that 39 candidates was “too many”. I think the fact that 39 candidates ran for Board shows that members have strong interest in making the OMA better. Are some candidates better than others? Sure – let the members decide. Let the candidates campaign (currently not allowed) to explain their positions. Is it messy? Sure, but heck democracy is messy. As Winston Churchill said:

In short, I would once again state that the changes the OMA Board has allowed to happen will not serve members well. We are going to get a weakened, Board that is very good in speaking politically and saying, well not much. The strong passionate member voices will be sidelined in favour of the milquetoast and bland. And physicians will not get the representation they deserve.

Only 25% of members said fees are worth it in 2022. The CFPC hasn’t asked since

My thanks once again to Dr. Greg Dubord (pictured inset) agreeing to post this on my site, (and doing most of the writing). Dr. Dubord is the founder of CBT Canada (www.cbt.ca) and a leading advocate of medical CBT. He completed his training under CBT’s Founder Dr. Aaron T. Beck and was the first Canadian Fellow of the Beck Institute. He has provided medical CBT workshops at many Family Medicine Forums. This blog originally appeared in the Medical Post.

Only 25% of CFPC members believe their fees are worth it.

That devastating verdict emerged from the College of Family Physicians of Canada’s own 2022 member satisfaction survey—unfortunately the last one they’ve published.

When three-quarters of your captive membership says they’re not getting value for money, you’d expect urgent reform and rigorous tracking of improvement. Instead, the CFPC did something remarkable: they stopped asking.

The survey, published by the CFPC’s own CEO Dr. Francine Lemire and executive director Eric Mang in Canadian Family Physician, contained another brutal statistic: Only 39% felt the CFPC was “listening to the opinions and needs of members.” More than 3,000 respondents delivered this indictment of their own professional organization—then watched the CFPC go silent on member satisfaction for three straight years.

Twenty-five percent is not a satisfaction score—it’s a vote of no confidence. In any other context, that number would trigger not just immediate crisis response, but deep organizational commitment to demonstrable change. A product with 25% customer satisfaction gets pulled from shelves. A restaurant with 25% customer approval likely ends up closing. A professional association with 25% approval hemorrhages members unless, of course, membership is mandatory.

When three-quarters of your customers—especially mandatory, captive customers who can’t leave—believe they’re not getting value for money, that’s not a minor problem requiring tweaks. That’s an existential crisis for the CFPC demanding comprehensive reform and continuous monitoring to track whether changes are working. Management guru Peter Drucker put it bluntly: “You can’t manage what you don’t measure.”

The CFPC instead chose this two-part treatment: 

  1. stop measuring whether members think fees are worth it; and
  2. ask for more money. No survey in 2023—but a 7% dues increase proposal that 83.86% rejected. No survey in 2024. No survey in 2025—but another fee increase attempt, also rejected.

Imagine asking your boss for a raise while refusing to do your performance review. That’s essentially what the CFPC keeps doing. 

This pattern becomes more revealing when you consider the CFPC’s demonstrated survey capabilities. During 2020 to 2022, the College conducted and published multiple iterations of COVID-19 impact surveys—2020, 2021 and June 2022—each with detailed, comprehensive reports and full datasets publicly available. These surveys served important functions, documenting physician challenges and supporting advocacy with government and policymakers.

The CFPC clearly has the infrastructure and expertise for longitudinal research. Yet member satisfaction—the metric showing only 25% believe fees are worth it—gets measured once, summarized briefly, then abandoned. When surveys document external challenges, members receive full transparency and accountability.

Although the CFPC’s 25% rating was horrible, it’s almost certainly a lot worse now. That survey was conducted before the PGY-3 controversy, and before the governance crisis that prompted our ten reform motions.

This brings us to one of our ten governance reforms for the 2026 AGM: Member satisfaction survey transparency. This motion would require annual CFPC member satisfaction surveys with published methodology, response rates and complete results (not curated summaries).

Healthy organizations that genuinely serve their members practice what the Japanese call kaizen—continuous improvement through regular measurement. When Toyota faced acceleration problems, they didn’t just stonewall—they analyzed data, implemented fixes, and reported progress transparently to regulators. 

The CFPC has a rather unique accountability problem: membership is mandatory for most, and the dissatisfied can’t leave. Captive dues payers are left to brux in high frustration while wondering if anything will change. Economists call this “moral hazard.” When an organization is insulated from the consequences of poor performance, accountability diminishes. This structural accountability gap—and potential solutions—will be explored in detail in upcoming articles in this series.

Our transparency motion is straightforward: the CFPC will be required to measure member satisfaction annually, publish complete results and let members judge whether their mandatory fees produce acceptable value. If the CFPC is delivering excellence, the data will prove it, and they will have every right to feel proud of it. However, if they’re failing, members deserve to know—with implications for the legitimacy of dues.

Our earnest hope is that this upcoming year we’ll see a highly member-responsive CFPC make genuine changes that demonstrably impact member satisfaction, and they’ll proudly make that public.

OMA Manipulates Board Elections and Weakens Members Voices

On November 20, Ontario Medical Association (OMA) Past President Dr. Dominik Nowak sent all members an email encouraging them to run for positions in the upcoming OMA Elections cycle. As Past President, his role is to oversee the elections for over 100 positions. He needs to ensure they are fairly run so the voice of all Ontario physicians can be heard.

