justanoldcountrydoctor

RePost: Hoskins Fails to Understand the Health Care System

NB: This article originally appeared in the Huffington Post on May 4, 2017. I am reposting on my own website as Huffington Post Canada has shut down and I want to preserve the article in case needed in the future.

Last week, the Ontario Liberal Government released the specifics of the 2017-2018 Budget. From a health care perspective, what became startlingly evident, was that the Liberals seem to be unable to comprehend exactly how the health care system functions. They are seemingly unable or unwilling to look at the big picture when trying to solve problems.

By Dr. Sohail Gandhi, Contributor

Last week, the Ontario Liberal Government released the specifics of the 2017-2018 Budget. Advertised as a prescription for a “stronger, healthier Ontario”, the budget had all the usual darts and laurels typically thrown at a pre-election budget. The Liberals claimed they balanced the budget and were making necessary investments. Their critics claimed not.

From a health care perspective, what became startlingly evident, was that the Liberals seem to be unable to comprehend exactly how the health care system functions. They are seemingly unable or unwilling to look at the big picture when trying to solve problems.

Let’s look at hospital funding. That hospitals in Ontario are under enormous stress is unquestioned. Stories of overcrowded emergency departments, long wait times, patients lying in hallways for days on end are rampant in the media. Additionally, budget pressures on hospitals continue to result in nurses being laid off despite the fact hospitals are full. Concerns raised years ago about how this will lead to adverse patient outcomes, are sadly now coming true.

In response, Ontario Health Minister Eric Hoskins has been repeatedly stating that he has ensured that hospital funding increase by $518 Million next year. A large number, but it represents only a three per cent increase in the hospital budget, which totals about $17.2 BILLION dollars (and Hoskins thought doctors were expensive!). It is also less than hospitals had asked for.

I won’t begrudge hospitals extra money. They have been starved under austerity level budgets during Hoskins leadership. But is throwing money at hospitals the only way to solve the problem? Is it the best solution?

However, one of the main issues that hospitals face is the persistently high rate of Alternative Level of Care (ALC) patients. The official definition of ALC is pretty complicated. The simple definition is patients are well enough to be discharged from hospital, but not well enough to return to their own home. The majority of ALC patients are waiting for nursing homes.

The rates of ALC patients vary in different parts of Ontario, but the provincial average is around 15 per cent. This means that if you have a hospital with 100 acute care beds, fifteen will be occupied by patients who should be in a different facility, usually a nursing home. But because there aren’t enough nursing home beds, they’re stuck in hospital.

So, when a patient comes to the Emergency department with, say severe abdominal pain due to internal bleeding, and needs to be admitted to hospital, a large part of the reason why she waits for 5 days in a hallway, is that there are no nursing home beds for the patients currently in hospital to go to.

Despite the fact that it is widely acknowledged Ontario is greying and that our percentage of seniors will rise to almost 18 per cent by 2021, there appears to be no discernable plan to actually build more nursing homes. In fact, the only investments that I can find are those to renovate existing beds. While that’s a nice enough thing to do, and will increase the comfort level of LTC residents (which I think is essential), it won’t offload the overcapacity from hospitals.

When I was the Health Links lead physician for my area, we were involved in a plan to reduce hospital admissions from nursing homes. As part of that, we found that the cost of a hospital admission was around $975 a day (standard ward bed). The cost of a nursing home? How about $143 a day? Seriously, you can fund seven nursing home beds, for the cost of one hospital bed.

So back to the hypothetical 100 bed hospital. Would it not make more sense to fund fourteen nursing home beds (at the cost of two hospital beds) to take the pressure off the hospital? Especially when we already have a nice mix of private and public companies willing to build LTC homes? And would that not reduce the costs to the hospital because hospitals are chronically paying staff overtime to handle overcapacity situations?

Now in fairness the final solution probably requires a combination of things. Hospitals do have fixed operational costs that increase yearly and need to be accounted for, and shouldget more money.

But a proper solution must also look at the big picture, and look at creative ways of reducing hospital expenses. Not only do we need 26,000 more nursing home beds right now, but given how our population is greying, we will need 50,000 more in six years. Otherwise the ALC rates will rise, and the Emergency departments will back up more. To not have a plan in place to address this shows a complete lack of comprehension of the stresses the system faces.

EricHoskins appears to only be capable of reacting to crises. Bad news story about hospitals affecting re-election chances? Throw money at them. That’s not good enough. We need leaders that understand how interconnected health care is, and how events in one part of the system, affect others.

The people of Ontario deserve better than what Eric Hoskins is offering.

Preparing for the August Covid-19 Wave in Canada

We’ve learned much about COVID-19 since the first infection was announced in 2019. This has helped us develop better treatments and better prevention strategies. We’ve learned that COVID has settled into a fairly consistent annual pattern. There’s a smaller summer wave (end of July to mid-September) and a larger winter wave (November to January). The larger wave ends around the time flu season starts.

This year the summer wave has started in the United States. Wastewater concentrations of COVID are starting to increase in southern and western states (yes they are still low, but they are trending upwards). ER visits with proven COVID cases are also growing in the southwest. So the wave is beginning.

As I write this, the Canadian wave has not yet begun. In particular, the Ontario numbers are still low overall. Local fluctuations are occurring however, and if trends hold as they have done over the past few years, we can expect the COVID wave to start in August, and peak in early September.

The current U.S. wave is due to an Omicron strain of the virus designated as Nimbus. Thankfully, it appears that the Omicron strains cause less serious infections (though may spread more quickly). This means that existing immunity from prior infection and immunizations continue to provide some meaningful protection against severe disease.

