justanoldcountrydoctor

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:

The Shrinkflation of Family Medicine

Dr. Julie Wilson (pictured inset) had a superb post on LinkedIN that she has kindly allowed me to reproduce here as a guest blog. A much smarter person than I, she is a family doctor,has been named one of Canada’s 100 Most Powerful Women, Top 40 under 40, 3 x Business award winner and much much more. I encourage you to follow her for more of her excellent insights.

There is a word for when the packaging stays the same but there is less inside. In groceries, we call it shrinkflation. In family medicine, the same process has been underway for years and we still do not have a proper name for it. The phenomenon is real, the consequences are significant, and the cause is structural rather than professional.

It deserves to be examined plainly.

What Family Medicine Was Designed to Do

When I completed my family medicine residency, the expectations were unambiguous. A graduating family physician needed to be able to deliver their own patients’ babies, follow them in hospital, suture lacerations in the office, perform biopsies and joint injections, insert IUDs, provide prenatal care, administer pediatric vaccines, conduct children’s wellness visits, and manage mental health from assessment through to ongoing treatment. You were trained to treat and manage every condition as though there were no specialists present, because in Canada, there often are not.

This was not an aspirational standard. It was the functional design of the role. Family medicine in Canada was conceived as the foundation of a system in which primary care would carry the load that specialist infrastructure could not be expected to cover across a country of this geographic scale and population distribution. Broad scope was not a luxury. It was a requirement.

What Has Changed Since the Pandemic

The erosion of that scope has been incremental and largely unremarked upon in public discourse. Since the pandemic, a substantial number of family physicians, including those whose practice is confined entirely to clinic-based work, have stopped performing procedures and providing services that were previously considered core to the role. Biopsies, suturing, contraceptive management, prenatal care, pediatric immunisation, children’s wellness visits, mental health assessments, and ongoing counselling have migrated out of the family practice setting into referral queues, specialist offices, and in many cases, emergency departments.

It would be tempting to attribute this to shifting training norms or changing physician preferences, and those factors are not entirely irrelevant. But they are not the primary explanation. Family physicians did not collectively decide to de-skill because they lost interest in comprehensive practice. The more accurate explanation is that the financial and structural conditions required to sustain comprehensive practice have deteriorated to the point where, for many clinics, broad scope is no longer economically viable.

The Economics of Comprehensive Care

Comprehensive care costs more to deliver than narrow care. It requires longer appointment slots, better equipment, more qualified support staff, more expansive insurance coverage, and considerably more time spent on coordination and documentation that does not generate a separate billing code. These are real costs that the clinic model must absorb, and for a significant proportion of BC primary care clinics, the current overhead structure cannot absorb them.

The 2025 Financial Review of Primary Care Clinics in Vancouver, produced by the Vancouver Division of Family Practice, provides useful context. Average operating expenses per physician run approximately $110,000 per year. A clinic operating at 25% overhead on a physician billing $450,000 generates $112,500 in revenue, leaving almost nothing above the average expense threshold and no margin whatsoever for the additional infrastructure that comprehensive practice requires. At overhead rates of 20% or below, which are increasingly common in recruitment conversations driven by alternative-revenue clinic models, the arithmetic becomes impossible well before extended scope enters the picture.

The result is a rational economic response to an irrational structural situation. Clinics on constrained margins contract their service offering to the minimum sustainable model. Services that require additional time, equipment, or staff are referred out. The physician’s role narrows not because of a change in values or training, but because the financial model of the clinic cannot support anything broader.

The Systemic Consequences

The consequences of this contraction do not remain contained within the family practice setting. They redistribute across the health system in ways that are cumulative, expensive, and in many cases preventable.

Canada operates on the stated premise of a primary care-based health system. The logic of that model is that a robust and comprehensive primary care foundation reduces the demand on specialist services, emergency departments, and acute care capacity. When the foundation contracts, the load it was carrying does not disappear. It transfers.

