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How To Vote By Proxy at the CFPC Annual General Meeting

On Wednesday, October 28 2026, the College of Family Physicians of Canada (CFPC) will hold its annual general meeting (AGM). There will be a number of important motions for discussion. I will say, however, that the CFPC, like a lot of representative medical organizations, often suffers from a lack of engagement from the broader membership. It seems that engagement only goes up when organizations do something to upset members, like trying to implement a third year of the residency program without a member vote.

This is unfortunate. Physician members’ organizations would benefit greatly if only it was easier for physicians, given their overwhelmingly busy lives, to get engaged in a meaningful way with those organizations. Emphasis on easier.

Hoping to make the CFPC stronger , Drs. Conte, Dubord and I have proposed six bylaw changes. We genuinely feel this will make the CFPC more democratic, transparent, and accountable. It would be foolish to suggest that simply passing these motions will fix the CFPC. There is no fixing of membership-driven medical organizations, there is only ongoing supervision and treatment. But passing these six will allow members to keep an eye on the CFPC.

The response from the current leadership of the CFPC seems well intentioned. However, a deep dive into the minute package shows a fair bit of institutional groupthink.

For example, according to their AGM Meeting Materials:

“Upon receiving the proposals, management invited the members to work collaboratively to address certain noted concerns with the proposals. The members declined, opting for the proposals to be presented to the membership as originally submitted.”

We suspect what the leadership meant was that we chose not to co-operate in the way that the leadership wanted us to. Dr. Dubord had clearly sent a response back asking for specifics about the legal concerns. The CFPC replied on Aug 12 it would not lay out legal concerns and hasn’t specified these concerns in the meeting package. Not sure how to co-operate given this.

The leadership of the CFPC says that our six motions are based on good ideas and a positive desire to transform and improve the CFPC. I thank them for recognizing that. They state they want something similar, and have proposed alternative motions, which they feel are better. I thank them for putting the time and effort into developing alternative suggestions.

Unfortunately, when unpacking their proposals with a moderate degree of scrutiny, many loop holes become apparent. The potential for none of the changes we want to be implemented in a meaningful way exists. The CFPC leadership has made it clear if both our motions and their 5 alternatives pass, then their alternatives will take precedence. In our view, their alternatives lack the bite of our six motions.

For example, the first motion is for the membership as a whole to elect their president. The board instead is offering board-recommended picks. This essentially means that the board can still choose who runs for president. My guess is that the CFPC is scared that someone ill suited for the role will be chosen.

But if we look at the Ontario Medical Association (OMA) – as part of their governance transformation, they realized that members had to decide who the most visible person on their Board was. The OMA has been holding member wide elections for president since 2018 (initially non-binding) and it was really only in 2018 that some uncouth, obnoxious, ill mannered lout was chosen to be President-Elect. The rest have all been pretty reasonable people.

Similarly, our second motion called for board and committee minutes to be posted, but instead the board is just offering summaries (no change). Our third motion codifies online voting (which will increase engagement!) whereas the Board wants to pick and chose. Our fifth motion demands a 90 day response, time while the Board’s doesn’t have the same teeth to enforce. And the motion on financial disclosure we propose is much stronger than the Boards alternative.

Here’s a chart with a nice summary of the differences in our motions and the Boards alternatives (a larger version can be downloaded here):

Here are the steps you need to follow if you support our motions:

First search your email inbox with the phrase “CFPC”. This should identify all the emails from the CFPC you have. Go to the email dated on October 7, 2026. That one will have a link to register, personal information and your control number. Then do the following:

1. Log in at: election-client.ca.electa.lumiconnect.com/cfpc/proxycard/ with their email and the control number from the College’s Oct. 7 email. NEVER send your control number to anyone else.

2. Item 1: Appointing a proxy. The default options are Board officers. Pick the middle option and type: Paul Conte. He has graciously agreed to hold proxy votes. He has set up an email just for proxies: paul.cfpcproxy@gmail.com

3. Items 2 to 9: This is all CFPC business. Vote as you see fit. As an FYI Item 5 approves keeping the fees where they are.

4. Item 10: This is the CFPCs own package of needed bylaw fix, and I support these and encourage you to support them too.

5. Items 11 to 21: I ask that you approve every Member Motion (Items 11, 13, 15, 17, 18 and 20). It is ESSENTIAL to REJECT EVERY Alternative Motion (Items 12, 14, 16, 19, 21). Remember, if the alternate motion gets accepted, it will supersede the six member motions, and no meaningful change will occur.

5. Submit by Oct. 25 at 11:59 p.m. ET. Before you do, turn on vote verification on the review page.

Some of you may disagree with the six motions we propose and support the CFPC Board. That’s fine. Healthy tension and disagreement is vital for any organization. But what’s not fine is for members to ignore this issue and NOT vote, particularly since you can appoint a proxy. (A proxy HAS to submit your votes the way you want, even if the proxy disagrees with you).

I truly hope that first and foremost, every member of the CFPC takes the time to vote. A healthy vote count means members want the CFPC to be better and sends a strong message as to steps that can be taken to achieve that goal.

GRAND ROUNDS: A 72-YEAR-OLD NATIONAL COLLEGE PRESENTING WITH CHRONIC MEMBER DISCONNECTION

N.B. Once again, my thanks to Drs Greg Dubord (mostly!) and Paul Conte for co-authoring this blog.

CHIEF COMPLAINT

Chronic member disconnection. By the patient’s own account, “some” physicians have felt disconnected, but investigation reveals this is very widespread. Self-Management (a column, a newsletter, a podcast and poorly attended town halls) failed.