Current Past President of the OMA, Dr. Dominik Nowak

Unfortunately, the current Board has sabotaged this process and rather than listen to the members, will only present pre-approved candidates for Board Director, the most important role. They have the responsibility of ensuring the OMA speaks for, you know, the members. Buried in his email were the following statements:

  • A streamlined shortlisting process for board candidates, with two to four candidates, whose skills and experience align with the board’s needs, being presented on the ballot for each open position 
  • Stronger screening and evaluation for consistency and fairness of candidates 
  • More transparency about how the board performs and what gaps are in the skills-based matrix

There is no explanation of what exactly this “streamlined” process is. But it’s clear that there will be now be increased vetting of candidates and some candidates will be found wanting and not allowed to run. Now, there always was some vetting of Board Candidates. Candidates had to be in good standing with College of Physicians and Surgeons, the OMA, pass background police checks etc. Some basic stuff.

But now, undoubtedly based on the fact that something like 38 people ran for Board last year, the OMA Board has determined to vet candidates even more and reject qualified people if they don’t meet these nebulous criteria. Importantly, the criteria will be to pick candidates who align with the BOARD‘s needs, not the MEMBERS. This is of course, all in the name of “fairness” and “transparency” and to make decisions “easier” for physicians.

But here’s the thing, the Board will NOT do the vetting. Board’s don’t actually do any operational work. Their job is to set policy, and then let the staff of the OMA implement it. So it will be up to the staff of the OMA to vet the Board candidates, and then approve whoever is acceptable……..to the staff.

Colleagues, we have a big problem.

The OMA staff are generally good people who work quite hard on behalf of physicians. They get a lot of unwarranted criticism for decisions that are actually made by physician leaders. Our elected leaders that should bare the blame.

But, at the end of the day, the OMA staff are only human, and prone to human tendencies and failures. My friend Dr. Greg Dubord, who I was honoured to pen a blog with, introduced me to Robert Michel‘s “Iron Law of Oligarchy“. It would seem to apply just not to the CFPC, but to what is going on at the OMA. From Wikipedia:

“… all organizations eventually come to be run by a leadership class who often function as paid administrators, executives, spokespersons, or political strategists for the organization. Far from being servants of the masses…. this leadership class, rather than the organization’s membership, will inevitably grow to dominate the organization’s power structures.[3]“

Robert Michels, a sociologist who described the political behavior of intellectual elites in the early 1900s

And that is exactly what is going to happen with these new changes. The OMA staff (not physician leaders, but employees of the OMA) will review the candidates for Board. THEY will decide who meets certain criteria. THEY will determine how many candidates run for each Board position, hiding behind a policy the Board has set.

Will they do their best to pick some good people? Sure. But their definition of “good” may not be what the members want. For example, someone like Shawn Whatley was openly critical of the OMA prior to being elected as President. Would he have passed these criteria? How about Nadia Alam? Prior to getting involved in medical political activism she was a relative unknown with little leadership experience (even though she is arguably the most well respected President of the past 25 years).

Dr. Shawn Whatley
pictures of Dr. Shawn Whatley and Dr. Nadia Alam, both of whom are past presidents of the Ontario Medical Association
Dr. Nadia Alam

Nope. My guess is they would have been found wanting. A total guess on my part would have been Dr. Whatley would be deemed “too disruptive” (he famously resigned from the OMA Board prior to being elected President). Dr. Alam would like be viewed as “too inexperienced.”

Worse, the blunt reality is that the staff will likely decide who is “best qualified” based on how well they can work with them (that’s just human nature). Not necessarily those who can, you know, push them and challenge them to do better.

The staff, generally being very nice people, always had a tendency to try to work co-operatively with the various government bureaucrats on bilateral committees. This is despite the over 30 years of evidence that always trying to be nice and reasonable just isn’t working. Cynics have suggested that its in part because they realize if they want to advance their careers – one of the places they can go after working in the OMA is the government, and it doesn’t help to burn bridges there. So why would they approve a candidate who had a reputation for being less than reasonable?

Want proof? Just look at how badly the OMA as an organization handled last year’s elections. I asked potential Board Directors to commit to filing a Freedom of Information Act request, to determine just how many patients Nurse Practitioners saw in a day and how much they cost the health care system per patient (easy to do with billing numbers). The goal was to get proof that they were more expensive overall (by a lot) than family physicians and slow down scope creep.

Not only did the OMA put a stop to that, they threatened the careers of people who signed that with a Code of Conduct violation. Can’t have people on the OMA Board who will be too aggressive can we? (Psst – hey Kim Moran, CEO of the OMA – how is sending strongly worded letters to the government asking them to stop scope expansion working out? Oh, right.)

Do you really think with that history, the current staff will allow someone even remotely controversial to run?

The OMA Board has shamefully allowed this to happen. As a result there will not be a diverse Board with many viewpoints that focus on members. Rather a bland, non-controversial Board that will be limiting to speaking in political jargon speaking points in response to all issues.

Physicians will truly be hurt by this short sighted decision.