With that in mind, what should Canadians do to prepare for this summer wave? For healthy people, I actually think we’ve reached a point where it’s unreasonable to say “avoid COVID at all costs.” With COVID being so widespread and so frequent, our goal should now be to take a risk-based approach.

What EVERYONE Should Do

We all benefit from better air quality, particularly indoor air quality. While all of us love air conditioning, opening windows when practical really helps increase airflow circulation and is very beneficial. Now let’s be clear if it’s an exceptionally hot day, or if it’s a wildfire smog filled day where it looks like the surface of Venus , then obviously the windows should stay closed. But when practical, opening windows is good for air quality.

The View from my office on a recent wildfire smog filled day

Make sure you have HEPA air purifiers. I have one in every room in my office. Putting an air purifier in high volume rooms in your home is a good idea.

Social gatherings should also be outside. Fresh air and sunshine – just what your grandmother ordered.

I appreciate this next bit of advice will go over like a lead stone for some people, but I think it’s important that you keep a few well-fitted N95 masks around as well. You can buy these online. I’m not suggesting you need to wear them all the time, I believe we’re past that. However, in the event that a wave hits and you have to go to a crowded environment, or you’re feeling unwell, it’s better to have these ready and available, rather than scrambling to find one at the last minute.

Similarly rapid antigen tests are also useful to keep at home. You can get these from most drug stores. They are unfortunately a little less sensitive for Omicron than they were against the early variants, but they’re still fairly useful. Again, I’m not suggesting you swab every day if you’re feeling well. But if you do develop flu-like symptoms in August, then it’s helpful to already have the tests at home. Please note that a negative test does not completely rule out an infection, especially during the first 24 hours of illness. Doing a second test a day or two after your first test will improve the accuracy of the test.

If you do become ill, then of course, I would hope that you would have the good manners to stay at home. Symptoms of a covid infection are generally the same as most other respiratory illnesses (sore throat, cough, low-grade fever, fatigue). Most physicians now do virtual visits, and so you can still arrange to speak to a physician or video call them if you’ve got these types of symptoms, without infecting their whole waiting room. If you are sick, please have the common decency to avoid visiting people who have significant health issues, as those people, if they get COVID, have a significantly higher chance of deteriorating rapidly.

Get immunized! Most patients should get a yearly Covid shot, generally in the fall. Enough of the clot shot/fakecine/frankenshot/globalist serum/fauci juice nonsense. By Aug of 2024 over 13.7 BILLION Covid Vaccines were given worldwide (including over a 100 million in Canada). None of overwrought, neurotic claims about how we’re all going to die if we got the Covid shots have come true. Protect your self and your loved ones and get an annual vaccine (click here to get your shot).

And of course, there is the same advice that grandmothers have been giving forever. Eat right, exercise regularly, maintain a healthy weight, control your diabetes, quit smoking, take your vitamins (2,000 international units of vitamin D daily and 500-1000 mg of Vitamin C daily would be a good start for Canadians). Doing all of that will not prevent you from getting COVID, but they certainly are associated with a much better outcome if you do get COVID.

What Those Who are Elderly or Have Significant Health Issues Should Do

In additions to the above, significantly ill or immunocompromised patients might benefit in getting a Covid vaccine twice a year. Please discuss this with your doctor. Additionally, knowing that they are at higher risk, they should be prepared to avoid indoor activities with the general public during the coming Covid wave. For example, many grocery stores deliver now, so there’s no need to go shopping. Avoid larger indoor events where possible. If travelling by bus or plane, just go ahead and wear a mask during a Covid Wave. Call your doctor when you first get sick as you may qualify for some of the newer treatments for Covid.

The last word.

This year appears to be trending for a moderate COVID wave as opposed to a severe one in August. If we all take reasonable, cautious precautions, we can hopefully keep it under control.

Innovation Winter

Recently, the Ontario Government announced plans for a province wide family practice record system. I was debating what to write about it when I came across this post from Dr. Shahin on LinkedIn. While I don’t agree with all of it, it’s an important point of view. He’s kindly agreed to allow me to post this as a guest blog, and I encourage you to give his LinkedIn page a read.

Dr. Ilan Shahin is a Family Medicine specialist who serves as the Primary Care Lead for Patient Attachment for the Central West Ontario Health Team (CW OHT).

He’s also a Board Member and Secretary-Treasurer of the Ontario College of Family Physicians (OCFP), has an MD and Master of Business Administration (MBA) from McGill University and is a co-founder of ConsultLoop, a former e-referral platform. Basically a whole lot smarter than I am.

Innovation Winter is a Canadian tradition of killing off product categories with the whisper of a large procurement.

Every so often in digital health, governments see small companies sprouting around a category, and decide to procure The Thing for the entire jurisdiction. This is ambitious, well-intended, and comes with its fair share of boosters. E-consults, e-referrals, and e-prescribing all had similar stories. However, these didn’t work out as intended.

E-consults remains a clunky product with uptake well below its potential, when once there was a physician-led startup that offered a nice mobile experience that was much easier to use and even log on to.

E-referrals is still maturing when it’s been 10 years since an original RFP was won via a single LHIN with the thought that it would be rolled out across the province. There too, there was a company (which I co-founded) that built the referral platform at less than 5% the cost of that initial RFP, produced unprecedented and yet unmatched wait time data, and had pilots shut down because of whispers that e-referrals would be deployed imminently across the province.

E-prescribing has the story of Infoway’s landmark project that was shut down after hundreds of millions in spending, with market penetration that was only a few percentage points of total prescriptions despite the virtualization pressure of a pandemic. Setting standards for companies serving the pharmacy market could have harnessed their competitive drives, rather than relying on one platform with its limited agility.