HISTORY OF PRESENT ILLNESS

In January 2022 the CFPC (“the patient”) surveyed its members and found that only 39% felt the College listened to them, and only 25% considered their fees worth the money. No full satisfaction survey published since. That same month it proposed a mandatory third year of residency, PGY3, without a member vote.

At the November 2023 AGM, members voted 91% to stop PGY3 and review how it came about. 95% asked for access to Board minutes. The patient withdrew the proposal and promised “a comprehensive, independent review process.” In July 2024 the patient declined to release minutes and recorded “no further need for an analysis of this direction.” Asked about PGY3 this year, the President said: “We learned a lot from that… But we have moved past that.”

PAST MEDICAL HISTORY

2013 to 2016: Merged its certification exam with the Medical Council of Canada’s, then unmerged it.
2019 The Board decides each year which “skills, experience and perspectives” it wants, its committee screens applicants for them, and the Board sets the final list of nominees “in its sole discretion.” Members then vote, but only among the names the Board has already chosen, and for the officer positions there is exactly one name each.
October 2023: Data breach, with members not told the details until more than five months later.
November 2023: Proposed a 7% fee increase. 83.86% of members rejected it.
2024 to 2025: Went to court to validate its own by-laws retroactively after, by its own affidavit, more than a decade of non-compliance with the federal Act. (Ontario Superior Court of Justice, court file CV-24-00096601)
March 2025-February 2026: Adopted a Member Code of Conduct binding on all 46,000 members, then added suspension or revocation of membership as penalties, with appeals decided by a panel the Board Chair designates and declared “final.” Never put to the members.
November 2025: Proposed a by-law allowing automatic annual fee increases tied to inflation, citing financial strain. Members defeated it. Surplus that fiscal year: $7.5 million.
March 2026: Fifteen member proposals for governance reform disqualified for arriving outside the 60-day window.

EXAMINATION

Vital signs.

Pulse: Only a few hundred (at most) out of 35,000+ members attend AGMs.

Approval: 37% of Members feel CFPC plays important role.

Intake: Member proposals accepted on only 60 days of the year.

Mental status: Pleasant and well groomed. Defensive thought processes noted:

Minimization (“some physicians have felt disconnected”)
Rationalization (minutes withheld on legal advice)
Displacement (a 37% approval rating is a problem of “how we’re portraying that information”)
Reaction formation (“We really welcome divergent perspectives and voices”)
Compartmentalization (accreditor and vendor of CPD described as two different departments behind a “firewall”)
Cognitive distortions: Catastrophizing (a projected $5.4 million deficit, “not sustainable to continue long term”; the year closed with a $5.1 million surplus
All-or-nothing thinking (either full minutes with “sensitive material” or two-page summaries; redaction, which is how every other body that publishes minutes handles sensitive material, does not occur to the patient)
Labeling (a 95% member vote becomes “advisory”; an unseen by-law package becomes “corrective”)
Risk to self: low. Risk to members: ongoing.

INVESTIGATIONS

Bloodwork (audited statements, year ended February 28, 2026): Revenue $59.5 million; dues $30.0 million (compulsory for anyone keeping the CCFP); surplus $7.5 million, after $5.1 million the year before; reserve fund $40.0 million; cash $11.6 million, up from $4.2 million; the Office of the CEO’s budget line (shared only with non-FMF meetings) up 41%, from $2.8 million to $3.9 million. Sponsors named: none. Legal fees: no subtotal, not itemized, somewhere inside $7.0 million of “corporate services.”

Imaging (the College’s governing by-law, read in full): Section 5.2: The Board sets the list of nominees “in its sole discretion.” Section 5.3: The President “will be acclaimed.”

Records review: Board minutes not available to members. A 95% vote in 2023 asked for them; the Board declined in July 2024 and offers two-page summaries instead.

ASSESSMENT AND PLAN

Primary diagnosis: Oligarchy (a form of government in which all power is vested in a few persons or in a dominant class or clique; government by the few.). Robert Michel’s Iron Law of Oligarchy suggests that all complex organizations develop into oligarchies. Hence no cure for the illness itself. But symptomatic treatment is warranted.

Picture of German Born sociologist Robert Michels who moved to fascist Italy in the early 1900s and contributed to the elite theory of political dynamics — Sociologist Robert Michels, authour of the Iron Law of Oligarchy

Treatment Plan: Support of six motions at the AGM by members essential to treat the most significant symptoms of this patient.

Problem 1. Electile dysfunction. Treatment: Members elect the President and Board directly; any member may run; no committee screens the ballot.

Problem 2. Transparency deficiency disorder. Treatment: Board and committee minutes posted within 30 days.

Problem 3. Restrictive Voting Syndrome, aka Evening-meeting exclusion syndrome with proxy-dependent syndrome. Treatment: Electronic advance voting on member proposals, on the system the College already runs.

Problem 4. Seasonal access disorder (member proposals accepted only during a 60-day window, in summer) Treatment: Member proposals accepted year-round.

Problem 5. Mandate amnesia. Treatment: A formal Board response within 90 days to any proposal that passes: An implementation plan, or written reasons that members then vote on.

Problem 6. Financial reserve hypertrophy disorder. Treatment: Five figures published every year: Travel and hospitality; sponsors over $10,000, by name; spending on the College’s own CPD products; consultant fees; legal fees.

PROGNOSIS

Prognosis with treatment: Good. The patient is solvent, well resourced and, on the President’s own account, wants to reconnect. Without treatment: Highly probable progressive deterioration. Adherence to treatment suggestions have historically been poor. Two unambiguous member orders above 90% went unfilled. That is why each treatment is written as a by-law the Board cannot repeal on its own.

FOLLOW UP

October 28, 7 PM Eastern, Virtual. There will be a notice of meeting arriving by October 7 (check your email). Directions for voting on treatment protocol by proxy will be reviewed in a follow up blog shortly after notice of meeting.

CODE STATUS:

Full code. The members want this patient to live. We just want it healthier.

How to Make the CFPC More Accountable to Members

NB: My thanks to Dr. Greg Dubord and Dr. Paul Conte for co-authouring this blog.

head shot of Dr. Paul Conte — Dr. Greg Dubord

Last June, Ontario physicians changed how the Ontario Medical Association (OMA) is governed. It wasn’t by writing angry letters. It was by registering for a virtual meeting, giving up some of their valuable time by showing up, and voting. The lesson was simple: members CAN change an organization that is supposed to advocate for and defend them, IF they are willing to get just a little bit involved.

The same opportunity is now in front of every practising member of the College of Family Physicians of Canada (CFPC), but the window is short.

WHAT’S ON THE BALLOT

In July, Dr. Greg Dubord, Dr. Paul Conte and I, each filed the same six proposals with the CFPC in accordance with the Canada Not-for-profit Corporations Act. On August 12 the College confirmed in writing that all six will go into the notice of meeting for the October 28 Annual Meeting of Members, exactly as we filed them.

Our motions are bylaw amendments, rather than ordinary resolutions. In 2023, members voted 95 per cent for access to Board minutes and 91 per cent for an independent review of the PGY3 process. Because they were not bylaw changes, the Board treated them as suggestions and declined to implement either. A by-law change means it is mandatory for the Board to follow it.

The full text of the motions (warning – there is a lot of legal jargon), can be found here. In plain English however, the six motions would:

1. Let members elect the President and the Board directly, with any member free to run and no committee screening the candidates.
2. Post Board and committee minutes to the member portal within 30 days.
3. Let members vote electronically in advance on member proposals, using the electronic voting system the College already runs.
4. Accept member proposals year-round instead of an easy-to-miss 60-day summer window.
5. Require the Board to respond formally, within 90 days, to any member proposal that passes: either an implementation plan or written reasons for declining, which members then vote on.
6. Publish five CFPC financial figures every year: travel and hospitality, sponsors over $10,000 by name, spending on the College’s own CPD products, consultant fees, and legal fees.

Number one is the big one. Right now the Board decides, in the by-law’s own words, “in its sole discretion,” who gets to be a candidate, and the President is acclaimed (i.e., installed without a vote) rather than elected. A small group choosing its own successors is the dictionary definition of an oligarchy. Motion 1 begins to democratize the CFPC.

WHAT ELSE IS COMING

The Board is bringing its own package of by-law amendments to the same meeting. At the September 9 member town hall (the recording is on YouTube) the President described it as corrective changes to bring the by-laws into line with federal law. She also said the Board will circulate its own commentary on our six motions alongside its package.

Fair enough. But not one clause of the Board’s package was shown at the town hall. Members will see the text for the first time when the notice of meeting arrives, which the College says will be by October 7. That leaves us just three weeks to read it before the vote.

We will be watching to see if the Board package touches the same sections our motions amend. We also want to see if the motion will be to approve the whole package in a single vote (i.e an omnibus vote) or each Board motion will require a separate vote. We prefer the latter.

One more thing to watch: the order of the votes. The Chair sets the agenda, and it would be natural for the Board’s package to come up before our motions. If their package rewrites the sections on elections, and then Motion 1 comes up, don’t be surprised to hear that the member motion “conflicts with the by-law as just amended.” It doesn’t. Our motions amend whatever by-law is in force at the moment they pass. But it’s the kind of thing that sounds convincing at 8:15 PM with a timer running, so it’s worth knowing before you log in.

HOW THE MEETING WORKS

The College has posted its meeting norms for October 28. If you read them you’ll see it allows only ninety seconds per speaker, with a visible timer. There’s no chat function, so you don’t have a clue what any of your colleagues are thinking. No amendments permitted from the floor.

In other words, nothing gets decided by debate on the night. Everything gets decided by who registers, and who shows up having already made up their mind. If physicians who simply favour the status quo, and the usual from the CFPC are the only ones that show up…….well…….

WHAT TO DO

The three of us recognize that family physicians are ridiculously busy. It has taken far too long for recognition of the unremitting nature of comprehensive family practice to be spoken about. Despite this, not nearly enough is being done to change things. This means that you all have precious little free time. However, the blunt reality is that we can’t change the CFPC for the better, unless members get involved.

We ask all CFPC members to do three things.

First, watch your inbox. The notice of meeting, with all six motions and the Board’s package, arrives by October 7. It will include registration and proxy instructions (yes, there does appear to be a proxy system for the CFPC, unlike for the OMA AGM).

Second, register the day it arrives. October 28, 7 PM Eastern, virtual. Put it in your calendar now.

Third, if you can’t attend, appoint a proxy. The notice will tell you how. A proxy vote counts exactly the same as one cast in the room.

And one question worth asking the College at amm@cfpc.ca: where on the agenda do the member motions sit, and will each be voted on separately? They’ve confirmed the motions are on the ballot. They haven’t said where, or how.

Regardless of what the leadership of member driven organizations may say, member engagement is always a good thing. The more members get involved and have their say, the stronger an organization will be. We encourage all family doctors to join us at the AGM.

We will post again with more information as the situation arises.