Open Letter to Premier Francois Legault

The Honourable François Legault, M.L.A.
Premier of the Province of Quebec
Édifice Honoré-Mercier, 3e étage
835, boul. René-Lévesque Est
Quebec QC G1A 1B4

Dear Premier Legault,

You probably don’t know who I am, and are wondering what propelled me to write an open letter to you. I decided to write to you after doing a radio interview with Greg Brady on his show Toronto Today. During the interview, Greg asked me to comment on the strife between you and the physicians in your province. He brought up the fact that in the past couple of weeks, 263 physicians from Quebec have applied for a licence to practice medicine in Ontario.

Now, I certainly don’t pretend to be an expert in how the health system functions in Quebec. Nor would I assume to know all of the intricacies of Bill 2, the legislation that you’ve introduced that has your physicians so angry. And no, I’ll say right off the bat, I don’t know what negotiations between you and the representative bodies of physicians in Quebec (FMSQ and FMOQ)have been like.

But I will tell you that my very first blog ever (in the Huffington Post) was an open letter to Ontario’s then health minister, Dr. Eric Hoskins. I wrote that blog because his government was talking unilateral actions against physicians (sound familiar?) In it, I warned Dr. Hoskins that acting in a unilateral manner would result in chaos for our health system:

“We cannot return to a system where there are three million or more people without a family doctor, or wait times to see specialists (already too long in my area) get prohibitively longer.”

I also warned of the political consequences of proceeding with unilateral actions and how this would hurt Liberals in the 2018 election. You perhaps know they were absolutely decimated in that election. While its true a large part of that defeat was because the feckless Premier Kathleen Wynne was so widely disliked, I maintain to this day the Liberals could at least have maintained official party status had they not botched health care so badly.

The reason I could make those statements in my blog with such absolute certainty, and have them proven right in the end was not because of any prescience on my part. It’s because I followed the advice of Santayana:

Look, I understand that some of the specifics of the policies and legislation that you are bringing in are different from what Dr. Hoskins tried to do. But at the end of the day, it amounts to you as a government saying that you know how to run healthcare. You don’t need advice or co-operation from doctors. You’re going to impose the changes you want.

I’d encourage you to go back and read the letter I wrote to Dr. Hoskins. I pointed out to him that he was repeating the mistakes (unilateral actions) of the Bob Rae NDP government in the 1990s. They destroyed health care by those actions and were wiped out in the 1995 election, never to see power again.

Take a look at the Jason Kenney PC government of 2019. The went to war with Alberta Medical Association in 2020. The only way they were able to salvage a victory in the next election after that, was to dump their leader, Jason Kenney. (It’s true unhappiness with how he handled the Covid pandemic played a role – but again, the point is there was no saving grace for him – if he had kept health care functioning…..)

Want more? Look at the actions of the Gordon Campbell British Columbia government. Between 2001-2002 they unilaterally tore up an arbitration agreement between the BC government and their doctors. Years of discord including a Charter Challenge (that the BC Government eventually lost), political strife, a strike vote by physicians and a vastly reduced majority followed. Eventually, given a failing health system caused by their own arrogance, the BC government had to come to an agreement with their doctors in 2002, and again in 2006 that restored binding arbitration and was viewed as extremely generous at the time.

As I pointed out to Dr. Hoskins the message is simple. Any government that takes on unilateral action will run the risk of losing doctors from that province. When that happens, the healthcare system suffers. When that happens patients suffer, wait times go up, care deteriorates. When that happens, people don’t blame the doctors, they blame the politicians.

In short, a government that imposes unilateral actions on physicians not only hurts the patients of their province, they always pays a political price. They always have to pay more in the long run than if they just worked fairly with their physicians in the first place.

Look, I don’t particularly care about you or your government. I could not care less whether you win or lose your next election. But I happen to care a lot about my physician colleagues and I know that they are very very angry (and rightfully so). I also care about the residents of Quebec, and I know that they are going to suffer a lot because of your actions. As of now, 28% of your population does not have a family doctor. Can you imagine what will happen if 263 leave? And do you really think any doctor with half a brain will actually come to Quebec when your government behaves like this?

Trust me on this one, if you don’t immediately reverse course, and start to work with your doctors – the harm done to your health system and the people you are supposed to serve will be enormous.

And if you don’t believe me – go read that quote from Santayana again.

Yours truly,

An Old Country Doctor

Lettre ouverte au premier ministre François Legault

L’honorable François Legault, député
Premier ministre du Québec
Édifice Honoré-Mercier, 3e étage
835, boul. René-Lévesque Est
Québec (Québec) G1A 1B4

Monsieur le Premier Ministre,

Vous ne me connaissez probablement pas, et vous vous demandez sans doute ce qui m’a poussé à vous écrire une lettre ouverte. J’ai pris cette décision après avoir fait une entrevue à la radio avec Greg Brady, dans son émission Toronto Today. Durant l’entrevue, Greg m’a demandé de commenter la chicane entre vous et les médecins de votre province. Il a mentionné que, dans les dernières semaines, 263 médecins québécois ont fait une demande de permis pour pratiquer en Ontario.