In each case, government comes with good intentions, and tries to build The Thing. In doing so, they create what is effectively a monopoly, which risks insulating the product from market forces that produce better value, and lower costs.

However we don’t need a large procurement to actually have happened, for the monopoly or oligopoly to be entrenched, in order to kill innovation. Just the mere whisper that something big is coming is enough to make rational actors across the system wait and see. This also includes small businesses, which is where the imperative to listen to customers, the urgency to improve, and the competition on price and quality actually lives. Ingenuity lives there too, in the companies facing short cash runways, the incumbent complex, and the need to prove themselves as trustworthy both clinically, operationally, and ethically.

Government has to be careful about what it does to the marketplace when it acts. Sometimes in raising its hand, it ushers in an innovation winter, which has the potential to block far more value in a robust, competitive market, than it uncovers in a RFP-led closed market approach.

Let government focus on building the strongest marketplace, driving to common standards to uplift the market’s value, while ensuring fair competition to harness the cost and quality pressures that come with it.

Market-making. That’s the game. Innovation winters are signs of failure.

Were the 2025 Re-Appointments of Non-Physician Directors Compliant with ONCA?

In the aftermath of the Ontario Medical Association (OMA) Annual General Meeting (AGM), I expected the non-physician board directors to resign their roles immediately. I appreciate they have skills/experience that can provide valuable information to the Board. That is a good thing.

But at the AGM, it was made clear physicians don’t want them to have voting authority at a board level. Give advice? Sure. But have a significant block of votes that could sway a close vote at the board? 57% of physicians voted against that.

The OMA has taken a somewhat different approach, going by the exact legal letter of the motion as opposed to the spirit of the motion. Board Chair Sharon Bal announced that the three non-physician board directors would continue on until their terms ended, which in one case won’t be until 2028.

It’s disappointing to me that the integrity to do the right thing is lacking. Reminds me of how the executive at the OMA tried to stay on in the aftermath of the 2017 vote of non-confidence. At that time “only” 55% of Council voted no-confidence, which was short of the 2/3 majority. There too, it was arguably legally correct for them to continue, but wasn’t morally correct. (They eventually resigned a week later).

This mess made me review the Agenda and the minutes for the AGMs. In doing so, I noted something quite odd. The 2025 AGM Agenda did not have a motion to ratify board directors by the membership. The 2025 AGM minutes also show no election/ratification of non-physician directors occurred. Yet two non-physician board directors were automatically reappointed by the OMA. Frontline physicians like myself were not given a choice on this. The 2026 AGM Agenda DOES have motions ratifying the election of all the physician directors, and the reappointment of the non-physician director.

Wondering why the difference, I went and reviewed the Ontario Not-for-Profit Corporations Act (ONCA). I’m weird that way. Section 24(1) states,

“…at the first meetings of the members and at each succeeding annual meeting at which an election of directors is required, the members shall, by ordinary resolution, elect directors to hold office for a term …..”

Note the phrase, “the members shall, by ordinary resolution, elect directors.” There is no exception for reappointment, and no authority granted to the board to simply declare a director routinely reappointed. If there is a vacancy, the Board can, but doesn’t have to, appoint a replacement until the next AGM (Section 28). This was not the case for the OMA in 2025 obviously.

The other exception is…….ex-officio directors. Under section 23, paragraph 4, that states the bylaws of a corporation may provide for persons to be directors by “virtue of their office“. This is current legal term for ex-officio directors. Additionally, there is no requirement for ex-officio directors to vote at the Board, the bylaws can prevent them from doing so.

This annoyed me more, so I looked at the OMA bylaws. (I told you, I’m weird). Article 9.3.3 states:

” …after expiration of director term set out in section 9.3.2, all directors shall be elected to hold office for a two year term.”

The word elected appears without qualification and applies to all directors. There is no provision in the OMA bylaws permitting a board-managed reappointment track for non-physicians. This, of course, does not stop the board from seeking out candidates and somehow preventing other non-physicians from running like they seemingly did this year (they only presented one candidate for the position). But Members have to elect/ratify the candidate.

It’s unclear to me how the Board and their Chair could have allowed this situation to occur. The 2025 reappointments of two non-physician directors were inconsistent with ONCA and even inconsistent with OMA bylaws. Heck, article 12.1 of the OMA Bylaws identifies member election of the directors as a core member right. As a result, their re-appointment appears to be illegal.

Obviously, somewhere along the way, the OMA as a corporation recognized the error in 2025, as in 2026 they presented board directors for ratification at the AGM. My personal view is that this is a tacit admission of the OMA having failed to follow ONCA and OMA bylaws in 2025. But to my knowledge there has not been an “oops, sorry about that” email from the then Board Chair. Worse, the OMA has yet to remedy the 2025 error in the appointments of the two, making it appear that they were trying to sweep this under the rug and hope nobody would notice.

What does this mean? I remember talking to one of the OMA’s external legal counsels at a social event AFTER a meeting. We got to talking governance issues at OTHER corporations. That particular counsel suggested that when appointments/decisions are made in good faith, and without being able to prove that there was malicious intent in any board decisions (apparently a very high bar), reversing or changing any decisions as a result of this would not happen. Similarly, attempting to remove board directors retroactively would be challenging.

There is apparently a remedial path called curative ratification. The OMA could hold a special meeting of the members to ratify the non-physicians. However, considering the outcome of the 2026 AGM, and the revelation that the OMA has sat on this issue with no negative consequences to their legal team, I doubt this will happen.

Given all of this, probably the best way to fix this mess is for both of them to resign early, then have elections where physicians are chosen to replace them. (I would suggest the third should resign as well). This would remove the thorny issue of how legal their re-appointments were to begin with, and frankly do what they should have done in the first place.