Every laceration that is no longer sutured in a family physician’s office becomes an emergency department visit. Every mental health presentation that no longer has a landing place in primary care adds to the demand on crisis services and inpatient psychiatric capacity that is already stretched beyond its design parameters. Every biopsy that moves from a family physician’s office into a specialist referral queue adds weeks or months to the interval between a patient’s first concern and a clinical diagnosis. Every prenatal patient who cannot access continuity of care through their family physician adds complexity to obstetric and hospital-based maternity services.

Specialty wait times lengthen not only because of specialist supply constraints but because specialists are now managing presentations that a well-resourced primary care system would have handled earlier and closer to home. Emergency departments are not simply overwhelmed by volume. They are absorbing a category of care that primary care has progressively stopped providing, without any corresponding expansion of emergency capacity to meet that transferred demand.

The diagnostic lag that results from this redistribution carries its own clinical cost. The interval between a patient identifying a concern and receiving a diagnosis has extended from days to months for an increasing range of conditions. In oncology, in cardiology, in neurology, earlier diagnosis consistently correlates with better outcomes. The compression of primary care scope is not a neutral administrative adjustment. It has clinical consequences that are difficult to measure at the individual encounter level but become visible at the population level in outcomes data.

Patients who have only ever experienced the contracted version of family medicine do not recognise what is absent, because they have no baseline for comparison. They do not know that the referral they received could have been managed in the same appointment by a physician who is fully trained and willing to do the work. The shrinkflation is invisible to those who have never seen the full product.

The Path Back

Restoring comprehensive family medicine will not happen through exhortation. Physicians who have adapted their practice to the structural constraints of their clinic model will not re-expand their scope because the profession asks them to. The conditions that made contraction rational need to change before expansion becomes possible.

Several directions are worth pursuing seriously. Funding models need to reflect the genuine cost of delivering comprehensive primary care, including the additional infrastructure, time, and staff that broad scope requires. The LFP billing model in BC represents progress in recognising longitudinal value, but it does not yet fully account for the procedural and extended scope work that a comprehensive practice involves.

Training culture matters as well. If residents observe that the physicians they are learning from no longer perform the procedures they are being taught, the implicit message is that those skills are aspirational rather than practical. Preserving broad scope in residency training requires that the training environment model it, which requires that the clinics where training occurs are financially equipped to sustain it.

Record transfer and cross-clinic infrastructure also warrant attention. A physician who might otherwise take on complex procedural or prenatal care is significantly less likely to do so if the clinical history required to do it safely is inaccessible because of the fragmented and non-interoperable state of EMR systems across BC. The administrative friction of comprehensive practice needs to be reduced, not compounded.

Finally, the conversation about what is being lost needs to happen at a scale and with a directness that it has not yet achieved. Policymakers, health system planners, and the public are not well positioned to advocate for the restoration of something whose disappearance they have not been clearly shown. Making the shrinkflation visible, naming it, costing it, and tracing its consequences through the system is a necessary precondition for addressing it.

The physicians are still trained. The capability is present. What is required now is a serious, sustained effort to rebuild the structural conditions that make comprehensive family medicine not only possible, but financially sustainable for the clinics and physicians who want to practice it properly.

Dr. Julie Wilson, MD, CCFP, FCFP

Use AI NOW to Reduce Bureaucratic Bloat in Health Care

On the heels of my last blog on the Auditor General’s report on AI systems in Ontario, I was asked “how then can AI help in health care?” Certainly policy makers often talk a LOT about how AI can help. Better diagnoses! Faster assessments! Better prediction of which patient is more likely to “crash”! Reduced admin time with the use of AI Scribes! Etc.

These are all valid uses for AI technology. I use an AI scribe myself (following the principle of “trust but verify”in signing off on the notes). I access some evidence based AI software to help me with challenging cases. I always have the final word on what to do next of course, but I would be lying if I said that the tools didn’t help me look after my patients.