Je ne prétends certainement pas être un expert du fonctionnement du système de santé au Québec. Je ne me permettrais pas non plus de dire que je comprends toutes les subtilités du projet de loi 2, la législation que vous avez déposée et qui met vos médecins en colère. Et non, je vais le dire d’emblée : je ne sais pas comment se déroulent vos négociations avec les organismes représentant les médecins du Québec (la FMSQ et la FMOQ).

Mais je peux vous dire que mon tout premier billet de blogue (dans le Huffington Post) était une lettre ouverte adressée à l’ancien ministre de la Santé de l’Ontario, le Dr Eric Hoskins. J’avais écrit ce billet parce que son gouvernement parlait d’imposer des mesures unilatérales contre les médecins (ça vous rappelle quelque chose?). Dans ce texte, j’avertissais le Dr Hoskins que des actions unilatérales allaient engendrer le chaos dans notre système de santé :

On ne peut pas retourner à un système où trois millions de personnes et plus n’ont pas de médecin de famille, ou encore à des délais pour consulter un spécialiste (déjà trop longs chez nous) qui deviennent carrément intenables.

J’avais aussi prévenu qu’il y aurait un prix politique à payer en allant de l’avant de façon unilatérale, et que cela nuirait aux libéraux lors de l’élection de 2018. Vous savez peut-être qu’ils ont été complètement anéantis à cette élection-là. Même si une bonne partie de leur défaite s’explique par l’impopularité de la première ministre Kathleen Wynne, je maintiens encore aujourd’hui que les libéraux auraient au moins pu conserver leur statut de parti officiel s’ils n’avaient pas magané le système de santé à ce point.

La raison pour laquelle j’ai pu écrire ces avertissements avec autant d’assurance — et avoir raison au final — ce n’était pas de la clairvoyance de ma part. C’est simplement que j’ai suivi le conseil de Santayana :

A picture of George Santayana, Spanish American philosopher with his famous quote "Those who don't learn from history are doomed to repeat it"

Ceux qui ne peuvent apprendre de l’histoire sont condamnés à la répéter.

Regardez : je comprends que les détails précis des politiques et du projet de loi que vous déposez ne sont pas identiques à ce que le Dr Hoskins tentait de faire. Mais au bout du compte, le message est le même : votre gouvernement affirme qu’il sait mieux que tout le monde comment gérer le système de santé. Vous n’avez pas besoin de l’avis ni de la collaboration des médecins. Vous allez imposer les changements que vous voulez.

Je vous encourage à retourner lire la lettre que j’avais envoyée au Dr Hoskins. Je lui avais souligné qu’il répétait les erreurs (les gestes unilatéraux) du gouvernement néo-démocrate de Bob Rae dans les années 1990. Ils ont détruit le système de santé avec ces actions-là et ont été balayés lors de l’élection de 1995, sans jamais reprendre le pouvoir depuis.

Jetez un œil au gouvernement progressiste-conservateur de Jason Kenney en Alberta, en 2019. Ils se sont mis en guerre avec l’Alberta Medical Association en 2020. La seule façon pour eux d’éviter une défaite à l’élection suivante a été de sacrifier leur chef, Jason Kenney. (Oui, c’est vrai que le mécontentement lié à sa gestion de la pandémie a joué — mais l’essentiel, c’est qu’il n’y avait rien pour le sauver. S’il avait gardé un système de santé fonctionnel…)

Vous en voulez d’autres? Regardez le gouvernement de Gordon Campbell, en Colombie-Britannique. En 2001-2002, ils ont unilatéralement déchiré une entente d’arbitrage conclue entre le gouvernement et les médecins. Cela a été suivi par des années de conflit, un recours fondé sur la Charte (que le gouvernement a perdu), du tumulte politique, un vote de grève des médecins et une majorité gouvernementale passablement réduite. Finalement, devant un système de santé en déroute — un échec dû à leur propre arrogance — le gouvernement a dû conclure une entente avec les médecins en 2002, puis en 2006, rétablissant l’arbitrage exécutoire dans des conditions jugées très généreuses à l’époque.

Comme je l’avais dit au Dr Hoskins, le message est simple :


Tout gouvernement qui agit unilatéralement court le risque de perdre des médecins.

Et quand ça arrive, le système de santé en souffre. Les patients en souffrent. Les délais augmentent. Les soins se détériorent. Et dans ces situations-là, les gens ne blâment pas les médecins. Ils blâment les politiciens.

En bref, un gouvernement qui impose des mesures unilatérales aux médecins fait du tort aux patients de sa province et paie toujours un prix politique. Au final, il finit toujours par payer plus cher que s’il avait tout simplement négocié de façon juste avec ses médecins dès le départ.

Écoutez : je n’ai pas d’intérêt particulier pour vous ou votre gouvernement. Ça m’est complètement égal que vous gagniez ou non la prochaine élection. Mais mes collègues médecins, je m’en soucie. Et je sais qu’ils sont très, très fâchés (et avec raison). Je me soucie aussi des citoyens du Québec, et je sais qu’ils vont énormément souffrir de vos décisions. En ce moment, 28 % de la population n’a pas de médecin de famille. Imaginez ce qui va arriver si 263 quittent. Et pensez-vous vraiment qu’un médecin sensé voudra venir pratiquer au Québec quand votre gouvernement agit de cette façon?