Will the OMA do the right thing?

Please Don’t Move to the Georgian Triangle (Collingwood, Clearview, Wasaga Beach)

Wait, doc, what’s this all about? You’re asking people not to move to where you live?!?

Yes. Please don’t move to this area.

But you always tell others how wonderful an area this is!

This is indeed true. I love living here. I consider myself very blessed for having come here 34 (!) years ago. We are a few minutes’ drive away from the world’s longest freshwater beach, a few minutes’ drive away from ski hills. There’s golf, boating, too many outdoor activities to list. I enjoy the trails myself and often bicycle to my office during the warmer months. A true four seasons resort area.

Is the problem the people?

Not at all. The people here are kind, generous and extremely supportive. Plus there’s an old farmers mentality in a lot of them (that’s a good thing). I’m grateful they have allowed me into their lives. It’s an honour to help them.

Is the problem the growth in the area?

I’d be lying if I said I was completely happy with the increase in the population over the past ten years. The towns have gotten quite crowded, and the roads are busy. Bicycling on the roads is now classified as a survival sport. And yes, I have seen traffic jams, which is something I never thought I’d see. But no, that’s not it exactly.

Okay, doc, you’ve got me really confused. What exactly is the issue then?

It’s the healthcare system.

That makes no sense. You’ve often talked about how proud you are of the fact that you were the inaugural chair of the Georgian Bay Family Health Team, and how closely the doctors in the area worked together to form a really cohesive medical community.

This is true. The Georgian Bay Family Health Team, under the leadership of their Grand Poobah (inside joke), Maria LaRose, is, in my opinion, the best health team in the province. The doctors and allied health care staff all work well together. We formed the first community wide Electronic Records system in the Province. It’s still the only one in Ontario that is integrated with other health care partners. It’s the best medical community in the province.

Okay, so is it the hospital? Goodness knows you’ve had issues with administration in the past.

Actually, we’ve been very fortunate to have better administrators at the hospital the last couple of decades. The nursing staff and other allied healthcare professionals (physiotherapists, occupational therapists, pharmacists, respiratory therapists, and so on – apologies to those I missed) really are excellent and hardworking as a team. They really want to help patients. The problem, of course, is that they are overworked.

So then your issue is with the capacity of the local healthcare system?

Exactly. You see, currently, we have seven thousand people in our neck of the woods who don’t have a family doctor. If you move to the area, you will be number 7,001. Therefore, you will wind up going to our after hours clinic, or the hospital emergency department, which will increase the stress on those facilities.

This is, of course, not the fault of the individual physicians, nurses, allied health care workers. The blunt reality is the health care infrastructure is not there.

But I thought you guys were building a new hospital?

We are. BUT. We’ve known we’ve needed a new hospital since the early 2010’s, and despite many pleas, won’t start digging until 2029. We are hoping to complete in 2032. Various layers of inept government bureaucracy at the Ministry of Health have thrown many roadblocks in the construction process. As a result, our over burdened hospital puts patients in “unconventional places.“

You mean like hallway medicine?

Actually, I believe the term now is “chair care“because even the hallways are full.

Wonderful. Are the local townships not doing enough to recruit doctors?

It’s not really a township responsibility to look after the healthcare system. Now, there are some local efforts (with a bit of success) to get more family doctors in the area. However, that’s a slow process until the wider provincial problems are fixed.

You’re saying don’t come to the Georgian Triangle, but don’t these issues occur elsewhere?

Absolutely. I mentioned the Georgian Triangle just because it’s the area I know the best. Ontario has many beautiful areas for people to live in. Lots of different type of communities to suit all needs from small town, to large urban settings. But, if you currently live in an area where you already have a family doctor and you have a number of health issues, you really may want to reconsider moving until you can assure yourself of getting continuous, comprehensive, ongoing care in the community. Without a local family doctor, you will be getting itinerant care seeing different doctors at walk in clinics or Emergency departments, and that’s not good for your health.

So don’t move anywhere if you already have a family doctor?

Well look, people often have to move for many reasons. Work, family, retirement. I get it. BUT, I would encourage you, if at all possible, to scope out not just the amenities of the area you are thinking of, but also check the local health system out. That is something most people don’t do, they just expect health care to be there for them. That mentality needs to change.

And don’t move to the Georgian Triangle?

Yah, don’t move here. Our doctors (and hospital, and home care) are full.

What Does the Leadership Change at the OMA Mean for Doctors?

On Thursday, Physicians across Ontario received an alert from Dr. Sharon Bal, Board Chair of the Ontario Medical Association (OMA) about a leadership change at the organization. Kim Moran is no longer the CEO. I think it’s safe to say the announcement caught most physicians off guard.

An OMA past president, Dr. Andrew Park, was appointed as interim CEO. I certainly wish Dr. Park well, although I note that he has, to my knowledge, not really run a comparably sized organization. I would also point out that while the title he had was “President”, the role really was media spokesperson (as I found out the hard way when I had the job). I do give him credit for holding an executive MBA, which makes him smarter than me.

Having recently been President, he would have a good idea of what’s going on internally in the organization, and for the sake of all physicians across Ontario, I hope he does well in the role while the search for a permanent replacement is carried out.

This doesn’t change the fact that the timing is exceptionally unusual. The continuation of the OMA’s Annual General Meeting (AGM) is in just a couple of more days (June 23 at 6:30 pm). The agenda has a number of member-driven motions that, in my opinion, are designed to make the OMA more responsive to physicians and a stronger advocate for us. Such a significant leadership change before what is shaping up to be a very important meeting is going to raise eyebrows.