However, in a health care system as byzantine as the one in Ontario, there is one area where AI can help almost immediately that is not talked about nearly enough. Given the topic, I get why the many government health care planners/bureaucrats/managers don’t mention this. I’m talking of course, about reducing the number of bureaucrats in health care in Ontario.

I’ve talked about Ontario’s health care system being over bureaucratized many times in the past. But there’s never been a better opportunity to meaningfully cut the bloat. It would be impossible for me to search the entire Ontario government data base to find out how many bureaucrats we have. So………I used an AI search on ChatGPT and Claude AI to review how many managers/bureaucrats we have across all government funded health care agencies in Ontario. (I will put the prompt at the end of the blog for those interested).

Both searches suggested the total size of the health care workforce in Ontario was about 500,000 people. Of that, astounding 90,000-130,000 were non-clinical employees (mostly administrative/support staff). The actual management/bureaucratic layer varied between 25,000-45,000. A precise number was difficult to define, because, in the words of ChatGPT:

“……Ontario’s healthcare system is fragmented across hundreds of entities with inconsistent titles and reporting structures.”

However, given all of that, I think Claude’s estimate of having 85,000 admin/management personnel across all Ontario Health care agencies is defensible. Heck, it’s lower than ChatGPTs 90,000 – 130,000. Claude AI further broke this down and suggested 52,000 of these were in Ontario’s 154 hospitals.

Can AI replace some of these jobs? Replace is probably not the right phrase. There can certainly be a consolidation of the actual tasks required from different jobs, and AI can do those tasks much more efficiently and accurately.

For example, AI can, as of today, help with information movement, repetitive analysis, scheduling, policy retrieval, document generation, compliance monitoring, coordination, coding, and referrals to name but a few examples. All of these tasks are currently being performed by bureaucrats, and it’s virtually certain that there is tremendous duplication in the work being done. There is plenty of software than can do these tasks right now (LeanTaas, Qventus, Nuance DAX to name a few). Yes they are mostly American, but surely can be modified to meet Canadian needs.

The cost savings from reducing the number of bureaucrats can be significant immediately, and frankly enormous as AI continues to evolve over the next five years.

For a case study, let’s look at the University Health Network (I’m not picking on them for any other reason then they are huge!). They have approximately 24,500 employees of which an estimated 4,200 are Admin/management of some sort. Many of these positions are people on Ontario’s Sunshine List (i.e. they make over $100,000 a year). Reducing the number of these positions by 10% should be easily do-able if you have the right AI software.

Then the hospital would save the money right? Especially since Ontario’s hospitals are facing massive deficits? I would say no to that. I would instead say if UHN could cut their admin staff by 420 (which should easily be done), then maybe they could hire 210 clinical staff in return (nurses, physio, rehab, RT, Xray techs etc). Instead they just fired nurses. They would still have 210 fewer positions (so some money saved) but they would have 210 more people who would actually, you know – look at a patient. People who could provide compassionate, front line care and assessments to patients and be an invaluable part of the health care team.

Looking forward five years as AI software continues to evolve, I genuinely believe UHN should set its goal for reducing Admin/Management staff by half (at a minimum). This would allow them hire over a thousand (if not more) nurses to provide that front line care that is so essential to patients well being.

From a system wide perspective, the numbers would be even more dramatic. Currently, Ontario has 38% less inpatient staffing than the Canadian average. In order to just meet the average, about 34,000 more nurses need to be hired. The money for that has to come from somewhere, and I can think of no better place than reducing the admin staffing to find those funds.

I get why the bureaucrats have not talked about these uses for AI. Bureaucracy by its very nature is self perpetuating. But we are facing a serious fiscal calamity in health care with our aging population. While it’s nice to have tools that can help physicians like myself make better diagnoses and provide safer care, the blunt reality is we desperately need more front line staff. No matter how good the tool, it will never be a substitute for the compassion or a real human being providing care. The emotional wellness we experience from having real people look after us at the bedside cannot be understated. We need to adopt bureaucracy replacing AI tools now, and put the money saved in front of patients.