Croyez-moi : si vous ne changez pas de cap immédiatement et si vous ne recommencez pas à travailler avec vos médecins, les dommages causés à votre système de santé — et aux gens que vous êtes censé servir — seront immenses.

Et si vous ne me croyez pas, relisez la citation de Santayana.

Cordialement,

Un vieux médecin de campagne

From Aloof Oligarchy to Professional Partner: Ten Motions for CFPC Reform

My thanks to Dr. Greg Dubord (pictured inset) for offering to co-authour this blog with me (and doing most of the work). His resume is too long to list but briefly Dr. Dubord is the founder of CBT Canada (www.cbt.ca) and a leading advocate of medical CBT. He completed his training under CBT’s Founder Dr. Aaron T. Beck and was the first Canadian Fellow of the Beck Institute. He has provided medical CBT workshops at many Family Medicine Forums.

In 1911, sociologist Robert Michels observed that most democratic organizations drift toward oligarchy. Given enough time, leaders insulate themselves from member accountability, prioritizing institutional preservation over their founding mandate—thereby betraying the founders’ intent. This is mission inversion: institutions founded to serve a profession end up prioritizing institutional interests over member needs. Michels called this the “Iron Law of Oligarchy,” predicting it would afflict even the most well-intentioned groups.

The iron law helps in understanding the behaviour of the College of Family Physicians of Canada (CFPC). When PGY-3 proposals drew overwhelming opposition at the annual meeting of members (AMM), when member motions achieving 94.78% support were later treated as non-binding, when members face detailed behavioral codes while the bylaws contain no published reciprocal standards, when automatic fee increases are proposed while “only 25% felt annual fees were worth the expense,” and when basic records requests under statutory rights receive no response addressing the request—these aren’t random frustrations. They’re textbook iron law symptoms of an organization completing its evolution from member-serving to self-serving. These observations reflect structural patterns common to many long-standing organizations and are not personal criticism of current leadership.

Which brings us to ten specific reforms. We are submitting ten governance motions for the November 2026 CFPC AMM. Each addresses structural gaps enabling oligarchic drift:

1. Board and committee minute transparency: CFPC bylaw is silent on minute access beyond requiring an annual report. This motion requires board and committee minutes be posted within 30 days of approval, with redactions only for privileged matters requiring board vote and logged publicly. This directly implements Motion 9a from the 2023 AGM, which passed with 95% support but appears unimplemented after two years.

2. Member portal for governance documents: Transparency requires accessibility. This motion creates a searchable digital portal for board minutes, committee records, policies with version history, redlined comparisons showing changes, and board voting records on contested matters. Modern technology makes this standard practice—if CFPC can build CFPCLearn, they can build member transparency.

3. Corporate records access policy: Section 21 of the Canada Not-for-profit Corporations Act (CNCA) grants members statutory rights to corporate records, but CFPC has no public policy operationalizing these rights. This motion establishes response timelines (acknowledgment within two business days, substantive response within 10 days), fee structures capped at reasonable copying costs and appeal mechanisms for denials.

4. Leadership code of conduct: CFPC leadership adopted a detailed member code of conduct in 2025 governing member behaviour toward staff. However, the bylaws contain zero reciprocal standards governing how leadership and staff interact with members. This motion creates a reciprocal leadership code requiring good faith, respect, courtesy, procedural fairness, and timeliness. 

5. Member satisfaction survey transparency: CFPC’s January 2022 member satisfaction survey (as reporting in Canadian Family Physician) showed 25% satisfaction ratings. This survey is no longer publicly available on the CFPC website (but is archived at the National Library of Medicine at this link). No member surveys have been published since. This motion requires annual member satisfaction surveys with published methodology, response rates and complete results, ensuring members can assess whether their mandatory fees produce acceptable value.

6. Policy change documentation and impact analysis: Major policy changes significantly affecting member time burdens or costs currently proceed without documented consultation, needs assessment or alternatives analysis. This motion requires red-lined comparisons showing exactly what’s changing, impact analysis quantifying time and cost implications, documentation of alternatives considered and 90-day member consultation periods before implementation.

7. Member complaint tracking system: Members who raise governance concerns have no way to track whether complaints were received, reviewed or resolved. This motion establishes a tracking system (with anonymized quarterly summaries published) ensuring acknowledgment, investigation timelines, outcome notification and appeal rights. Transparency prevents complaints from disappearing into administrative black holes.

8. Electronic voting for annual meetings: The current annual meeting voting system restricts participation to those who can either attend in person or can navigate proxy procedures. The CFPC’s Lumi platform has supported secure, real-time electronic voting for member meetings for many years—yet CFPC has not consistently activated this functionality for member motions. This motion requires the permanent activation of electronic voting with real-time results display, expanding democratic participation using existing technology. 

9. Member motion submission reform: CNCA Section 163 grants members statutory rights to submit motions 90-150 days before AGMs, but CFPC’s practice has stretched this to 140+ days—effectively disenfranchising members who observe problems after the extended deadline. This motion reduces the submission window to 60 days prior and creates emergency procedures for urgent matters arising after the cutoff, ensuring responsive member democracy.