Medical politics is a funny business.

But more importantly, what does it mean for physicians right now? In my opinion, it is even more essential for all of us to show up at the continuation of the AGM. For those of us who have been frustrated with certain things that have gone on at the OMA, this does not mean that we can say, “Oh, good. The CEO is leaving. Things will be different,” and ignore the OMA again. I continue to maintain that the OMA is at its best and most effective when members keep a close eye on it and prevent it from going off the rails. If the member motions don’t pass, in my opinion, what’s going to happen is that the OMA will simply revert to its old ways and non-physicians will continue to have decision making authority over physicians.

This is not acceptable.

The first member motion is to end the idea of having non-physician Board Directors at the OMA. This has been discussed ad nauseum and I won’t restate the rationale here. You can just look at my blog on why the OMAs AGM really matters this year, or on why I hate non-physician Board Directors (I don’t).

But the second motion is also incredibly important. It prevents the OMA from screening or gatekeeping Board Director candidates. Dr. Paul Hacker has done a really excellent analysis of this motion. He points out, quite clearly:

“The OMA currently uses a third-party vetting process for Director nominees, overseen by the Governance and Nominating Committee. The GNC is the only body that sees the complete list of candidates and the full vetting results. The criteria weighting used, the rankings produced, and the reasons for including or excluding specific candidates are not shared with the full Board. The Board is asked to approve a slate based on information it does not have access to in its entirety.”

This is just plain wrong and needs to be fixed.

Dr. Hacker was going to do a guest blog for me. But with the news about the CEO, I felt compelled to write a different blog about the importance of the AGM. However, I strongly encourage you to read his blog on why the second members motion is so important.

There are also other members motions that I am not seconding that physicians really should have a say on.

However, I guarantee you that none of these changes will occur, regardless of who the CEO is, unless all of us show up at the AGM and vote in favour. As Dr. Greg Dubord if fond of pointing out, the “Iron law of oligarchy“means that without members acting, organizations insulate themselves from member accountability, prioritizing institutional preservation over their founding mandate. In essence, they wind up placing themselves above the members. So please, please, please, if you haven’t already registered, do so by clicking here and attend the meeting.

You must register by Monday June 22 at 6:00 pm.

The OMA will only be as strong as the amount of supervision and guidance that physicians give it. This leadership change does not mean we should take our foot off the gas pedal. We all need to attend the AGM and make our voices heard.

The OMA Investigated Itself and Found Itself Not Guilty

My thanks to former OMA Board Director Dr. Paul Hacker for guest blogging for me today. He’s done a thorough analysis of the OMA’s report on the May 7 Annual General Meeting (AGM) and provides us with an excellent summary of where the report is strong, and where it is lacking.

The OMA has released its formal response to the May 7 AGM failures: a summary of findings from an unnamed third-party reviewer and a legal opinion from Wayne Gray of Gray Whitley LLP. Both are substantive. Both reach conclusions favourable to the OMA. And both are built on a foundation the OMA itself controlled.

The Review: What It Found and What It Missed

The review identifies twelve problem areas. Several recommendations are sensible: earlier registration cutoffs, mandatory test votes, end-to-end technical rehearsals, experienced vendor teams. Credit where due. But four findings deserve scrutiny.

Finding 3 states the voting platform “worked as designed” and attributes login failures to “a combination of user error and possible technical issues.” The 77 petition signatories who could not register or enter the meeting did not fail to read the instructions. They never received them.

Finding 4 states that “voting logs confirmed that no duplicate votes were recorded.” Multiple written accounts from petition signatories describe the page resetting unprompted, presenting the vote again without any action on their part. One member wrote: “I was able to vote more than once on motion 7.” Either every one of these members is mistaken, or the voting logs do not capture what happened at the user level. The review does not engage with this discrepancy.

Finding 6 admits the OMA used a less experienced local vendor team and no dedicated production manager for what turned out to be its highest-turnout AGM. This was a decision, not a malfunction.

Finding 8 states that procedural motions from the floor “consumed significant time” and contributed to the meeting running out of time. Those motions were submitted by members, followed all OMA rules, and were duly accepted. If the OMA did not allocate enough time for members to exercise their procedural rights, that is an organizational failure, not a member one.

The reviewer is not named. Members have been given a summary, not the full report. Members are being asked to accept the conclusions of a review whose author, methodology, and completeness they cannot evaluate.

The Legal Opinion: Sound Analysis, Wrong Numbers

Wayne Gray is a respected ONCA practitioner. His math is correct. His case law is sound. The problem is the factual premise.

Gray builds his opinion on the number 79, drawn from my petition: the total of categories A (could not register: 34), C (no login instructions: 10), D (could not enter: 20), and E (could not vote: 15). Even assuming all 79 had voted in favour of Proposal #1, the motion to remove non-physician Directors, it reaches approximately 60%, short of the two-thirds required. The motion still fails. That math is correct. Here is why it does not settle the question.

79 is a floor, not a ceiling, and the OMA knew it. My petition submission almost certainly represents only a fraction of the total number of affected members. I asked the OMA to conduct a member-wide survey of all 50,000 members to establish the true number. They declined. They then provided the incomplete data to their lawyer. The opinion is only as good as the facts it was given, and the OMA chose not to collect better facts.

Gray excludes Category B (no acknowledgement email), writing it is “hard to see how” missing an email resulted in a lost vote. The written accounts, which Gray says he did not see, describe exactly how: members were told by OMA staff it was too late to re-register because their confirmation email was required and they never received one. They were locked out. Including B raises the floor to 92.