For those interested, this is the AI Prompt I used to get this data: “Review the number of bureaucrats/managers in the health care system in Ontario, Canada. Include ALL health care agencies that are government funded like hospitals, Ontario Health at Home, hospitals, community health centres and more – all government funded health care agencies. Get an approximate number of bureaucrats. Then show where AI can result in cuts to management/bureaucrat jobs right now, and in five years. Use the University Health Network in Toronto Canada as an example to show how many bureaucrat/management jobs could be trimmed, allowing them to funnel resources to hiring front line clinical personnel like nurses.”

Auditor General’s Report on AI Highlights Failure of Ontario’s Health IT Bureaucrats

There’s currently a lot of talk about the recent report from Ontario’s Auditor General on AI Scribes. The headlines seem mostly to be dealing with the fact that she found numerous AI Scribe generated reports had errors. The errors happened for various reasons, including AI hallucinations, transcription errors, incorrect entry of medications and so on.

Ontario’s current Auditor General, Shelley Spence

However, to my mind, that’s not the real story.

I feel somewhat conflicted in saying this next part, mostly because I think I generally have a reputation for being an advocate for physicians, their views and their well being. However, the blunt reality is that we are all required to check any report that’s generated by an AI scribe before we sign off on them. Physicians, being human, will make mistakes. For example, this past weekend, I got a message from a colleague of mine, pointing out an error that had been made in an AI-generated note on a patient I saw. That was my fault for not double checking. I think to try and blame some software for those kind of mistakes would be inappropriate.

No, the real story is the continued ineptitude of the healthcare bureaucrats at the Ministry of Health who are in charge of health care IT systems today. If one does a deep dive into the Auditor General’s report, there are many, many legitimate question she has, all of which the hard-working taxpayers of this province deserve an answer to.

In particular she found gaps in how these AI systems were evaluated by Supply Ontario, Ontario Health, and to a certain extent OntarioMD. Yes there were three agencies all involved, triplicating the amount of work necessary and adding to the confusion.

Heck the issues began right from the initial procurement stage. The weighting given to different criteria revealed a fundamental misalignment of priorities. The accuracy of medical notes generated by AI scribes accounted for only four per cent of points awarded to potential vendors, while domestic presence in Ontario was weighted the highest at 30 per cent. Data privacy/legal controls were weighted at 23 per cent and system security controls at 11 per cent.

Think about that for a minute. You could have software from a poorly run company, that was completely inaccurate in its transcription and system security, yet still have it approved if it happened to be Ontario based. Yet a company with the best transcription and system security would lose, if it was from out of province. Even Spence was shocked by this, stating, “In my mind, that doesn’t make sense….when we’re dealing with personal information and we’re dealing with artificial intelligence, I think security is of the utmost importance.”

Additionally, the evaluations didn’t actually watch vendors operate the software in real time! There were no live test. Vendors were apparently given recordings and ran the system offline learning. Spence said, “this allowed vendors to potentially overstate their compliance with security and privacy requirements.”

Well, duh!

Worse, 11 of the approved vendors for AI software didn’t actually meet the mandatory submission requirements. They got approved anyway. Five didn’t even submit risk assessments and privacy impact assessments as part of their bid process. They got approved anyway.

This kind of amateurish, ineffectual assessment is supposed to help increase confidence in healthcare IT?

Most damningly, it appears from the auditor general’s report that there is a broad absence of strategic governance. The auditor general benchmarked the AI strategy against Canadian and international public sector organizations and found that there were no specific actionable items, no clear plan to prioritize AI use across ministry areas, and did not identify any prohibited AI practices or areas where technology posed an unacceptable risk.