A Tale of Two Charter Challenges

Authour’s note: To paraphrase the original old country doctor, Leonard “Bones” McCoy of Star Trek fame, I’m a doctor, not a barrister. The following represents my understanding of the legalities in the Charter Challenge, and should not be taken as gospel. For more detailed questions, email the OMA: info@oma.org

Last week, the Ontario Medical Association (OMA) held an online webinar updating members on the status of its excruciatingly long gestating Charter Challenge against the government of Ontario. The Challenge was initiated in 2015 after the repugnant unilateral actions of the then governing Liberals. Ironically enough, last week the Ontario Nurses Association (ONA) also informed the public that they were moving forward with their own Charter Challenge.

On the surface, it would seem that the Challenges are about the same thing. Both argue that the government has too much power. Both rely on the Charter’s protection of freedom of association. Both say that meaningful collective bargaining requires more than simply sitting across a table and talking.

But there is a crucial difference.

The OMA’s Challenge

In 2015, the disastrous duo of Health Minister “Unilateral” Eric Hoskins, and Premier Kathleen “No-Wynne” claimed the absolute right to impose changes to physicians compensation. The OMA, through the Challenge, made a pretty straightforward argument. If a government could impose compensation, and physicians were unable to strike to protest, the two sides do not have equal bargaining power. A meaningful way of resolving an impasse was needed. The OMA’s Challenge argued that the Charter’s protection of freedom of association requires an effective dispute resolution mechanism. It further argued that a Binding Arbitration Framework (BAF) is that mechanism.

The Supreme Court had just handed down a decision in the Saskatchewan Federation of Labour case that recognized that the right to strike for non-essential services is constitutionally protected because it can be an essential component of meaningful collective bargaining. This seemed to be very supportive of the OMAs position that an alternate mechanism is therefore required for essential workers like physicians who can’t strike. However, the Court did not say that every group deprived of the right to strike must automatically receive binding interest arbitration. That distinction matters (more on that later).

Eventually of course, Premier “No-Wynne” realized how inept her health minister was as the system was collapsing under his watch. She forced him to give doctors a fair BAF even though he was on record as opposing it. The OMA’s Challenge shifted from asking the Supreme Court to impose a BAF, to asking the court to recognize that physicians have a Constitutional entitlement to a BAF, so that no incompetent Premier/Health Minister could take it away in the future. (I guarantee you that at some point in the future, some bumbling government will try to do this).

Former Health Minister Eric Hoskins and Former Premier Kathleen Wynne

The Nurses Charter Challenge

In contrast, Ontario’s nurses have had access to arbitration for over half a century. The Hospital Labour Disputes Arbitration Act (HLDAA) of 1965 states clearly that when collective bargaining reaches an impasse with essential employees, disputes are sent to binding arbitration. This was meant to prevent strikes and lockouts. (Physicians are considered independent contractors, so HLDAA does not apply to us).

The nurses are arguing that this is NOT enough. Their argument appears to be that taking away a worker’s most important bargaining weapon (the right to strike), and enforcing compulsory arbitration doesn’t make the system fair. Essentially, if employers know employees can’t strike, there is less incentive to compromise. They will just send everything to arbitration. This removes too much bargaining power according to the nurses.

ONA says that this is particularly problematic when the issues being negotiated are not simply wages, but staffing levels, working conditions, patient safety and the ability of nurses to provide appropriate care.

ONA is not saying arbitration is bad, just that being forced into it without both sides agreeing is bad.

What has the Supreme Court Been Up To?

Since 2015, the Supreme Court has continued to develop law around freedom of association and collective bargaining. It has made clear that meaningful collective bargaining is constitutionally protected. It has also recognized that the right to strike can be an essential part of that process.

But there is an important limitation.

The Court has suggested that the Charter does not necessarily guarantee a particular bargaining system. It protects the ability to engage in meaningful collective bargaining, rather than guaranteeing that negotiations must occur according to the precise system preferred by a union or professional association.

Which really is where the difficulty lies for the OMA. The Court would likely say that there must be a fair negotiations process, but may not impose the preferred option. They may also say – “well, doctors have a BAF now, come back to us when some future government unilaterally rips it up, and we can discuss it then”.

The Other Issue

ONA represents employees in a conventional unionized labour relationship. The OMA represents physicians who, for the most part, are independent contractors rather than employees of the Ontario government. That distinction could become important in court. Not sure how, like I said, I’m doctor, not a legal expert.

The Irony

That is what makes these two Charter challenges particularly interesting.

The OMA is saying: “We need constitutionally protected binding arbitration because we don’t have enough bargaining power.”

The ONA is saying: “We don’t have enough bargaining power because we are forced into binding arbitration.”

However

The cases are connected by the same fundamental question. Exactly how much constitutionally protected bargaining power are representative organizations and people entitled too? That is why these two Charter challenges deserve to be watched together (assuming the OMA carries through). They may ultimately tell us something much bigger than whether nurses can strike or whether doctors are entitled to arbitration. They may define how much bargaining power the Constitution requires when the government is on the other side of the negotiating table.

And in Ontario’s publicly funded health-care system, that is a question with consequences far beyond the courtroom.

Addendum:

For physicians in Ontario, it does appear that the OMA is laying the groundwork to stop pursuing the Challenge. There may be many good reasons for that (wait till a government takes away BAF and fight the issue then for a better chance of success). I encourage you to check out the recorded version of the OMA webinar on the Charter Challenge, and to fill out the survey on the member survey on the issue.

Re-Post: Health Care Has Crumbled Under Eric Hoskins’ Watch

Old Country Doctors Note: This blog originally appeared in the Huffington Post on April 24, 2017. It is being reproduced here on my own website so that I can access in the future if needed, and for my own posterity.

Recently, Ontario Health Minister Eric Hoskins introduced Bill 87, a.k.a. the Protecting Patients Act. Its goal is one that no right-thinking person could disagree with, namely to identify and punish health-care professionals who sexually abuse patients. The problem is that it is sloppily written, hastily put together to deflect from other health-care stories and will have significant unintended consequences that will harm patients.

My colleague Dr. Nadia Alam wrote an exceptional piece on how Bill 87 is flawed. She detailed how it breeds a culture of fear, will negatively affect practice patterns and abandons the principle of “innocent until proven guilty.”

Predictably, some of the people who commented on her column felt that she was off base. One even argued that the provisions in the bill that supercede tenants of jurisprudence dating back to the Magna Carta were “common sense.” A feeling that doctors are criticizing this bill to protect their own interests certainly permeates the media.

Except, of course, it turns out that the critics of Bill 87 are right. Last week the Canadian Civil Liberties Association, an independent non-governmental organization dedicated to protecting the rights and freedoms of all Canadians, came out with a strong critique of the bill.

Concerns listed include:

Setting a dangerous precedent for ALL regulated professions
Open-ended provisions that allow a health minister too wide discretion
NO explicit limitation of the type of personal information to be collected
Information collection to be done solely at the discretion of one person (health minister)

What we see yet again, therefore, is another sure-to-fail piece of legislation by minister Hoskins. Frankly, to this somewhat cynical eye, this legislation is a continuation of his incompetent style of running the health ministry. The pattern all along from this minister has been to act unilaterally on issues, refuse to accept input from front-line health-care workers and, when things get “politically hot,” deflect by having press conferences on unrelated items to try and shift media attention away from just how much health care has crumbled under his watch.

The fact that all his previous unilateral actions have been failures seems lost on him.

For example, three years ago, Ontario had a significant budget deficit. In light of this, the Ontario Medical Association (OMA) offered a four-year wage freeze for physicians. In return, they asked for a co-operative, bilateral committee to identify efficiencies in the health-care system. Not good enough for Unilateral Eric, he instead implemented a series of reckless unilateral cuts that have significantly damaged the health-care system.

How reckless? Remember how he recently announced more funding to deal with the opioid-addiction crisis and mental-health issues? Did he bother to tell you that he cut funding for addiction services the year before? And that he admitted that he “found it challenging” to understand how cutting funding to a service would result in loss of that service? Economics clearly isn’t his strong point.

Or how about the ridiculous Bill 41, the Patients First Act? He was warned repeatedly by both front-line physicians and the OMA that this act would NOT help patients and would only increase the bureaucracy.

Didn’t stop Unilateral Eric. Rather than work co-operatively with others to improve the bill, he did it his own way. The result? Even the Toronto Star, which Kelly McParland states lives to promote eternal Liberal rule, was forced to admit that the supposed savings from Bill 41 may not come to pass. (My two cents — I’ve never, ever, ever seen taxpayers save money when governments increase bureaucracy).

Worse yet, his approach to dealing with any negative publicity has been to deflect by targeting physicians. Stories in the press about long wait times for joint replacement surgery? Hold a press conference and accuse an ophthalmologist of bilking the health-care system by “overbilling.” The fact that wait times for cataract surgery are growing exponentially get ignored.

Stories of children with special needs not getting home care and stories of overcrowding hit the press? Launch a diatribe suggesting that doctors should become civil servants instead.

Now, most recently, we are hearing about some wait times for assisted living called a “50-year wait,” and even delays in cancer surgery. How does he deal with that? Unilateral Eric hurriedly launches this flawed bill and shuts down debate to allow broader input. Attempts by the OMA to suggest amendments that will strengthen this bill are ignored.

Unilateral Eric barges ahead anyway. The fact that all his previous unilateral actions have been failures seems lost on him, and reports of patients suffering from gaps in care seem to be neglected. In fact, it is likely because these stories are in the press that he is rushing ahead with this bill to make it look like he is actually doing something positive.

The completely unacceptable part in my opinion is that it is going to be the real victims of abuse who suffer. The first time someone is charged under this law, the unconstitutionality of it will be challenged, resulting in a strong possibility that a perpetrator could get off on a technicality. Can you imagine the impact this will have on a victim? To see someone who harmed them so egregiously walk away without punishment?

The government of Ontario’s Premier Kathleen Wynne is in a lot of trouble. She is woefully unpopular. Her party is badly lagging in the polls. Senior members of her Liberal party have publicly asked her to resign. She has, at best, one cabinet shuffle left to try and reverse her fortunes.

Wynne may very well owe Unilateral Eric big for making her premier. It was his backstabbing of Sandra Pupatello at the Liberal leadership convention that gave her the leadership, after all. But if Wynne is serious about governing the province properly, her next step must be to shuffle the most disastrous health minister Ontario has had in recent memory out of his portfolio. She needs to replace him with a competent minister, who will at least attempt to work co-operatively with front-line health care workers. Only then can we begin to reverse the damage done to the health-care system.

It’s time for Unilateral Eric to go.

Re-Post: Dear Premier Wynne, It’s (Still) Not Too Late To Fix Health Care

Old Country Doctors Note: This blog originally appeared in the Huffington Post on May 16, 2016. It’s being re-posted here so that I can easily access if needed in the future, and for my own posterity.

The Right Honourable Kathleen Wynne

Premier of the Province of Ontario

Dear Premier Wynne,

Last week, I had written to you and pointed out that you needed to fix health care. I suggested that there were seven steps that you had to take to fix health care, and due to space constraints, I was able to provide the first four. Since you haven’t started implementing the changes yet, I’m assuming you were waiting for steps five through seven. Here they are:

5) Mandate that ALL health care software have an API by April 1, 2017

An Application Programming Interface (API) essentially allows different types of software to talk to each other. Ontario right now is a complete mess in terms of health care software. Hospitals generally use one of three different products, none of which can communicate with each other. Nursing homes use a different product. There are something like 15 different approved software systems for physicians’ offices. Pharmacies use different software. So do various allied agencies.

However, NONE of these programs “talks” to the other, which means that data can’t be transmitted from one system to another. So if a patient goes from one hospital to another, the information is not transmitted automatically to the receiving hospital.

Worse, software vendors don’t want to voluntarily add this feature, as they want people to just buy their product instead. While this makes sense from the point of the vendor’s bottom line (encourage more sales = more revenue for the company), your job as premier is to take care of the health care needs of the people of Ontario.

You can mandate the implementation of an API (meeting a provincial standard) on all health care related software by April 1, 2017. This would allow a physician’s office to communicate with hospitals (e.g. send lab results to the hospital on a patient so they don’t have to be repeated); allow nursing homes to securely communicate with pharmacies about medication renewals; home care to contact physicians about patients who are declining; and so on. This will lead to huge efficiencies.

Look up the data on the ePrescribe Project in Georgian Bay. You’ll see that the success of the project was based on tight integration/sharing data and secure messaging between pharmacies and physicians office. Imagine if this was possible between ALL health care providers. It can be with API on all the software.

N.B. I was chair of the Georgian Bay Family Health Team when we implemented ePrescribe, and I’ve seen the benefits first hand. In my opinion, it’s criminal that despite spending billions of dollars on eHealth, the rest of the province doesn’t have something we’ve had since 2009.

The software vendors will say that it can’t be done. That would be far from the truth. Some of the companies already have prototypes of APIs and it’s just a matter of having them align with a provincial standard. Force them to do it or tell them to stop selling their products in Ontario. Our health care deserves it.

6) Have local advisory committees for the MOHLTC

By now you’ve already disbanded the LHINs (see point three from last week). However, you will still need to get local input and involvement for health care decisions. Different areas of the province have different populations, all of whom have their own unique requirements.

The easiest way around this is to convert the existing LHIN boards (which are all made of volunteers, and hence don’t cost the taxpayers much) into local advisory committees that report directly to the Ministry of Health and Long-Term Care (MOHLTC). Ensure that these committees have actual teeth to provide strong recommendations. This way you can get rid of the bureaucratic cost of running the LHINs ($90-plus million dollars) but still have the local input so that communities can advocate for their own unique needs.

Frankly, from a clinical and patient care point of view, the structure of the MOHLTC makes absolutely no sense.

7) Re-organize the MOHLTC along clinical lines

Last week, I called the MOHLTC Organizational Chart a Gordian Knot. Frankly, from a clinical and patient care point of view (which is what health care is supposed to be about), the structure of the MOHLTC makes absolutely no sense. You’ve got at a minimum 16 separate departments, with too many sub departments for me to bother counting. Based on the chart it doesn’t look like the departments can easily co-ordinate with one another.

According to your chart, if you want to do a health analytics project on patients with mental health/addictions issues, the health analytics group would have to go through a minimum of five departments for the relevant approvals before getting to the Mental Health department. Yes, I know there would be some direct communication between the two, but the reality is that for final approvals, each department would have to go up their chains.

The MOHLTC should be re-organized along clinical lines. You only need three main departments. One department for institutions (hospitals, LTC homes), a community department (family health teams, home care, public health, other outpatient-based services) and the OHIP department (which pays not just physicians, but other professionals like optometrists, physiotherapists and pharmacists).

Measures relevant to each area (e.g. quality assurance, funding, information technology, regulations) can be kept in each department, improving efficiency.

So there you go, seven steps to improve health care. In case you think I’m asking you for more money for health care, I’m not. The $51 billion currently budgeted is enough, it just needs to be spent more efficiently.

There will be significant immediate cost savings from cutting the bureaucratic bloat as described in steps two, three and seven. The savings can then be put to pay for patient services (step four) and hiring more nurses. Step five will result in even more savings, but those are down the line.

Will this be enough to get you the election win you so badly desire in 2018? I have no idea. A lot of the next election will depend on just how many more times the OPP comes knocking on your door to investigate yet another spending irregularity.

You will certainly not have my vote, as I think you and your party are a wholly desultory lot. I even vacillated about sending you these ideas, as I didn’t want you to get credit for making needed changes or improve your chances of winning. But the reality is that many of my patients are suffering on incredibly long waiting lists, and many others are dying waiting for needed services. It’s time to right the health care ship. Get to it.

Yours sincerely,

An Old Country Doctor

Re-Post: Dear Premier Wynne, It’s Not Too Late To Fix Health Care

Old Country Doctors Note: This blog originally appeared in the Huffington Post on May 9, 2016. I’m re-posting on my own website so that I can keep it for easier future reference.

The Right Honourable Kathleen Wynne

Premier of the Province of Ontario

Dear Premier Wynne,

So I hear you are thinking of proroguing the Provincial Parliament, likely as a prelude to a cabinet shuffle in the hopes of raising your incredibly poor poll numbers.

While there has been no shortage of scandals for your government, the reality is the biggest issue facing you is health care. If you can fix that, then maybe, just maybe, you can pull out a victory in 2018. What’s that you say? If that’s the case, stop writing articles about how bad health care is and start offering suggestions instead? Glad you asked! Here’s how you can fix health care in seven easy steps.

Since I’m limited to 1,000 words or less on my blog post, I will give you four steps this week, and next week, we will go with steps five through seven.

1) Order an administrative review of the senior management at the MOHLTC

Start right from the top (Deputy Minister Bob Bell) and include the rest of the senior management team. There’s a real problem with morale in Ontario Health Care. Last year, Ted Ball from Quantum Transformation Technologies did a survey of health care leaders that showed damming results for just how little faith they had in the leadership and direction of the MOHLTC.

Between 50 and 70 per cent of responses were in the “Poor to Fair” categories for virtually every single question. In addition, in the comments section there were repeated calls to cut down on the bureaucracy (and this from bureaucrats!). One exasperated person simply extolled “Just do something!” This is abysmal.

Since then, a new vision, Patients First, was introduced by Health Minister Eric Hoskins. Quantum did another survey after this, and the results were worse! Amongst other deplorable numbers only 20 per cent of health care leaders have confidence in the MOHLTC to manage the enhanced LHIN’s proposed in the document.

Additionally, in the comments section, the top adjectives used to describe the managerial/leadership capacity of the MOHLTC were words like “uninspired,” “obstructionist,” “incompetent,” “autocratic” and a plethora of similar negative terms.

The people of Ontario pay a lot of money through their taxes (in the case of Bob Bell, $426,535 according to the Sunshine List) to ensure health care is run properly. It’s not happening. A formal administrative review can give the leaders some good advice as to how to encourage other leaders to follow them. It’s sorely needed.

2) Read Dr. Shawn Whatley’s blog on health care bureaucracy in Canada

Make sure you read all the excellent links. Memorize all the data that’s there. Keep those figures at hand, as you will need them when you try to push through the next set of changes you need to make.

[In 1995] people realized that in a universal health care system, cutting payments to doctors equals cutting services to patients. They will realize this in 2018 as well.

3) Get rid of multiple ‘arm’s length’ agencies

Look, every time you create an “arm’s length” agency (e.g. Cancer Care Ontario), that agency has to create an administrative bloat. Things like policy and procedure manuals, human resource departments, various administrative levels and so on. In health care, the problem is that all of these agencies have to report to the MOHLTC (who funds them). The MOHLTC, of course, has a policy and procedure manual, human resource department, administrative levels and so on. What’s worse is that the MOHLTC has departments solely dedicated to liaising with all these other external agencies.

For example, the Gordian Knot that is the MOHLTC organizational chart, clearly shows that there is an eHealth strategy and investment branch of the MOHLTC. Their job is to liaise with eHealth. So, why not just bring in eHealth into the MOHLTC and get rid of the redundant bureaucracy?

Now, I get that politically, the goal was to try and have these agencies take flak when things go wrong, so that bad news won’t stick to the health minister. But guess what, it’s not working anymore. People won’t blame Cancer Care Ontario for the stem cell disaster in the 2018 election. They will blame YOU.

So, get rid of the LHIN’s, eHealth, Health Quality Ontario, Cancer Care Ontario, CCAC and a whole bunch of others. Bring them all into the MOHLTC so you don’t need multiple HR departments and policy manuals. This is why mergers and acquisitions are in vogue in the business world. Go with it.

4) Offer binding arbitration to the doctors.

Like it or not, you can’t make a fundamental transformation to the health care system without the help of the doctors. Even though I didn’t like it much, I understood the political rationale behind trying to shame them into coming back to the table by attacking their billings. Problem is, it didn’t work. People believed their doctors, not your political stunt.

As an aside, go back to the last time an government cut payments to physicians (Bob Rae’s NDP government of 1990-1995). Go dig up their election ads. They all started with “Bob Rae has cut payments to doctors.” The thought was to portray to the public that by cutting payments to doctors, there was more money for other services. Sound familiar?

See how he did in the 1995 election (hint: it wasn’t pretty). People realized that in a universal health care system, cutting payments to doctors equals cutting services to patients. They will realize this in 2018 as well.

Giving binding arbitration to physicians puts YOU in a no-lose situation. If the arbitrator sides with physicians, you can say to the public that you have no choice but to go along with it, as it’s part of a collective bargaining process. If the arbitrator goes sides with the government, the physicians will have gotten what they asked for, and will have to go along with whatever settlement there is.

Either way, you then have physicians re-engaged in the process of transforming health care which is an engagement you badly need.

Yours sincerely,

An Old Country Doctor

Reflecting on Entering Decade Seven…

This is a somewhat personal post. I don’t share my birthday on social media (mostly because your date of birth is one of the security checks companies use to identify you). But I will allow that a little while ago, I was fortunate enough to complete decade six on this planet.

Starting decade seven felt odd. I normally think of birthdays as just another day. But, I guess as cliched as it is, hitting the big 6-0 did feel different. There was, as is typical, the comprehension that there were likely fewer days ahead than there were behind. Like many people, it also triggered a “life review,” a natural psychological process of reflecting on past decisions and unresolved regrets.

It was also somewhat bittersweet. My mother died at age 59 (stomach cancer). The realization that I have spent more time on this planet than she did certainly brought many mixed emotions.

But at the end of the day, I became aware of just how blessed I am. While my parents followed the typical immigrant path of working hard and living cramped quarters, we always had a roof over our heads. My kids may not have a yacht, but they always had food on the table and were fortunate enough to do a bunch of activities growing up that I never could. I was able to put them through school and get them a good head start on life. We were not victims of some horrific war, or famine, or natural disaster. I feel truly blessed to be healthy and for having kids without major health issues. (I’ve seen first hand just how much stress is put on families when a loved one has medical problems. I have nothing but admiration and respect for how they deal with it).

What does the future hold? Who’s to say? I can only tell you what I hope to accomplish with however much time I have left. First and foremost, I hope to be able to continue to help people who are in need (whether for health or other reasons). How I do that will likely continue to evolve as it has during my first six decades. But I think we should all try to others when we can. It’s particularly incumbent upon those of us, like myself, who have had a more fortunate time on this Earth.

Some people mellow with age. I suspect I will get grumpier. Which means more opinionated blogs with strong views as time goes on. (I’ll go out on a limb and suggest bureaucrats in general will be even more unhappy with me, which is really saying something.)

Finally, I, like many of you, also have a bucket list. I hope to begin chipping away at that while I can still stand on my own two feet. Which is why, I decided to start this decade off like this:

Wasaga Beach’s Much Needed Nursing Home Reveals Haphazard Government Bureaucracy

Recently, the Ontario government announced a hundred million dollars of new funding towards a new, 288 bed nursing home in Wasaga Beach. What’s really impressive is that the project is already ready to put shovels in the ground. Construction is expected to begin in late 2026, and it’s anticipated that the first residents will be welcomed in 2029. This will become the largest nursing home in the South Georgian Bay region.

From the development project announcement

To be abundantly clear, Ontario does need more nursing home beds. In 2017, I wrote about the then desperate need to build 35,000 nursing home beds. For reasons that I can’t fathom, the previous Liberal governments never really did anything to build up healthcare infrastructure, despite the fact that we had a growing and aging population. That particular government seemed to think that the healthcare needs of the population would simply fix themselves.

I’ve been critical of some of the things that the current Conservative government has done in health care, but they do deserve credit for significantly ramping up healthcare infrastructure builds. Whether it’s new hospitals being built, new equipment like MRIs being purchased, and yes, finally building new nursing homes, this particular government has recognized that you simply can’t provide healthcare to an aging and growing population without increasing the capacity of the infrastructure.

However, I continue to be frustrated by the fact that a government whose leader is famous for having made extremely critical comments of overlapping and haphazard bureaucracy, hasn’t done more to get the various facets of the healthcare system to be streamlined and work together.

The Wasaga Beach Nursing Home (as much as it’s needed and should be built) is a perfect example of this.

Nursing homes, by definition, have complex patients with significant health care needs. Some of them, will get sick and will need to be transferred to the nearest hospital Emergency for assessment. For Wasaga Beach, this means the Collingwood General and Marine Hospital (CGMH). Being complex patients with multiple health needs, some will be admitted to hospital.

However, as of 2024/25, the CGMH already showed over 39,000 ER visits (up 8% from the year before!) Their inpatient status showed overcapacity for the entire fiscal year. All hospitals have fluctuations and times where they are more full than others, but to be overfull for an entire fiscal year is extra ordinarily busy.

How much more stress will be added to the CGMH by the new nursing home?

Trying to find reasonable data is painfully difficult. I searched a number of sites, but the best that I could come up with was a 2018 analysis. Yes, there was fluctuation during Covid, but we are back to pre-Covid numbers. Crunching a lot of numbers (so that you, dear reader, don’t have to) gives the following, what I consider to be reasonable, projections:

The CGMH can expect about 160 ER visits per year from the new nursing home. These patients are very complex so their ER visits will take much longer. (By comparison, 288 seniors who live independently in the community would only result in 58 ER visits per year).
Given that just under half of all nursing home patients who go to the ER wind up getting admitted to hospital, we are looking at about 75 more admissions to hospital per yer.
It was even tougher trying to find out how long patients who are admitted to hospital from a nursing home will stay in hospital. That link above had some information, but hardly enough to be accurate. The best guess I could come up with was between 5-7 days per admission, so if we go with 6 days in hospital on average, we’re looking at about 450 days in hospital per year.

Now let’s keep in mind that the CGMH is already full. We no longer have hallway health care. We have chair health care (the hallways are full). So where are these patients going to go? (N.B. I do appreciate that there might be some relief as some of our hospitals Alternate Level of Care patients will now have a nursing home to go to – but I’m going to make an educated guess that the stress on the hospital will outweigh the benefit).

My three loyal readers might be aware of the fact that Collingwood is getting a new hospital. Once again, kudos to the current government for approving a badly needed new facility. However, there are still a bunch of bureaucratic approvals needed, and shovels won’t go into the ground until at least the fall of 2028. Hopefully, the project will be complete in 2033 (because government run projects always come in on time).

And this is the part that really drives physicians and healthcare workers crazy. Could there not be some common sense in the eyes of the bureaucrats at the ministry of health who approve these projects? If you are able to approve shovels in the ground by this fall for the nursing home, why can’t you do it for the hospital? You know that patients from the nursing home are going to wind up in hospital and stress an already overburdened place. You know that the new hospital’s been approved. Why doesn’t the Ministry of Health co-ordinate the builds? Do these bureaucrats from each department (hospital and nursing home) not talk to each other? (Having been involved in many meetings with many bureaucrats at different branches of the ministry when I was president of the Ontario Medical Association, I can tell you the answer to that is no.)

Overbureaucratization of our health care system has been a problem for decades now. It’s been unrelenting and farcical at times. The Wasaga Beach nursing home, as needed as it is, is just one more example of this. It’s where the real silos exist in health care and our system will not improve until we get a government that is willing to tackle the bureaucracy.

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.