Gray’s footnote describes the petition as conducted by members “whose interest in the vote outcome is not disclosed” who asked “certain participants (selected by the surveyors).” Both characterizations are wrong. The petition was public, open to any OMA member, shared through physician Facebook groups and the Medical Post. No one was selected. 84% of signatories provided a CPSO number for verification.

The Circular Logic

The OMA needed to know how many members were affected. They had two options: survey their 50,000 members, or use the petition data. They chose the option that produced a smaller number. The resulting number sustained a validity finding. They declared the matter closed.

If the OMA had surveyed its members and found a larger number, the conclusion might have been different. They ensured that could not happen by choosing not to ask. That is not transparency. That is institutional self-preservation.

Did the OMA respond to members?

You be the judge. Here were my formal requests when I submitted the petition data:

❌ Conduct and publish a member-wide survey on AGM technical access failures, using the A through G framework from the attached petition, within 30 days;

❌ Report the vendor review findings to members with specificity, providing actual numbers rather than summary language;

✔️ Have legal counsel advise the Board and report to members on the implications of the access failures, including the voting integrity issues documented in member accounts, for the validity of votes taken at the May 7 AGM (but incomplete information provided);

❌ Resolve the outstanding bylaw deficiencies relating to proxy voting, election rules, and the appointment process for non-physician Directors, including a remedy for the 2025 reappointments; and

✔️ Commit to a general member satisfaction survey, the resumption of which has been promised to members since 2023, to be conducted within 90 days.

June 23

The review and the opinion are not bad-faith documents. But both were commissioned by the OMA, informed by data the OMA controlled, and reached conclusions the OMA can live with. Members should read them carefully and draw their own conclusions about whether this constitutes the transparency the OMA promised.

The continuation meeting is June 23, virtual only. Registration closes June 22 at 6:30 pm. The motions remaining before the membership are important. Attend. Vote. The OMA responds to organized member engagement, even if they do not seek it out directly. That is the one lesson of this entire experience that is beyond dispute.

Register for the AGM here.

Past OMA Leaders Find Legal Review of the AGM is Wanting…

This blog has been authored by the following physicians (in alphabetical order):

Dr. Paul Conte – former OMA Board member, former OMA Board Chair and former Chair of GNC during much of the transition to the new Governance Model

Dr. Sohail Gandhi – OMA Past-President who was tasked with giving the speech at Council leading to the governance transformation.

Drs. Paul Hacker and Lisa Salamon – Past Co-Chairs of the GT20 Governance Transformation Task Force that oversaw the governance changes

Dr. Jesse Wheeler – former member of the GT20

The five of us would like to encourage ALL Ontario physicians to attend the Ontario Medical Association’s (OMA) continuation of the Annual General Meeting on Tuesday, June 23rd at 6:30 PM. This meeting will be virtual. The OMA’s bylaws do not allow proxy votes, so you will need to be there virtually. A registration link is at the end of the blog.

We were heavily involved in the governance transformation that the OMA underwent starting in 2019. We attended many many meetings, reviewed many pieces of legislation and consulted widely before making our recommendations. All of us feel that much of the work we did is being undermined by the current OMA leadership.

It is true that many of the changes that have occurred have been very good for physicians. The move to a smaller Board that represents physicians as a whole was badly overdue. The previous Board was too unwieldy. Despite best efforts there was some element of trying to represent your constituency on the Board as opposed to the profession as a whole. The current smaller board size is ideal for a forward-thinking organization that will need to respond to unexpected threats that come out of the blue.

Additionally, we’re very pleased with the move away from Council and into the Priorities and Leadership Group (PLG). While OMA Council had many dedicated members who gave of their time to represent their colleagues and did a lot of unrecognized work, the very structure and nature of Council created a bit of a divisive environment. Instead of building consensus, Council often times was reduced to entrenched voting blocs. This was unhelpful.

Judging by feedback from the last two PLG meetings, this mentality seems to no longer exist, and there seems to be a genuine cooperative effort to come up with ideas and to prioritize them for the OMA to tackle. We’re very pleased that this has happened. This can only be a good thing for physicians going forward.

Unfortunately, however, we continue to have significant concerns about how the OMA has handled the issue of governance at the Board level, and in particular, how the OMA has, in our view, manipulated the process for physicians choosing Board Directors. Specifically, having non-physician Board Directors voting on matters that affect physicians has proven to be unhelpful.

Drs. Conte and Gandhi presented a motion at the AGM to remove non-physician directors. To be abundantly clear, we are not at all opposed to the idea of the board seeking out external expertise in areas as needed. It’s imperative that a member advocacy association does that. It’s a good thing, and in our best interest.

The issue is who makes decisions on behalf of physicians. We feel strongly that that should be physicians only. Only physicians have the lived in day to day experience in health care that will help determined whether external advice, however well intentioned, is actually good for other physicians. We are disappointed that the current OMA leadership is fighting us on this. We’re further disappointed at some of the tactics being used.

Last week, the OMA Board Chair released 12 findings of an independent review of issues around the first part of the AGM. We thank her for sharing that. Issues ranged from insufficient testing, to late registration challenges, to login difficulties, and so on. The majority of their recommendations are good supportable recommendations.

We are concerned at the recommendation for including templates for anticipated motions and procedural motions. One of the most frustrating aspects of the first part of the AGM was what we viewed as gamesmanship. The clear impression was the leaders of the OMA were trying to get a certain result, regardless of whether the members wanted it or not. We are concerned that by openly stating the need for procedural templates, attempts will once again be made by those few to bog down the meeting in procedural delays, instead of letting members debate the merits of the motions.

Furthermore, we have significant concerns about the legal opinion on the validity of the vote of the first motion at the annual general meeting. We are not questioning the background, or the knowledge, or the expertise of the external legal consultant Wayne Gray. Rather, it appears that his opinion is based on information provided by the OMA. That is worrisome.