Essentially, this report paints a picture of Ontario Health/Supply Ontario/Ontario MD approving AI systems through a process that underweighted accuracy, did not require live demonstrations, accepted incomplete documentation and failed to assess bias risk. All while having no clear plan to rectify these gaps going forward.

The thing is, this kind of insanity has been permeating the politics of IT health systems for decades. I’ve written about the bloated and inefficient bureaucracy for years now. The lack of ability to get a truly integrated health care system speaks to a lack of vision and focus in the bureaucracy. It’s incredibly discouraging that it continues unabated after all these years. It seems that no one has the knowledge, wisdom, ability to fire the incompetent bureaucrats, streamline the process by getting rid of multiple agencies, and apply an overarching vision for health care IT.

And yet, instead of fixing the bureaucratic mess first, streamlining health IT infrastructure, and developing on overarching health IT vision, Ontario is instead now going ahead and launching a Provincial initiative to create a province wide primary care medical record system. The people in charge of choosing the software for this? The same bunch who botched the AI scribe issue.

I can’t wait to read the Auditor General’s report on that one in, say 2029.

The OMA’s AGM: Locked Out and Let Down

Old Country Doctor’s Note: In my last blog, I downplayed the technical glitches at the Ontario Medical Association’s Annual General Meeting (OMA AGM) because I only had a couple of issues. Turns out a lot of people had much more trouble. My thanks, to Dr. Paul Hacker for guest blogging for me today about those issues. Please sign his petition linked at the end of the blog.

Dr. Paul Hacker (pictured inset) is a former Vice-Chair of OMA Council, former co-chair of the GT20 Governance Transformation Committee and former OMA Board Member.

On May 7, a “record turnout” (according to the OMA) of members attended the Annual General Meeting of the OMA. This means that a record number of physicians cleared their weeknight schedule, put clinical obligations on hold, set aside family time and sat down at their screens at the appointed hour. I personally know of emergency physicians who felt attending this meeting was so important that they worked with colleagues, while on shift, to be able to participate in voting on important matters.

And nothing worked.

The purpose of the meeting was to conduct some routine business of the OMA corporation and to consider, debate, and vote on a number of proposals submitted by members.

The routine business went ahead, but the members’ motions were beset with technical snafus.

Even worse, this one annual event where members can hear directly from their leadership, obtain updates and ask questions was blocked for many who had difficulties registering and logging in. They were locked out of our organization’s most important annual event, on their own, with no way in and inadequate help from staff.

The Board’s Response: What It Says and What It Doesn’t

Let’s look at the response from the OMA’s Board Chairs (both outgoing and incoming):

“…we all left the meeting frustrated by the technical and procedural difficulties that occurred as the meeting progressed…”

“The AGM included a significant number of motions and proposals within a limited timeframe, and technical issues related to the hybrid format affected the flow of the meeting and prevented completion of the full agenda before members called for an adjournment.”

Firstly, there is no mention of the registration and login issues. The Chairs completely disregard this as an issue worth addressing to the many members who were shut out completely. (The silver lining for them is that they didn’t have to endure the “procedural difficulties” that have many saying they will never attempt to attend an AGM ever again.)

Second, the email subtly but firmly places the responsibility for the time pressures on members. Those motions were submitted by members, followed all OMA rules, and were duly accepted. The implication that their volume contributed to the problem is a subtle but pointed deflection. Where is the accountability for an organization that has held many members’ meetings in the past and should have a full understanding of how long it takes to properly hear and consider different viewpoints on the issues? Where is the accountability for the unusually cumbersome handling of motions and amendments, when these have been handled well in several past meetings?

A Legal Obligation, Not Aspirational Language

It is important to note that the OMA has a legal responsibility — under the Ontario Not-for-Profit Corporations Act (ONCA) — to ensure that all members can participate reasonably in electronic meetings. This is not aspirational language. It’s a statutory obligation. The OMA is not a tech startup that gets credit for trying. It is a mature corporation with legal duties to its members. The fact that this happened at all, let alone to the extent it did, reflects a failure of preparation, not just execution.