10. Independent ombudsman with enforcement authority: The nine preceding motions mean nothing without enforcement. This motion establishes an ombudsman structurally independent from CFPC management, with authority to receive confidential complaints, investigate with full document access, issue binding recommendations, and report publicly on systemic patterns. Real accountability requires independent oversight—not self-policing by the same leadership structure these motions address.

These motions aren’t attacks—they’re the structural reforms many organizations need after 70 years of the iron law doing its mischief. A transparent, accountable CFPC could become the powerful advocate physicians need—championing educational excellence, defending professional autonomy, and ensuring Canadian families have access to well-supported, continuously learning family doctors. Details will follow here in the new year, and CFPC members will decide at the November 2026 AGM whether their college serves them—or itself.

Dear Specialist, You’re Awesome, but PLEASE STOP Calling Me A Provider

To my specialist colleagues,

In over 30 years of family practice, when I have been uncertain about a diagnosis you’ve been there. When I needed some advice on best treatments, you’ve been there. You’ve helped me and my patients, and you deserve many many thanks for that.

As with all things, there have been some ups and downs over the years (we really need to talk about the “go see your family doctor to have your staples/sutures removed” thing). Perhaps it’s because I work at a fairly small hospital with generally collegial colleagues, but I genuinely have positive feelings about our relationships and interactions.

There is, however, one thing that is starting to creep in to the vernacular that needs to be addressed before it goes too far. I’ve noticed it increasingly in reports from specialists. It seems to be particularly endemic in notes from the Emergency Medicine specialists and younger specialists.

It is the unfortunate tendency to use the highly offensive and derogatory term “provider” when referring to the family physicians. As in “the patient should follow up with their primary care provider.”

A couple of months ago, I attended the biennial menopause society update (yes, the same one where I discovered family physicians were giving up). At one of the small breakout groups, I happened to sit with a couple of my specialist colleagues. We were talking about how to handle various clinical scenarios, when I noticed both of them using this abhorrent term.

My personal observation (and I suspect I’ll get in trouble for saying this, but I’m going to say it anyway), was that the two of them looked like they weren’t even born when I entered medical school. It’s a credit to them just how involved they were in their hospital and community and patient advocacy at such a young age. As I understand it, they had been told that “primary care provider” was the appropriate new terminology to use.

I don’t really fault them. They were not aware of the negative connotations involved in that term or how objectionable it was. In fact, I credit both of them with being very open to change when I spoke to them about this.

What exactly is the problem you may be wondering? What’s the big deal about using the term provider?

Because language matters. Words matter. Definitions matter. Just as it is highly reprehensible and dehumanizing to use the word “client” when referring to a patient, it’s pretty offensive to use the term “provider” when referring to a family physician.

The term “physician” has meaning. It denotes a person who is entrusted to help you heal. It signifies a sacred bond between the healer and the sick that dates back to Hippocrates. It infers respect and dignity. It attributes professionalism, honour, and morality. It automatically speaks of the implicit trust that patients have.

The term provider, in health care, is egregious and appalling. To quote an excellent article by Jonathan Scarff:

“The word provider does not originate in the health care arena but from the world of commerce and contains no reference to professionalism or therapeutic relationships.”

He goes on to state:

“This terminology suggests that the clinician-patient relationship is a commercial transaction based on a market concept where patients are consumers to be serviced”

I could not agree with him more.

One of the things that the bureaucrats who run health care have long resented is the respect that physicians have from patients. Despite all of the attacks against physicians on social media, and even from official government types like RFK Jr in the States, physicians consistently continue to be shown to be among the most respected professionals out there (yes we are behind nurses). We receive these high rankings based on the proven belief that we are honest and adhere to ethical behaviours and high standards.

I firmly believe this is why bureaucrats have tried to bring in new terminology to describe physicians. They know that if we speak out against their brilliant ideas to “fix” health care, physicians will inherently get more trust than bureaucrats. I’ve seen the resentment of physicians first hand at a bunch of bilateral meetings between the OMA and the Ministry of Health. Trust me, it’s there, both implicitly and in some cases, very explicitly.

So the bureaucrats, under the guise of “inclusivity” or “patient centredness” or some such thing, are now introducing the term “provider” to diminish the significance of our roles. Their goal is to curtail our value in the eyes of the public, so when we call out their (many) mistakes, there will not be implicit trust in what we say. Think about it, which sentence below has more impact:

“Ontario’s providers speak out against government’s health proposal “

or

“Ontario’s physicians speak out against government’s health proposal”

Get the point? I beseech my specialist colleagues to not fall into this trap. Being a physician (as you know) is a sacred responsibility that all of us take seriously. We routinely make life altering suggestions to patients, and have a strong bond with them. Our role in their lives is not a commercial transaction. We do not treat patients as consumers who need to be managed. As the Section of General and Family Practice points out:

This term (provider) devalues the training, expertise, and vital role we play as physicians in the healthcare system. Family physicians are not providers; they are physicians.

So I ask you my specialist colleagues, the next time you write an Emergency Department note, or a consult note, be mindful of what you write. Recognize and respect the value of the person you are sending it to. Ignore the bureaucrats self serving machinations when they try to change the terminology.

Tell the patient to follow up with their FAMILY PHYSICIAN. (Except for the staple/suture removal – you can do that yourself).

Yours truly,

An Old Country Doctor

CFPC Fails to Learn its Lesson, Makes the Same Mistake Again

Here we go again. You know, after all the body blows the College of Family Physicians of Canada (CFPC) has taken over the years, you’d think they’d learn the most basic of lessons. A membership driven organization should not cheese off its members. Do that and bad things will happen. Yet somehow, they never seem to learn this basic principle.

First, you don’t insult your members, you support them. So when someone (anyone) writes an article that criticizes all your members, don’t publish it. Otherwise, you are basically telling people that you know better than them, and that they should do as you tell them. I actually had warned them when they allowed a miserable, hateful missive to be published that they should pull it and apologize to all their members or family physicians would lose confidence in the CFPC. Alas…….

Second, if you are truly concerned that trainees are not getting an adequate experience, you should first focus on improving the current training program instead of automatically extending it by one year. Do residents really need to go for all these “clinical day backs”, “forum days”, “research days” and “retreats”. Shouldn’t they be laying hands on a patient instead? Should they not be taught real life skills like how to run the business side of things? And so on.

And if you really, really believe that the training period needs to be extended, then communicate properly why it’s not possible to improve the program based the current times. Show every thing you’ve done to fix it. Then clearly explain how an extra year would help – don’t just force it down everyone’s throat.

Thirdly, if you need to raise dues, don’t just ram it down the members throats in a ridiculously convoluted manner. Otherwise people will smell a rat and will fight against it. Instead, clearly communicate why it’s necessary and how the membership will benefit from the increase. The fees we pay should be viewed as a value proposition. Yes we paid $X, but in return we get Y services. Prove Y services are worth it.

Alas, despite promising a “humbler and more transparent organization” just two years ago, the CFPC is at it again. They are once again attempting to get around the membership by baking in annual fee increases that do NOT require member approval.

Buried deep in the meeting package for the CFPC annual meeting, is a motion to amend section 10.5 of the bylaws (copied verbatim):

“THAT section 10.5 of the CFPC Bylaws be amended as follows: The Members shall pay the annual College membership fees applicable to their class of membership, as determined annually by a majority vote of the Board. If the Board intends to increase the existing membership fees for any class or category of membership by an amount that exceeds the annual Canada Consumer Price Index (as published by Statistics Canada for July of each year), and rounded up to the nearest dollar, such proposed increase must be ratified by an Ordinary Resolution of the Members at the Annual Meeting before it becomes effective. Any increase to the annual membership fees becomes effective on July 1 of the ensuing calendar year. Such membership fees shall subsequently be ratified by a simple majority of the membership eligible to vote at the Annual Meeting. Membership fees shall be directed towards the cost of College programs and activities, as determined by the Board.“

In essence, what the CFPC is asking, is to set in place a process where dues go up annually up to the CPI, without any rationale provided to the members. They are guaranteeing themselves annual increases in revenue. To quote a colleague: “It’s really an unprecedented consolidation of power, and removes member centredness from a member centric organization”.

Look, I actually get the need to raise fees (honest!). Contrary to what Ladouceur wrote in his offensive editorial, I actually run my office as a business. I know inflation has taken its toll. My expenses are up. Despite my best efforts at efficiencies, my overhead is higher than it was 5 years ago. I suspect this is the same for the CFPC.

But the solution is not to give the CFPC carte blanche to keep increasing dues. The CFPC needs to show real leadership and say to the members:

“This is what we’ve done with the money. This is the value we bring. These are the efficiencies we’ve implemented. But despite that, this is the increase we need to bring you the organization you deserve.”

And next year, it needs to do the same thing. And the year after. And so on. And that’s how you build an organization worthy of the trust of your members.

In the meantime, if you want to make your voice heard and vote against this nonsense, here’s how to stop it (shamelessly mostly copied from a colleague who gave me permission to do so):

  1. Live, at the Annual Meeting of Members (AMM). Wed Oct 29 from 7-8:30 PM. Details on how to join this were emailed to you by CFPC.
  2. If you cannot attend the AMM, assign a proxy by going here: https://reg.lumiengage.com/cfpc-2025. You will need your unique control number. See the email called “The CFPC’s AMM participation details“.

The bylaw in question is called “Bylaw Amendment Regarding Membership Fees”. Vote “Reject“.

By assigning a proxy, that person you assign does not know your vote, and must submit your ballot as is, so they can’t change your vote. You can assign your proxy to one of the CFPC leadership, or a specific individual with a backup option of CFPC leadership, or a specific individual alone. The danger of the last option is that if that person does not or cannot attend the AMM, your vote does not count. I personally would recommend you assign the CFPC President (who is pretty well guaranteed to attend the meeting) as your proxy.

Let’s stop the CFPC from getting out of hand on this issue. Then we can work on trying to figure out how come the organization never seems to learn its lessons.

Expanded Scope of Practice Will Ultimately Hurt Patients

On October 1, the CBC published an article on how a program to expand the scope of practice of pharmacists in New Brunswick completely fell apart and was cancelled. There’s a litany of reasons why the project died. But the ones that stood out for me were (italicized quotes are lifted from the CBC article):

  • the project promoted a “a convenient new option” as opposed to to focusing on quality health care first
  • the project’s hypothesis – “..every patient getting care at a pharmacy would take pressure off the public system — remained unproven..”
  • there is a lot of focus on the fact that pharmacists need to be able to order bloodwork
  • There is significant mention of the role of Perry Martin, a paid lobbyist for Shoppers Drug Mart pushing for this change. There’s also this line – “the pilot pharmacists were being deluged with patients prescribed point-of-care tests by Maple, the private company operating the eVisit virtual care service.” Curiously, even though Maple referred patients to Shoppers Drug Mart pharmacies, there’s no mention of the fact that Shoppers Drug Mart invested $75 million into Maple. One would think that if company “A” invests in company “B”, and then company “B” sends business to company “A”, and company “A”makes money from the government for that business (though public health insurance), that should get a mention.
  • The provinces physicians feared duplication of tests and fragmenting of care
  • There was significant push back to the statement that letting pharmacists treating minor illnesses led to a 9.2% drop in Emergency room visits in Nova Scotia – “Health officials checked, however, and concluded the drop was because of a combination of several initiatives.“
  • Unsurprisingly, the government noted “an Ontario report that surveyed pharmacists who complained of corporate pressure to hit quotas and revenue targets“
  • Most importantly to my eyes: “Nicole Poirier, the director of primary care, pointed out the report contained “no conclusive findings” that it reduced pressure on the public system, and did not show better health outcomes for patients.“

I bring this up because in Ontario, we continue to fail to heed these warning signs. On Sep 17, the Ontario government announced plans to consider expanding the scope of practice of many allied health care professionals (AHCP).

It’s not just this report from New Brunswick that should raise concerns. There has been a growing body of evidence over the years about how the idea of offloading “minor” illnesses to non-physicians doesn’t achieve the benefits intended.

For example a three year study of expanding Nurse Practitioner (NP) autonomy in US Veteran’s Health Administration hospitals found that:

  • There was a 7% increase in immediate costs to patient care, and an overall 15% in costs for caring for patients when one included downstream costs. This was attributed to NPs taking longer to evaluate patients and ordering more tests.
  • Sub optimal triage of patients was also noted leading to things like under‐admission when needed (leading to worse outcomes and later, costlier interventions) or over‐referral/overuse
  • Patients under NP care had worse decision‐making about hospital admissions and increased return ED visits (which cost more)

It’s not just studies that are opposed to scope expansion that have expressed concerns. In Australia, a generally favourable report to having AHCPs work to their full scope of practice, still mentioned the significant need for training, regulation, and funding to support safe expansion. The training part is important because contrary to what’s being put out, many AHCPs are not trained to recognize a potentially serious issue from a minor one. (You don’t know what you don’t know). The same report also mentioned significant concerns about more fragmented care, waste and higher long term health system costs.

Another generally supportive of scope expansion of NPs study purports to show that NP delivered primary care for patients with multiple chronic conditions show similar outcomes to care delivered by family doctors. BUT, a deep dive into the study showed that the models studied often included physician-NP teams, or limited scope expansions. They did not always include fully independent NPs. Training, team collaboration, and oversight often remained intact.

With respect to AHCPs expanding their scope of practice in general, a number of concerns need to reviewed.

First is antibiotic stewardship. This is a big problem as overprescription of antibiotics is increasingly resulting in more and more virulent and drug resistant strains of bacteria. As I’ve pointed out before – CANADIAN provinces which allow pharmacists to provide antibiotic prescriptions- have a higher per capita rate of antibiotic prescriptions than others. That’s just reality.

Secondly the reality is that AHCPs will over order diagnostic testing, particularly if they “are not sure” about the diagnosis. We saw that with the Veterans Hospital study above. We will see that if, as suggested, AHCPs will be able to order more and more tests.

Thirdly, there is going to be an increase fragmentation of care. Whether one looks at Japan, Norway, Great Britain, or really any other country, it’s been repeatedly shown than having a consistent family doctor will result in better health care outcomes and reduced costs to the health care systems. Central to this is the family physicians ability to provide a medical home where all of the patients information can be consolidated at one spot, and their ability to help patients understand and navigate health care.

In Ontario our system is so disjointed and disorganized that it is not possible for all of the testing/prescribing done by allied health care providers to get to the family physicians easily. This very quickly will lead to fragmentation of care and will eventually come back to hurt patients. To their credit, both OMA Past President Dr. Domink Nowak and current President, Dr. Zainab Abdurrahman have repeatedly pointed this out.

OMA President Dr. Zainab Abdurrahman
OMA Past President Dr. Dominik Nowak

Finally one thing that has not been discussed is the liability concerns. I don’t see any of the people talking about expanding scope of practice acknowledging that there will be increases in the cost of liability insurance. We’ve already seen in the US that NPs have had increased lawsuits against them. I’m positive that this will happen to other allied health care professionals if these changes go through.

It’s fair to note that much literature also finds benefits (e.g. improved access, equivalent outcomes in many primary care settings, especially for chronic disease management), and some cost savings under certain models. The risk is that decision-makers may generalize from settings where allied expansion worked well under supportive conditions to settings where such supports are weaker. Which appears to be where we are heading in Ontario.

All of which means we should expect a newspaper report in about 2029 showing that expansion of scope of AHCPs has not shown the expected results. Say, isn’t that about the time of the next Provincial Election?