Mr. Gray states that the number of votes on the first motion (to remove non-physician Board Directors) was 534. But there needed to be a revote and only 483 people voted the second time. Additionally he was told 79 people were unable to cast votes. Based on that, the first motion wouldn’t have passed. That is true, but that 79 number came from a survey done by Dr. Paul Hacker. The survey had limited reach. The OMA certainly didn’t survey all the members. That number also doesn’t include those who couldn’t register or those who couldn’t log in. In short, we really don’t know how many people would have voted had there been no technical issues.

We are left with the strong sense that had the first motion passed, the OMA would be trying much, much harder to hold a re-vote on the first motion to get the result they want.

Additionally, the OMA leadership is putting up videos opposing the member motions for attendees to view. We were notified on Friday that we could add a video supporting the motions. This gives us less than ten days, while the OMA has had weeks to put theirs together, and also has the resources to make their videos look more professional. (This reminds us of the days of the 2016 tPSA when the Board produced all sorts of promotional videos to promote a bad deal to the members). Additionally, there were NO videos supporting or opposing the motions for the first part of the AGM. This creates a fundamental inequity in how the two halves of the AGM are managed, and we don’t think that’s appropriate. We will NOT be doing videos.

Drs. Conte and Gandhi also have motions to prevent the OMA from providing commentary on candidates and removing arbitrary criteria for banning members from running for Board. Other physicians have motions about tax information being used by the OMA and strengthening Districts.

What can you do dear member? Well, the answer is simple. It will take some of your very valuable time (and we recognize that). We ask all of you to register for the continuation of the AGM. Important, you MUST register by 6:00 pm, Monday June 22. It is essential that you make your voices heard. YOU have control over the OMA and its direction, if and only if you choose to exercise your authority. We sincerely hope you will.

Click here to register for the AGM.

FHO+: The Good, The Bad, and the Reality on the Ground

My thanks to Dr. Wael Guirguis, (pictured inset) who had a superb post on LinkedIN that he’s kindly allowed me to reproduce as a guest blog. Dr. Guirguis got his MD in Egypt in 2003 and has been practicing in Canada since 2011. He’s the lead physician for the Fairway FHO and provides comprehensive care for patients at the Danton Medical Centres. A thought provoking read which I hope you’ll enjoy.

Over the past couple of months, Family physicians across Ontario have started experiencing the reality of the new FHO+ model in day-to-day practice.The goals behind the reform are understandable.

Improve access. Support continuity of care. Encourage after-hours coverage. Create more accountability in primary care.

These are important goals, and family physicians should absolutely be part of improving the system. Some aspects of FHO+ deserve recognition. Organized after-hours coverage matters. Continuity of care matters. Accountability matters. But as implementation unfolds, many front-line physicians are beginning to identify operational consequences that may not have been fully appreciated during policy design.

The Efficiency Problem

One of the biggest concerns is the relationship between productivity and compensation efficiency. Under FHO+, physicians are now heavily constrained by hourly and monthly thresholds tied to direct patient care time. In practical terms, physicians can work harder, see more patients, and still experience a significant reduction in compensation efficiency. The unintended consequence is that the model may discourage efficiency during regular clinic hours.

A physician who develops efficient workflows, uses technology effectively, and safely improves patient throughput may actually feel penalized for doing so. That creates a concerning signal within primary care. Healthcare systems should reward:

safe patient access
continuity
quality
responsible innovation
sustainability
burnout prevention

Not unintentionally encourage physicians to slow down to remain within operational thresholds.

The Hidden Mental Burden

One of the least discussed consequences of FHO+ is the cognitive burden it creates for physicians throughout the day. Doctors are now not only thinking about patient care, they are also continuously tracking:

direct care hours
monthly hour accumulation
reimbursement thresholds
after-hours eligibility
continuity metrics
outside-use implications
whether additional work will still be compensated fairly

That constant background calculation creates mental fatigue. Family physicians already operate in an environment of nonstop decision-making: clinical care, inbox management, staffing issues, documentation, urgent requests, abnormal results, hospital follow-ups, and administrative work. Adding another layer of continuous operational tracking changes the psychology of practice itself. Instead of focusing entirely on patient care and clinic efficiency, physicians may begin constantly asking themselves:

“Am I crossing another threshold?” That is not a healthy foundation for sustainable primary care.

The Bigger Problem: Complexity Itself

This discussion is larger than FHO+ alone, It reflects a broader pattern in healthcare reform. With each reform cycle, the Schedule of Benefits seems to become increasingly complex rather than simpler.

New rules. New modifiers. New exceptions. New thresholds. New formulas. New tracking requirements. Yet very rarely do reforms focus on reducing front-line operational complexity for physicians. And complexity itself has consequences, It increases cognitive load, administrative dependency, billing anxiety, operational inefficiency, and eventually burnout. Complex healthcare systems may be unavoidable. But complex systems still require simple front-line workflows. That principle is often overlooked.

Continuity of Care Should Be Managed by the System, Not Punitive Billing Rules

Continuity of care matters. Family physicians understand that better continuity leads to better long-term outcomes, fewer fragmented records, reduced duplication, and safer patient care. But enforcing continuity through increasingly complicated physician payment penalties is not the right approach. A simpler and more effective solution already exists. If the Ministry of Health wants to strengthen continuity of care within capitation models, the responsibility should sit primarily with the system itself, not through constant billing complexity imposed on physicians.