“We Take This Seriously” Is Not Accountability

The OMA, as usual, frames this total failure as a learning moment, with no commitment to report back to members:

“We are committed to working with our CEO, Kimberly Moran, and the leadership team to understand what occurred, identify where improvements are needed, and ensure physicians are well supported for the followup meeting.”

“We want to thank our colleagues for their patience, and continued involvement throughout the evening. Even in moments of disagreement and frustration, physicians continued to demonstrate how deeply we care about the OMA and its governance.”

Well, there is at least that last bit. Members do care about how the OMA goes about its business. Members do care about who represents them at all levels of the organization. And unfortunately, due to the ongoing shredding of the fabric of our health care system, something the OMA has failed to significantly impact, members are quite familiar with disagreement and frustration. We are a resilient bunch, but there are limits. When our organizations are not accountable, not transparent, not fair and truthful about their responsibilities, members lose faith. Many, including myself, have lost faith multiple times.

Members Have Power — And a Petition

But members have power. Members have their own voices. Members have shown, in the debate that was allowed to occur at the AGM, that they can push back on unfair, opaque governance. Similarly, we can push the OMA to own and be transparent about its own failures.

The OMA responds to organized member pressure. That’s one lesson of this AGM. We can apply that pressure to get answers — to ensure the OMA is accountable not just for the things it wants to be accountable for, like ‘technical difficulties,’ but for things like failing to meet its obligation to ensure members can participate in their organization, and then not even acknowledging these issues in its communications.

I have created a petition to demand that the OMA conduct a full survey of members to determine how many had issues, how many were excluded, and how this event has impacted member attitudes towards the OMA. It’s been over three years since the OMA last surveyed members to ask them “how are we performing on your behalf?” If one truly positive thing can come out of this AGM debacle, maybe it can be the resumption of the OMA doing some asking of members, not just telling them.

The petition can be accessed here: https://tally.so/r/44A225

You gave your time. The least the OMA can do is count you.

AGM Shows That Front Line Physicians HAVE Power Over the OMA

This year’s Ontario Medical Association Annual General Meeting (OMA AGM) was more exciting than usual. There’s much to talk about. But to my mind, it appears that members have once again exerted a degree of control over their association. That is a good thing.

The meeting got off to a very inauspicious start when both Board Chair Cathy Faulds, and CEO Kim Moran blatantly misled (at best), or at worst, lied to the members. Both of them repeated how the OMA secured agreements with the government to provide significant funding increases for physicians. This is, of course, patently false. An independent third-party arbitrator imposed an award that the OMA and government have to abide by.

It is true that after the money was awarded, some aspects of the byzantine physician services contract were negotiated. Many others, including the much-hyped FHO+ program for family physician, were arbitrated. To suggest this represents an agreement with the government that was acceptable to everyone is insulting to members and outright false.

The highlights of the meeting were two speeches. First, by outgoing president, Doctor Zainab Abdurrahman (whose last name Dr. Faulds still couldn’t pronounce properly). I think she’s done a very good job as being spokesperson for the profession, no more so in her advocacy around trying to fix the outdated and incompetent OHIP billing system. Doctor Rebecca Hicks, the incoming President also gave what I thought was a truly inspiring speech. This bodes well for how she’s going to represent the profession in the future. And, it’s the first time the OMA has had two female presidents in a row – which is well overdue.

OMA Past President Dr. Zainab Abdurrahman

Unfortunately, the meeting went downhill from there. I will not blame the technology. I’ve attended many virtual meetings for many different organizations. The technology for the software is expanding much faster than the server resources are allowing, and so there are always going to be significant glitches. I also need to point out that the parliamentarian who was hired to run the meeting did an excellent job given all the limitations that he was facing. And I want to give a shout out to the frontline OMA staff who diligently tried to keep the technology moving.

Sadly, my criticism is going to be directed at many of the physicians who did their best to obstruct motions that were duly presented, met all the timelines, and followed the bylaws. Unfortunately, we physicians are sometimes done in by a small number of our colleagues who seem to think they know better than the rest of us, and can’t have us expressing our contrarian views. This was never more evident than last night.

Immediately after Dr. Conte’s first motion (to change the bylaws to remove non-physician Board Directors) came up, there was a motion to defer for one year. This was to let the Board create committees to “study the implications” of the motions. This is, of course, nonsense. One of the things the OMA did do fairly well is they put out a package on the implications of what would happen if these motions passed and if they failed. It was very thorough. It was available to every member who attended the meeting. The fact that some people chose not to read it is a reflection on them.

More suspiciously, the people who spoke out for the motions to defer were the usual suspects (double entendre intended for a couple of select friends of mine). The type that sign up for every committee and collect their stipends from members dues. Thankfully, the majority of attendees were going to have none of this, and deferral failed.

Unfortunately, this did not stop more shenanigans. There were all sorts of attempts to block this motion, questions about process, points of order – too many to remember really. But eventually, fifty-three percent of members at the meeting supported his first motion. However, the motion needed 67% to pass as it was a bylaw change.

This brings back shades of the motion of nonconfidence in the then Ontario Board Executive in 2017. That motion also required sixty-seven percent, but got fifty-five percent at council. The Executive eventually did the right thing and resigned. One hopes that the non-physician Board Directors, who by all descriptions are decent people with integrity, will see the writing on the wall and resign.

The fact that this motion actually had majority support sent supporters of the current leadership structure into a state of panic. The next motion, which would have removed the non-physician Board Directors, but at the end of their terms, only required fifty percent plus one to pass. This meant that this glorious structure that had been put together where the OMA chose candidates for board and not the members themselves, and the OMA could manipulate the elections to satisfy a select few was in danger. More motions to delay, more procedural gimmicks. More “we haven’t had time to study this.”

Eventually, as the meeting was running over time, the decision was made to defer the rest of these motions to another meeting that will occur within six weeks. This puts the OMA in the same kind of limbo that it was in after the board executive of 2017 was rejected but refused to resign. Not a good place for an organization to be.

More importantly, however, despite what I’m sure is being said about people like Drs. Conte, Hacker and yes myself, these events actually show the true power of the governance transformation. As the guy who was tasked with giving the speech to the then OMA Council to convince them to go down this path, let me state clearly that the driving force behind the transformation was always to give front line physicians power to control the organization if they felt it was not serving their interests. It has not been easy, or quick, and will drag on due to the shenanigans at the AGM, but members are exerting a level of control, and pressure over the OMA that they have every right to do. It may very well be painful for those in charge (they didn’t get their way) and it may very well require members to invest more time (yet another meeting), but it is a very good thing.

Ontario physicians deserve a strong and responsive OMA. This year’s AGM, as messy and complicated as it was, is a step in the right direction.

If you have any questions about the meeting, and what happens next, I encourage you to sign up for the OMA Webinar on May 13th at this link.

Animal Farm and the OMA

I was thinking about what to write about the current state of the Ontario Medical Association (OMA). Being of a certain age, my mind went back to the classic George Orwell book, Animal Farm. It tells the story of how a group of animals were not well represented by Farmer Jones. They wound up rebelling against Jones and took over the farm.

In the aftermath of the revolution, attempts were made to reform the farm so it could advocate for and protect all animal citizens. The guiding principles were the seven “commandments” that every animal agreed to abide by. The most important being, “All animals are equal.”

However, some vested interests began to manipulate the situation. The pigs eventually took over the running of the farm and bent the rules to their own advantage. When the rest of the animals went to complain, they found the most important commandment had been re-written to “All animals are equal, but some animals are more equal than others.”

It would of course be ridiculous to suggest that the OMA is a drunken, abusive farmer. It would be even more ridiculous to suggest that the staff of the OMA have the malevolence of Mr. Jones. The staff there are well-intentioned, good people. However, as my friend Greg Dubord pointed out to me, there is something that’s inherent in all organizations known as the “iron law of oligarchy.” Essentially, organizations eventually think of themselves first, not their members.

So it is with the OMA.

Our “revolution” did not have Old Major, or Snowball, or Boxer. We did, however, have Dr. Shawn Whatley, who famously resigned from the Board when he recognized that the association was going off the rails. We had Dr. Nadia Alam who inspired a legion of physicians by her activism. We had 25 brave Council delegates who successfully called for the first ever vote of non-confidence in the leadership of the OMA. There were a lot more but you get the point.

In the aftermath of the revolt that booted out the Board Executive in 2017, there was a strong desire to modernize and improve the OMA. A significant change in the governance structure was enacted. To this day, I support a lot of the principles and rationale behind that change. And there was a strong desire to ensure that the membership had the power to oversee the association and correct it if things went wrong.

We never encountered an evil character like Napoleon the pig. Rather the “iron law” principle itself became our nemesis. Organizational desire to protect itself, not members, began manipulating processes that were put in place into something much different than intended by the rebel physicians.

Nowhere can this be seen more obviously than in the selection process of non-physician board directors. Initially (2021), there was a genuine open election. Non-physician candidates competed alongside physician candidates and were subject to the same member vote.

However, only two years later (!) the process began to diverge. Non-physicians directors seeking a further term were presented for “ratification” as a reappointed director, as opposed to running for a competitive re-election like physician Board Directors are required to. This year the process evolved further. The AGM materials confirm that rather than a standalone ratification vote, non-physician reappointments are woven into the AGM business as a simple “yes/no” matter.

The OMA’s own communications make it clear. What began as a fully competitive open election process for non-physician directors has gradually shifted to a board-managed reappointment track. But physician directors continue to face competitive, multi-candidate elections chosen by the membership. (The physician candidates were also screened by a supposedly independent third party before being “allowed” to run, but I‘ve already gone over that in a past blog.)

In essence, some Board Directors are more equal than others.

The OMA also realized that by changing this process, they could have a stronger hand in selecting non-physician board directors. They could select board directors that on paper had significant skills, but would perhaps be more in line with a corporate philosophy.

One senior OMA executive told me that in the corporate world, there is no running for elections on Boards. The organization recruits who they feel is best and “people of that calibre” don’t submit themselves to votes. “I certainly wouldn’t.” I’m happy for that executive, and wish them luck. However, all those other organizations are not member driven organizations, they are corporate organizations beholden to shareholders.

In a member driven organization like the OMA, there needs to be some degree of political and strategic oversight of the staff. This is not a bad thing. Again, the staff are well-intentioned and want to help physicians. But they need a strong, independent Board to guide them and set strategy. To let them know what will not work for members.

This cannot happen if a block of Board Directors are non-physicians, and worse, have been selected by the OMA (I don’t buy the independent third party bit and neither should you). The voting Board Directors need to be truly independent practicing physicians. This is why Dr. Paul Conte is making four motions at the Annual General Meeting on May 7, with the goal of eliminating the positions of non-physician Board Director, so that once again, all Board Directors will be equal. If successful, this would constitute a sort of “mini” revolution after the big one in 2017. (Full disclosure – I’m seconding all the motions).

Since there are no proxies allowed, I would once again encourage all Ontario physicians to register for the AGM by clicking on this link. You can attend virtually, and make your vote count.

At the end of the book version of Animal Farm, the animals realize that despite their best efforts, they are once again subjugated and really no better off and live in despair. The 1954 movie version changes the ending into something somewhat more hopeful. The animals are once again able to unite, and launch a second “mini” revolution, like Dr. Conte wants to.

Will the OMA follow the path of the book or the movie? We’ll find out on May 7.