For example: If a rostered patient repeatedly seeks care outside their enrolled medical home beyond a defined threshold, the Ministry could automatically review or remove the patient from the roster. The patient would be notified directly by the Ministry of Health not by the physician. This creates clear accountability while avoiding unnecessary tension between doctors and patients. Most importantly, it removes one of the major hidden burdens currently placed on family physicians: constantly monitoring continuity metrics, outside use calculations, and roster penalties while simultaneously trying to run busy clinics.

Continuity of care should be encouraged through smart system design and patient accountability not by forcing physicians to navigate increasingly complicated billing formulas and penalties. Doctors should focus on delivering care. The healthcare system should focus on managing the system.

The Human Side Nobody Talks About

Most family physicians are not trying to maximize billing. They are trying to:

keep clinics financially sustainable
reduce patient wait times
manage inbox overload
supervise staff
complete documentation
respond to urgent patient needs
avoid burnout

When systems unintentionally penalize high-functioning clinics for being efficient, morale suffers quickly. And eventually, patients feel the impact.

A Better Path Forward

Primary care reform is necessary. But reforms work best when governments collaborate closely with front-line physicians who actually operate clinics every day. The goal should not simply be measuring physician hours. The goal should be:

maximizing safe patient access
improving continuity
reducing unnecessary administrative burden
supporting sustainable family medicine
encouraging innovation and operational efficiency
protecting physicians from burnout

Ontario has extraordinary family physicians who want the system to succeed. The question is whether the system is being designed in a way that allows them to succeed too.

Why You Should Attend the OMA’s (Continued) Annual General Meeting

Last week, the Ontario Medical Association announced that the continuation of the 2026 Annual General Meeting (AGM) will occur on Tuesday, June 23rd, at 6:30 PM. This meeting will be virtual only. Once again, proxies will not be allowed. I would suggest that it is essential for every member to make an effort to attend.

My three loyal readers will remember that there were six member proposals (4 by Dr. Conte seconded by myself). Only one got voted on at the May 7 meeting, and the remainder will be voted on, on June 23. Regardless of what you may think of the individual motions, I would suggest the fact that members take the time to make proposals, and attend to vote is a good thing. It is important, as I’ve learned over the years, to pay attention to what’s going on at the OMA because so much of our livelihood depends on them.

This year’s AGM is proof of what can happen when members show up and make their voices heard. Now, I was criticized for my blog on the last AGM for calling out the shenanigans that occurred at the meeting. This all surrounded what were in my opinion, the two most important motions.

Both motions pertained to removing non-physicians from having voting authority over physicians at the Board of the OMA. To be abundantly clear, neither of these motions would have prevented the organization from seeking external expert advice on an ongoing basis. Organizations, particularly advocacy organizations like the OMA, do that all the time, as they absolutely should. Physicians are not experts in everything, and seeking out the best possible advice in different areas from experts in their fields is always a good thing to do.

No. These motions would simply have said that after getting the advice, and carefully reviewing it, the voting authority for who makes decisions at the organization should fall only on physicians. Only physicians have innate knowledge and lived in experience of how the healthcare system affects them. Only physicians will inherently know when such advice, well intentioned though it may be, will actually help, or those times when it is unhelpful.

At the last meeting, for reasons that are unclear to me, as I’m not a lawyer, the first motion, which would have removed non-physicians from the Board immediately, required two thirds of a vote. This motion, after much debate, got fifty-three percent. Now, I fully expected some of our colleagues to throw up roadblocks to the first motion. That happened. I won’t do a line by line analysis of that as I don’t think it’s relevant, but if it had just stopped there, I probably wouldn’t have made any comments about “shenanigans” or “the usual suspects.”

What happened was that once it became apparent that the majority of physicians at the meeting did want not want non-physicians voting at the Board level, it became crystal clear that the second motion, which only required fifty percent plus one, would likely pass. A friend of mine, who also attended virtually, commented to me, “I wasn’t in the room, but I swear I could hear the jaws drop and the shock from many of the people in the room.”

Rather than accept that the debate had already been had, that all of the points had already been made, and accept the will of the membership, some of our colleagues continued to try and delay the process and play games. Eventually they succeeded. The meeting was paused and now we have to do it all again. And those are the shenanigans that had me, quite frankly, extremely annoyed.

At any rate, the membership has another chance. If we all show up, we can vote on the second motion and determine if we do, in fact, want a large part of our futures decided by non-physicians. (Non-physicians have just over twenty-five percent of the vote at the board currently).

Other motions that are important for us to decide upon include the director election ballots process. This year marked, as far as I’m concerned, a new low in how the board director elections were run. The OMA screened candidates for board director and limited who could run based on their own criteria, that was fed to a third party firm to try to avoid blame. In essence, the OMA chose who we physicians could vote for. Furthermore, they impugned the reputation of one of the president elect candidates by printing subjective opinions about his social media posts.

The second motion would stop the OMA screening candidates and allow the members to pick who they want leading them.

Other motions include eligibility for board if you had previously held the role of president in the association. Once again, it is really the decision of the members, not the OMA, to rule out who can and can’t run (and yes, there’s a conflict of interest in there for me). There’s also a motion recommending the OMA not access personal tax information. The OMA has never actually accessed personal tax information despite significant misinformation about this. However, I personally see no harm in restating that again. And finally, there’s actually a really good idea asking the OMA to support their districts by sharing email lists in compliance with privacy legislation. Our districts do need strengthening, and this would help with that.

None of these changes, however, can occur without physicians showing up. It will take time. It will take effort. It is a couple of hours out our very busy days. I feel bad asking for members to sacrifice this amount of time, but at the end of the day, if we don’t pay attention to what’s going at the OMA, we will not get the results we deserve.

I encourage all Ontario physicians to register early for the AGM by clicking the link below: