Author: justanoldcountrydoctor

Dr. M. S. Gandhi, MD, CCFP. Practicing rural family medicine since 1992. I still have active privileges at the Collingwood Hospital. One Time President of the Ontario Medical Association. Follow me on Twitter: @drmsgandhi

Are You Accepting New Patients?

Dr. Madura Sundareswaran guest blogs for me today. She’s a community family physician who’s resume is too long to print here. She helped found the Peterborough Newcomer Health Clinic and is a recipient of the CPSO Board Award which recognizes outstanding Ontario Physicians. This article originally appeared on her LinkedIn page.

The day people stop asking this question is the day we have fixed the primary care crisis.

I’m a family physician doing community-based comprehensive family practice in Peterborough, Ontario. I currently work in three different primary care models in our community – fee-for-service, a team-based family health organization, and nurse-practitioner led clinics. All of my colleagues work very hard providing excellent care to their patients.

Despite this, the latest figures suggest that 32,000 people living in the Peterborough region do not have a family doctor.

What does that look like?

A woman in Peterborough notices a breast lump today and is very worried about it. She frantically searches google and reddit to learn that there are no walk-in clinics here. She calls a number late in the afternoon for a local clinic for unattached patients, but all the spots are full for the day. Her options are a virtual doctor who will never conduct a physical exam – but she thinks an exam is important – how will they ever know what this lump feels like virtually? She wants someone’s expertise, she wants reassurance. She decides to go to the emergency department for this problem…but leaves after waiting for 9 hours. She is guilt-ridden as she waits there – she is not as sick as the others in the waiting room. No physician or nurse practitioner will have enough of a relationship with this woman to know that she recently lost her best friend to breast cancer and the impact this has on her illness experience. She is freaking out about this lump…alone.

Or…

A 68 year old male has seen a few pharmacists and virtual family doctor for his hemorrhoids over the last year. He decides that he just has to live with hemorrhoids. A google search says his symptoms are classic for the problem; he’s reassured. As a doctor, I know that this gentleman needs a physical exam but this man cannot find someone to do it. After a few months he winds up in the emergency department with terrible pain – a physical exam very obviously demonstrates rectal cancer. It’s had a year to grow.

Or…

George is a 58 year old man who has never had a family doctor. He has been on Health Care Connect for four years but no one has ever called him to say they have found him a family doctor or nurse practitioner. He is in “perfect health” so he does not need a doctor. He has never had his blood pressure checked, never been counselled on smoking cessation, and has never had bloodwork done. What he doesn’t know is that his Hemoglobin A1c is 7.4 (he has Type II diabetes but too early for symptoms), he has hypertension (high blood pressure – which in its most common form has no symptoms or signs), and his cholesterol is really high. George will probably have a heart attack in the next 10 years. The potential consequences of a heart attack are death. This was entirely preventable.

What we know: attachment to a regular primary care provider (family physician or nurse practitioner) leads to more preventative care, better chronic disease management, and lower rates of hospital admission (ref)

We need a solution ASAP

I eagerly watched as Ontario announced $110 million that will “connect up to 328,000 people across Ontario to primary care teams.” For my community this also translated to a promise for a community health centre (CHC) to connect 11,375 people to primary care. This is much needed but not enough.

Ontario Health Minister Sylvia Jones announcing expansion of primary health care teams

In order to develop a community health centre – a building must be built or set up, policies will need to be implemented, and several primary care providers including physicians, nurse practitioners, social workers, pharmacists, dieticians, etc. will need to be hired. Even if this could be set up within 12 months, where does that leave the other 20,625 in the region without a family doctor? I’ll tell you – scrambling door to door and still knocking asking if anyone is accepting new patients.

But wait! There are other options. A single full-time family physician working in one of Peterborough’s existing family health organizations can roster approximately 1300 patients and join an existing team-based model. We currently have job openings in every one of our five existing multi-disciplinary teams for family physicians. A clinic could be up and running in a matter of weeks. There are family doctors in this community who are very eligible to take on this job – and would likely consider it if they were fairly and adequately compensated.

Learning from British Columbia

I am a firm believer in learning what works and never reinventing the wheel.

In 2023, British Columbia completely revamped its pay structure for family doctors. They paid their doctors better and restructured compensation models – and apparently within a year they got 700 more doing comprehensive, community-based family medicine.

Dr. Ramneek Dosanjh, Past President of Doctors of BC, who called the new funding formula for family physicians in BC a “seismic shift”

I am going to make a few assumptions but I want to illustrate and oversimplify something here.

  • In the new BC payment model, the pay per full time doctor increased by $135,000/year (assume per full time equivalent). It wasn’t just a pay raise – it involved a few critical changes regarding what doctors could bill for and some restructuring. But the end result was a pay raise.
  • This resulted in an increase of 700 family physicians (assume full time equivalent) practicing comprehensive family medicine over one year.
  • Let’s say 1 full time doctor rosters 1300 patients.
  • If Ontario could get 700 new full-time family doctors to provide comprehensive, community-based family medicine, 910,000 people could now have a family doctor.
  • The entire rollout for the BC program is budgeted at $708 million over three years but this would include complete restructuring from fee for service care. Ontario already invests over $1 billion annually in interdisciplinary primary care teams and we have a significant head start compared to BC a year ago.
  • In contrast, Ontario plans to spend an additional $110 million to connect up to 328,000 people across Ontario to primary care teams.

Providing family doctors with the financial support and resources to set up their own practices is the best bang-for-your-buck approach if the goal is patient attachment to a primary care provider.

We need an all hands on deck approach. Support community health centres, nurse practitioner led clinics, but please also support family physician’s practicing family medicine. That is the only way you will achieve attachment for all Ontarians.

Your most obvious solution is pay family physicians better today – so they will hold off retiring for a couple more years and may actually sign on to take a practice.

British Columbia just proved that fair and competitive compensation for family physicians may result in more of them doing it.

Why do I care?

I have been in family practice for five years. I have a roster of patients who have access to a whole range of team-based primary care services – a pharmacist, a social worker, a nurse practitioner, an RPN and multiple other service through our family health team. Every day I get asked if I can take on a friend or family member as they do not have or just lost their family doctor. This simple ask creates a great deal of stress and guilt for me. I know what happens when someone does not have a family doctor or nurse practitioner. They will be sicker, they may die sooner, they will be alone trying to “doctor” themselves.

The moral distress of being made to feel like I am determining people’s fate – giving some people a high standard of care while others are left to fend for themselves will be what ultimately leads to my exit from this profession in this province. Why do I get to give a small handful of people comprehensive team-based care, while the rest (often marginalized, more vulnerable patients) get nothing? It is not fair.

What next?

We are all eagerly awaiting the next negotiation between the Ontario Medical Association and the Ministry of Health.

If we do not see a pay raise for physicians, or worse, we pay them less – everyone in Ontario can accept the reality that they may have a lovely multidisciplinary medical home with a diverse range of primary care providers – but a family doctor probably will unlikely be part of it.

The next time a leader or politician is raving about their new model for care – or pitch a strategy that does not include a family doctor I urge every tax payer and journalist to ask them:

1.     Do you have a publicly funded family doctor? (Do you truly understand what it means not to have one? Have you ever had to endure the struggle?)

2.     If you are so confident in your plan, would you be willing to give up your family doctor to one of the 2.3 million people in Ontario without one?

3.     Why is fair and competitive financial compensation of family physicians not part of your multi-pronged approach?

We are listening to politicians and leaders sell us on an idea of a fully-funded, glorious renovation. Meanwhile the house is on fire. Your family doctors are a dwindling number of people who cannot contain the flames. What are they worth?

Exploring Medical Tourism? Here’s What to Consider.

Full disclosure: I am a consultant for Medicte, a medical tourism firm that provides high quality, cost-effective medical treatments for ALL health conditions in Turkiye. Contact: info@medicte.ca for more information.

Recently, former Ontario Medical Association (OMA) President Dr. Shawn Whatley wrote an opinion piece in the National Post (later reproduced in the Medical Post) quite correctly rebuking Federal Health Minister Mark Holland for insulting people who consider leaving Canada for medically necessary health care. According to an Ipsos Reid poll, that’s 42 percent of all Canadians. As Dr. Whatley pointed out, this isn’t exactly a new phenomenon. In 2017, well before the Covid pandemic that people like to blame for just about everything, over 217,000 Canadians left the country for medical care. God only knows the 2023 number, but it will most certainly be higher.

Federal Health Minister Mark Holland
OMA Past President Dr. Shawn Whatley

Ironically enough, the day after Dr. Whatley’s piece was reproduced in the Medical Post, the Medical Post sent me their daily email which included a link to an article that showed Canadians are waiting even longer for surgical procedures than they were in 2019, and it’s not like the 2019 numbers were any good to begin with. It’s well known that increased wait times result in worsening morbidity and mortality (i.e. the longer you wait, the sicker you become). So it’s no wonder that Canadians are exploring ways to get treatments quickly, even if they have to pay out of pocket. Heck, I’m already on record as saying that I will go to Turkiye if Allah/God/Yahweh forbid I got a serious medical illness.

If you too are exploring medical tourism, here’s a list of things to consider.

How safe is the country I’m going to?

The sad reality is that the world has turned decidedly ugly these past few years. Picking a safe country can be hard. Stories like the one about Americans who went to Mexico for medical tourism and got shot by drug cartels get widely publicized. But there are many unsafe countries in the world. If I was looking at south of the United States, I’d probably limit my choices to Costa Rica and Cayman Islands. There are simply too many economic, political and frankly criminal elements in the rest of the countries south of the U.S.

Even in different continents you have to look at safety first. About 5 years ago a patient of mine of Ukrainian descent went back to Ukraine for a procedure. Obviously would not suggest that now with the war on. So look for somewhere stable.

What is the quality of the hospital I will get treatments at?

No hospital is perfect. But you should at least ensure that the hospital you are going to get care at is accredited by the Joint Commission International (JCI). They are the leading international organization that accredits hospitals and other health care organizations in 70 countries across the world. JCI Accreditation won’t guarantee a successful treatment, but it comes with the assurance that you will be getting appropriate health care.

After ensuring JCI accreditation at the facility you are looking at, then check for references. See if you can talk to people who got care there for their first hand experience.

Get a video consult first.

It’s the 21st century people. Video calls are a thing. If the health care organization you are looking doesn’t offer you the ability to have a video consultation with their doctors, before flying out to their country, well that’s a bad sign. During the consultation, ask lots of questions. Specifically ask about their complication rates and what is covered if you are unfortunate enough to get one. Get a “feel” for the doctor. It’s a big decision, be 100 per cent comfortable that the health care organization you are considering, will be able to take care of your needs.

What’s the Cost?

Obviously, at the end of the day, you are going to have to pay for your treatment. I would, of course, not suggest getting the cheapest possible treatment – because that institution has likely cut a lot of corners to get the price down. But at the same time, I weep for the lady from British Columbia, who, frustrated with the long wait times to see an oncologist, spent over $200,000 (US) on cancer care in the United States. She could have gotten the same treatments for around $70-80K in Turkiye. That’s obviously a lot of money, but still a significant savings.

This is actually why I would recommend you NOT go to the United States for medical tourism. Firstly, they have quite a bit of variability in terms of the care they provide. Some facilities are really good and others……well, some are really good. Secondly, the cost just isn’t worth it. A joint replacement that costs $50,000 US in the United States, could likely be had for $15-$20,000 US in another country.

If you are on a budget, or if you, like many others, are going to take out a loan or dip into your retirement savings to pay for these treatments, that difference is significant.

In Conclusion

While some provinces are making necessary investments in health care, the reality is that improvement in wait times are likely years away. The Canadian public is not stupid, they know this. Only 17% of Canadians feel the health system will improve in the near term.

In the interim, I fully expect the number of Canadian citizens who opt for medical tourism to increase. This can be a safe and effective option for Canadians willing to explore this route, but it is important to do your homework first.

Open Letter to Premier Ford: Fix Family Medicine or Risk Losing the Next Election

Dear Premier Ford,

Just me again, your erstwhile, somewhat (but not completely) humble old country doctor. Like last time, I would point out that I am really not your harshest critic. I want to recognize that you have done much for health care infrastructure over the past few years.

For reasons that I cannot fully explain, the previous Liberal regime simply stopped building the necessary infrastructure to help Ontarians. Whether it was new (badly needed) nursing homes, new hospitals, or new teams, the Liberals basically did, well, nothing in terms of infrastructure. To your credit, you’ve reversed that trend and are building facilities we in Ontario need. (As an aside, you seem to like building things a lot!)

Ontario Premier Doug Ford

But all of that building will not mean much in two years (when the next election is – nudge, nudge, wink, wink) if, as projected, over 25% of Ontarians don’t have a family doctor. Yes, you can correctly point out that the decline in family medicine was caused by the Liberals (it truly was – Eric Hoskins was by far the worst Health Minister I personally have seen in my time in health care). You can point out that the Liberals slashed the capitation model favoured by most family docs that started the downward trend. You can also point out that their favoured Deputy Health Minister Bob Bell thought family medicine was so easy he could return to it after over thirty years away:

Screenshot

He even tried to mansplain one of the true leaders of family medicine on how the system should work.

It’s true Bell and Hoskins were completely wrong. That will NOT matter because by 2026, the general public will say – “well you’ve had 8 years to fix this – you haven’t done enough”. That’s just how politics is, and I think deep down you know that.

You can, truthfully, also say that you are listening to organizations like the Ontario College of Family Physicians or the Ontario Medical Association (OMA) and who continue to go on about how team based care is the future of family medicine and how it can help solve the problem. You may not know this but I was the founding Chair of the Georgian Bay Family Health Team . I happen to believe in physician led team based care.

But here’s the thing. It will take a minimum of five years (if we’re lucky) to build out all those teams. That’s assuming the bureaucrats from the Ministry GET OUT OF THE WAY and let front line family physicians be in charge of the teams. But we are losing family doctors by the week. The people of Ontario can’t wait five years.

There is one thing that can be done now however, to stem the tide, and stabilize the system. You need to give comprehensive care family physicians an immediate, and significant raise. How significant? You will need to give an immediate 35% increase to comprehensive care family docs along with annual normative increases for the next four years. If you think that’s outrageous – I invite you to look at Manitoba’s contract or Saskatchewan’s or British Columbia’s. The competition for comprehensive care family doctors has increased significantly, and Ontario is falling behind.

I can pretty well guess what your “advisors” are telling you. They will say you are in arbitration with the OMA, just promise to abide by the result. Honestly, I do believe you will abide by the result, both this year and next.

But…

Arbitration will take months this year, and months if not a year next year. Frankly, I doubt that the OMA, despite their strong words, will advocate for an increase of the amount necessary for comprehensive family medicine (hopefully I’m wrong).

I have absolutely no doubt that the Arbitrator, William Kaplan, will give a raise to family docs, especially after the recent award to nurses. But if the raise isn’t enough, you going out to the general public in two years and saying “we honoured the arbitrators rulings” – will make zero difference to the close to five million people who won’t have a family doctor. They will still blame you for not having been pro active.

William Kaplan, Chair of the Arbitration Board

Listen, I’m on the conservative side of the political spectrum. I’ve always voted for the Conservatives in every provincial election since I was eligible to vote. I live in Simcoe – Grey which is one of, if not the most strongly conservative ridings in Ontario. Heck, in the early 1990s we were the ONLY riding east of Manitoba to vote for a Reform Party MP.

I’m telling you that most of the voices on the ground are really upset about the lack of family doctors. We have about 7,000 patients without a family doctor in our area last I heard. It’s true that when asked who they will vote for in polls, they, like most recent polls, say they’ll vote conservative. However, they always add “I guess, there’s nobody else out there”. That softness in your vote is a problem, and that softness doesn’t show up in the poll numbers.

Listen, I want you to win the next election. I personally think the NDP would be a complete disaster. I have no faith the Liberals, who showed just how much they hate doctors, have changed their tune. But in order to do that, you’re going to need to bite the bullet, and stem the haemorrhage of family docs.

Go to tell your negotiations team to offer up a deal that strengthens family medicine. Mask the increase with things like retention bonuses (like Manitoba) and matching RRSP payments (like BC) and other methods (paid admin time, paid supervision of team members and pensions would be nice). But get it done ASAP.

Otherwise, I genuinely think you will be in more trouble than you might be led to believe by your handlers in 2026.

Your sincerely,

An old country doctor.

A Message for Medical Students Who Didn’t Match on CaRMS Day

The following blog was written by Dr. Darren Cargill (pictured inset) and originally appeared in the Medical Post in a modified form and it’s full form on his substack. It’s a great message for medical students who didn’t match on CaRMS day, and is being re-printed here with Dr. Cargill’s permission (and my thanks) so that it is more widely available in an un-gated site.

J.J. McCarthy and the UnMatchable

“Those Who Stay Will Be Champions”

On November 14, 2020, Michigan was blown out by Big Ten rival Wisconsin by a score of 49-11, dropping the Wolverines to 1-3 in a pandemic-shortened season. Questions were swirling about if former Michigan quarterback Jim Harbaugh’s would remain as head coach at his alma mater. The Wolverines would finish a the season a disappointing 2-4.

On November 15, J.J. McCarthy sent out this tweet:

What does this have to do with health care in Canada?

I have previously written about my own failures and setbacks. From dropping out of University in 1994 (and 1995, just to be sure), to going unmatched through CaRMs in 2003.

Match Day 2024 is March 19th. I could have simply reposted my Substack from last year and moved on.

But Michigan’s 2023/24 run to the National Championship was calling me.

Anyone who knows Michigan football understands how it works. They run the ball down your throat. They tell you what they are going to do and then challenge you to stop them. Four yards and a cloud of dust. Big Ten Football.

Former Michigan QB Tom Brady played with a chip on his shoulder his entire career. After winning a national championship at Michigan in 1997, Brady was drafted 199th in the 2000 NFL draft. He was not expected to be the GOAT, experts weren’t even sure he would make the team. Yet 10 Super Bowls later (and 7 rings), he is the undisputed greatest Quarterback of all-time (talk to me about Patrick Mahomes in 20 years).

After Michigan’s loss to TCU in the College Playoff last year, McCarthy stood on the field and watched TCU celebrate.

As detailed by Sports Illustrated: “There’s perhaps no greater insight into an athlete’s psyche than seeing how they act following a crushing loss. Michigan quarterback J.J. McCarthy gave fans a small glimpse into his mindset after the Wolverines’ devastating 51–45 defeat in Saturday’s Fiesta Bowl.

Playing in the College Football Playoff for the second straight year, Michigan (13-1) was unable to overcome a handful of missed opportunities and came up just short in the national semifinal against the Horned Frogs.”

I see a lot of Brady in McCarthy. Quiet confidence. A leader of men. Resolve in defeat.

Today, J.J. is QB1 for the 2024 College Football National Champion 15-0 Michigan Wolverines.

J.J. enters the 2024 NFL draft this spring. A lot of people (usually Buckeyes) question his ability. They call him a “game manager.” They doubt his arm strength.

Going unmatched in 2003 gave me some serious doubts about my abilities. My skills.

Was it a mistake to go into medicine? Could I be happy in another field? Did I leave the stove on?

Today, I am the only physician in North America with Fellowship in the College of Family Physicians before Canada, Royal College of Physicians and Surgeons of Canada and the American Association of Hospice Palliative Medicine.

The NFL draft is much like the CaRMs match. It distills years of hard work and sacrifice into one binary answer: matched/unmatched.

To my fellow UnMatchable: Take 3 deep breaths…and have faith.

“Destiny is calling. Open up your eager eyes.”

#GoBluE

PS I rushed the field at Michigan Stadium for the first time this year when the Wolverines beat THE Ohio State Buckeyes (again). Destiny calls.

I then watched the Championship game with my friend Mark, who recruited me to Windsor. Destiny calls.

About Asking for Reduced Admin Burden From the MOH….

Lots of talk on the net about how the economic model for family physicians no longer works in 2024. My own blog site has had guest posts dedicated to this issue. There has been some criticism of this position. Dr. Darren Larsen in a reply to the post linked above suggests he is “not seeing or hearing…ideas for solutions“. He further states that all paying doctors more will do is create a “better-paid, unhappy professional. Nothing has changed.”

Others have made the similar comments. There is nothing philosophically wrong with the argument to reduce workload instead of raising pay. Practically speaking however, history has repeatedly taught us that the Ministry of Health (MOH) bureaucracy is incapable of delivering on that promise.

Some personal stories:

In the mid 2010s I was a Peer Lead for OntarioMD (no really!). I was frustrated by the Ontario Lab Information System (OLIS) because I had to manually retrieve all the lab work for a patient individually in their chart. Hospital Report Manager (HRM) by comparison, sends reports on all my patients directly to one inbox. (why we need two systems – and now more, is another story). The then VP of OntarioMD informed me they were working on “Practitioner Query” – which would allow me to get all my lab work from OLIS in one inbox. This was supposed to be ready in six months. That was over a decade ago.

From 2014-2018, thanks to the vision of my colleague Dr. James Lane, we developed an integrated health portal as part of our Health Links project for South Georgian Bay. For $35K a year, we were able to ensure that nursing homes could message physicians on their EMR. We dramatically reduced paperwork for physicians from nursing homes, improved health care outcomes, and reduced hospitalizations thus saving the entire health system money.

The MOH bureaucracy couldn’t wrap its head around this and wouldn’t allow it to continue.

For those of you who think I should have told people about this project, I wrote an article in the Toronto Sun about it. Afterwards, I got invited to do a presentation on this with the then CEO of eHealth Ontario and her senior team. Heck, when I was a keynote speaker at OntarioMDs Every Step conference in 2019 (no really!) I presented this project. The then head of the MOH Digital Health Team was there and heard it. Still, the bureaucracy couldn’t see their way towards allowing a project that saved physician time (and improved health care outcomes) could continue.

Ok, ok, so this blog is just for me to complain about not being listened to right? Well no, there are multiple other examples.

One workload issue for family physicians is keeping track of which of our patients get immunized for which vaccines. If only there was a central tracking system that sent the information to us directly. Wait, there is! The Covax system for tracking Covid vaccinations. Obviously the easiest and most sensible thing to do is expand the already existing system to add all the other vaccines so we get notified (eg when public health gives Gardasil). Yet 3 years after Covax, the MOH can’t even make this simple common sense change.

More? When I was on the SGFP Executive, one of our senior physicians told us the story of how he was on a working group to make the schedule of benefits (the fee schedule for Ontarios doctors) easier. After six months of meetings, they made a decision to add a comma to the descriptive sentence of one code. One comma in an 800 page schedule.

I could go on but you get the point. It’s fine for the MOH to say that that they promise to reduce the Admin burden for family docs. But frankly to these aged and cynical ears, it just sounds like them saying “This time we really mean it, honest!” – kinda like when Lucy promised to hold the football down for Charlie Brown for real this time, with predictable results.

Look, we have a five alarm crisis in family medicine in Ontario. Just about every week brings a story of another physician who is struggling with the economics of running a practice, and is considering quitting.

As with all emergencies, we need to have an effective triage system in place. Deal with the most urgent thing first, then go on to other things. We clearly can’t wait until 2034 for the MOH to implement some of the workload reducing schemes they might have (and no matter how much they promise they really mean it – it will take that long). So the first thing that needs to be done is bring financial stability to family practices so that they can continue to function while we sort out everything else.

Now, given Ontario physicians are in the midst of negotiating a new contract with the Ontario government, I expect the MOH team to say to our own negotiations team something like – “I know you guys want X% increase, but we can only give you 1/2 of that, but we promise to reduce your admin burden so you are working less hard”. I would do the same if I was them.

But, my expectation, and the expectation I think of the majority of doctors in Ontario, would be that the OMA negotiations team looks at the MOH team, and quotes the best engineer in the history of Starfleet to them.

With apologies to Geordi Laforge, B’elana Torres, Trip Tucker, Jett Reno, Andy Billups, and Hemmer – but Scotty was the BEST ENGINEER in the history of Star Trek!

The first step towards fixing the crisis in family medicine is a new physicians service agreement that stabilizes family practices. Once that’s done, work can begin anew on health systems transformation/workload reduction and so on. To try to do it the other way round, or even hand in hand, is a recipe for further collapse of the health care system.

Mark Dermer: On the Ethics of Telling Residents to Avoid Comprehensive Family Medicine

 Recently Maria DiDanieli, a system navigator with the Burlington Family Health Team who holds a Masters in Medical Bioethics, wrote an article criticizing myself, Dr. Silvy Mathew and Dr. Nadia Alam for recommending family medicine residents NOT start a comprehensive care family practices at this time. Dr. Mark Dermer responded so eloquently to that, that I asked his permission to reproduce his response as a guest blogger, and he kindly agreed.

Dr. Mark Dermer, a recently retired family physician whom I’m honoured to have as a guest blogger today.

As a recently retired family physician, I am troubled by the fact that you (Maria DiDanieli) have mistaken the fact that you work adjacent to family doctors as sufficient to understand what they face. Worse, your assessment of Drs. Alam, Gandhi and Mathew is unjust. 

But that’s not why I am commenting. Instead, I am coming at this as someone with some experience in medical ethics, both as a long-time member of community and teaching hospital ethics committees, and as a teacher of medical ethics to family medicine residents. 

To put it simply: Your ethical analysis of my colleagues publishing the opinion piece in question is both facile and flawed. 

I crafted an ABCDEF mnemonic to help residents remember six fundamental principles of medical ethics:

A – the right to Autonomy in decision-making

B – the moral duty of physicians to be adhere to Beneficence when caring for patients

C – the obligation to safeguard patient Confidentiality

D – the patient’s right to receive Disclosure of all information pertaining

E – Equity in dividing finite resources among patient populations

F – First, do no harm (nonmaleficence) 

We then apply these principles to a given situation, understanding that the principles might conflict with one another. It is very rare that a single principle can be used to judge a given question. We also must accept that there are almost never absolute rights and wrongs, just better and worse answers. 

I am confident that we can agree that the current primary care crisis is first and foremost a violation of equity: present circumstances have divided the people who want a family doctor into those who have one and those who don’t. I also expect that you are aware of the evidence that demonstrates that patient outcomes are better when people have an ongoing relationship with a family doctor. 

But you make the elementary mistake of applying a single ethical principle, nonmaleficence, to the matter at hand. Furthermore, you seem unaware that physicians graduating from family medicine programs have been entirely consumed with their training over the previous 5-6 years, nor aware that the medical education system has largely withheld what graduating residents will face as they enter practice. In that light, the letter is a long overdue disclosure that brings transparency to the current state of family medicine. 

That’s right, physicians have the right to disclosure too. We also have rights as people to autonomy, confidentiality and equity. Yet when it comes to our work, we are forced to accept legislated pay and work conditions from a monopoly payer, the government. And the government uses the fact that physicians are independent contractors to justify the fact that we are not entitled to the same cost-of-living increases paid to other health or educational professionals. 

Finally, I think you fail to recognize that in family medicine, we face unusual challenges to persistently align with all the principles of medical ethics, which work best when applied to “cases” (a single patient at a single moment in time). In contrast, family physicians’ work is longitudinal and includes significant responsibility to populations of patients as well as to individuals. That means that we accept short-term harm when we do things like stick vaccination needles in people’s arms or wean them from opioids, understanding that we are looking to provide a net benefit in the medium to long term. 

To my mind, that is precisely what Drs. Alam, Gandhi and Mathew have done. In other words, they are acting very ethically. For while the short-term consequences of their disclosure may accelerate the intensification of the immediate crisis, the sooner the crisis provokes action the sooner we start climbing out of this horrendous hole. 

Dr. Alex Duong: The Challenges Facing an Early-Mid Career Family Physician

Dr. Alex Duong, a family physician from the Vanier district of Ottawa (which amazingly enough is one of the more underserviced areas of Ontario).

Recently, Maria DiDanieli, the clinical lead for system navigation at the Burlington Family Health Team, published an opinion piece in Healthy Debate that was critical of the decision of Drs. Alam/Mathew and yours truly to recommend that family practice residents bide their time instead of starting up a comprehensive care practice in Ontario. Dr. Duong replies and has kindly allowed me to reproduce his reply here.

I am a full-time community family physician, and I read this article with great disappointment.


I am at the face of our health care system. When patients cannot get a timely breast biopsy or a knee replacement, they come to ask me. I address their frustrations, alleviate their pain, and manage expectations.


I am the backstop when issues are missed during transitions in care and issues that require follow up.


I am the navigator that helps patients, and their families orient themselves to housing resources, mental health and financial resources.


I am the advocate for my patient’s health when they deal with their employer or insurance companies.


I do all these things and more, alongside everything from newborn care to palliative medicine.


I, like the great majority of family physicians, take pride in our work, and in what we contribute to our patients and the community at large. But Banks do not grant loans for a new clinic based on my contributions to Ontario’s healthcare system. My rent payments do not decrease because of the positive impact I make on my patients’ lives. The salaries of our exceptional staff are not funded by the sound of clanging pots and pans.


Today, to outfit a new clinic with the minimum number of physicians for a FHO requires high 6 figures to 1 million dollars, loaned at 6.95% interest. We guarantee our own lease – we are on the hook for ensuring it gets paid for the entire term. We are responsible for hiring and ensuring our staff are paid a living wage. We invest our own time in making sure the clinic runs. For many community family physicians like me, there is no assistance for any of this from any level of government. No money for staff, no incentives for starting up, no support for logistics. We are in a precarious, failing business model with ever growing administrative burdens patching the system equal to a part-time job. We have been trying to expound on this, and frankly have been completely unsuccessful in this.


You realize that “… there does not seem to be much political will to improve this situation at this time.” Yet, you ask family physicians to work harder expecting a different result from the government.


You state that “With these current barriers and shifts, any new practice can feel fragile or vulnerable to imminent obsolescence.” Yet, you expect new graduates to take on a massive financial risk: long term lease, EMR contracts, and double their already tremendous debt in start-up costs.


You lament that “Instead of acting as beacons of wisdom, encouragement and level-headed advice, we see a growing shift toward inciting everyone to walk out!”. Do you apply this standard to the teachers in Quebec who recently concluded a strike? Are they less dedicated to their students? Do you apply this standard to all groups who organize to make their voices heard?


The authors, Drs. Alam, Gandhi and Mathew made it clear that there are many options available to new family doctors. They warn of the current state of specifically locking into comprehensive family medicine, to ensure that new grads do not put themselves in a position where they will be burnt out early in their career. To me, leadership requires honest conversations, not empty promises, or exploiting the ideals of new family doctors. I find it unethical to sell a romantic vision of what it is like to start and maintain a Family Medicine practice in the current environment. It is a recipe for moral injury when those ideals run flat into the economic realities, as I have experienced.

And frankly, to say to those of us, like myself, still practicing longitudinal family medicine we should be working harder, or we are just doing family practice wrong is demoralizing. It is grossly offensive to my early-mid career family medicine colleagues who have burnt out through great moral struggle and guilt. Disillusioned family physicians who leave longitudinal family practice will not return. The greater harm to the public and to patients is not the Star article that speaks truth to the issue, but the issue itself: that family physicians, whose concerns are being gaslit, continue to leave longitudinal practices.

Another Open Letter to the OMA Board: Re-visit the Negotiations Mandate

Dear OMA Board Member,

Just me again. The grumpy, aged quack with a history of being a bit of a thistle in your obliques. Well intentioned I assure you (although I’m told some may not see it that way).

Negotiations with the provincial government on a Physicians Services Agreement (PSA) continue and mediation began on February 20th. That’s all great and part of the process. However, things HAVE CHANGED a lot since the last time I wrote to you and urged you to set a strong mandate.

I am asking you to revisit the negotiations mandate at this time, in light of three new key pieces of information that are very relevant to Ontario doctors.

To recap – the negotiations mandate is the bare minimum ask that the Negotiations Task Force (NTF) can accept on behalf of the Board. If the government makes an offer that meets or exceeds that – well, then they accept it on behalf of the Board and the Board is compelled to endorse it. The mandate is, quite correctly, confidential (you can’t let the other side know your bare minimum ask any more than they would let you know their mandate). But it’s up to the Board to determine if the mandate is enough (not the NTF).

Now to be clear, I’m not saying you should revise it, just revisit it. Perhaps the mandate is already sufficiently strong. That would be great. But things are different now.

The first reason to revisit the mandate:

Other provinces have surpassed Ontario physicians in terms of income. BC and Saskatchewan have significant deals to stabilize the physician work force. Manitoba’s deal with physicians appears to be the best of the bunch. Manitoba has not only a well deserved increase for all physicians, but significant steps towards gender pay equity.

As an aside, while I applaud the fact that DoctorsManitoba made steps towards gender pay equity, I’m forced to wonder what happened to Ontario? When I was on the OMA Board we were proud of the fact that although it was too late, we were the first PTMA to report on the issues around gender pay equity. We proved that the pay gap was not because “women work less hard”. What happened ?

Also, to be clear I want to acknowledge that the negotiations counsel (Messrs Goldblatt and Barrett) are very well aware of any topic that could affect negotiations. I remember Darren Cargill, who at the time was on our NTF, told me “they read everything.”

Howard Goldblatt, Negotiations Counsel for OMA
Steven Barrett, Negotiations Counsel for OMA

Therefore, I know they read the Manitoba Schedule of Benefits which is available online and reported back to you. I’m sure you are fully aware of the retention bonuses in that deal. I’m sure you know about the significant changes that decrease the gender pay gap. I’m sure you know about the fact that Manitoba pays physicians for Admin time. And that their capitation model has no negation (although a lower base rate). And that they have an age premium. A pelvic exam premium (gender equity again). And that they allow extra payments for dealing with more than one problem at a visit. I have absolutely no doubt that our negotiations counsel has fully and thoroughly advised you of this, along with the benefits of the deals in BC and Saskatchewan.

The second reason to revisit the mandate:

The crisis in family medicine is spiralling out of control, faster than I thought possible. Not only is it badly affecting patient care, but the health, well being and morale of physicians is sinking like a stone. Last September, I never dreamed that I, along with Drs. Alam and Mathew, would write a letter to Family Practice residents telling them to stay away from comprehensive family medicine in Ontario. I never dreamed that there would be story after story after story of individual family physicians openly talking about how they were burning out. This situation has gone form bad to desperate frighteningly quickly.

The third reason to revisit the mandate:

Bill 124, the piece of legislation that limited increases to the public sector, was used to promote a low ball PSA to us the last time. You even, admittedly and embarrassingly, convinced a guy who should have known better. It’s ruled unconstitutional and the government will not appeal this. In fact they will repeal the Bill entirely. In light of that, many other public sector workers will be asking for catch up pay.

So it really is time for you to re-visit the negotiations mandate. Just double check to make sure it’s as strong as it should be given the above factors. Make sure it takes into account that the the BC deal has attracted over 700 physicians to comprehensive family practice. Make sure it recognizes that Manitoba will likely be showing a net growth in physicians shortly, and can reasonably attract physicians from out of their province. If you have to revise the mandate upwards after looking at it, then do so.

NB – IF the NTF were to push back if you do revise the mandate upwards, then make sure you hold your ground. Remember, YOU are the Board and YOU give direction to ALL committees and task forces, including the NTF. I’ll be careful how I say this so as not to divulge Board confidentiality, but the NTF in my day did have a proposal on one particular issue (not the whole PSA) that they told us to approve and our Board pushed back and said no. We had to listen to some (quite eloquent) speeches about how hard they worked and this undermined their work and so on and so forth – but after that they went back and kept negotiating as directed. Don’t do any less this time.

These negotiations are likely to make or break the profession for decades to come. They are that important. You owe it to your members to take another look at the mandate.

Yours truly,

An Old Country Doctor.

Open Letter to All Family Practice Residents

Dr. Nadia Alam
Dr. Silvy Mathew
Yours truly

The following letter was jointly written by the three of us and published in the Toronto Star on February 20, 2024. It is being reproduced below so that we can share the letter on Facebook as we believe it will be of interest to physicians across Canada.

To All Family Medicine Residents, 

We are writing to say congratulations! You are nearly at the end of a decade of hard work, perseverance and sacrifice; ready to start your career and “real life”. You have joined a beautiful and unique specialty. You will be the key to the healthcare system. You will find answers when patients arrive with ambiguous symptoms. Others will tag in and out of a patient’s health journey. You will stay and be an essential part of the beginning, middle and end of every patient’s story. You will save lives. 

Your skill and knowledge are unparalleled, and there is no substitute for your expertise. 

Which is why with heavy hearts, we, the undersigned, recommend that you do not start your own family medicine practice in Ontario. Not right now.  

Family medicine is in crisis. Family doctors in Ontario are unable to provide the care they could and should. We face unprecedented levels of administrative burden, unsustainable business expenses, lack of healthcare resources, lack of social and cultural support for our patients and ourselves and finally, a lack of respect. This has led to widespread burnout and exhaustion.

In short, it is becoming frankly unsafe to run a family practice in Ontario, especially for those just starting.

We are family doctors with decades of experience. We are also physician leaders, past-presidents and board directors of the Ontario Medical Association (OMA), academic faculty, and health policy experts. We understand the situation well. 

Do not sign that contract. Do not sign a lease, hire staff, buy equipment, contract with an EMR or any of the million things that must be done so that you can start a comprehensive care family practice. 

Starting a practice at this time will require you to continue to sacrifice everything else in your life. If you have debt, you may not be able to pay it down, let alone start living the life you and many others have postponed for so long. You will struggle to spend time with your family, buy a home, care for vulnerable loved ones and more. You will continue to work at a non-stop pace, this time with no end in sight.

You will burn out and like many others, leave family medicine for good. This is why millions of Ontarians no longer have a family doctor.

The Ontario Ministry of Health can solve this crisis. 

Governments in Manitoba, Saskatchewan and British Columbia have done so. This past year, they made family medicine a priority – and backed their words with targeted funding toward key programs to support both new and established doctors. It comes as no surprise that they have welcomed hundreds of new family doctors into their communities.

If they can do it, so can Ontario.

What can you do in the meantime? Work in hospitals, hospices, operating rooms and long-term care. Work in obstetrics, anesthesia, as a hospitalist, in emergency or palliative care, oncology, sports medicine etc. Be a locum. Bide your time. 

You are skilled, smart, and adaptable. Your knowledge is extensive, demonstrating an unmatched depth and breadth of training. Use it.

When people leave comprehensive care family medicine, they almost never come back. 

We don’t want that to happen to you. When the government of Ontario recognizes family doctors as the foundation of medical care, negotiates a fair contract and improves health policies to reflect patient needs in 2024… well, when that happens, we will write a different letter and welcome you to the world you were meant to be in.

 We hope by then it is not too late.

Sincerely,

Dr. Nadia Alam, comprehensive care family physician and anesthetist, past-president of the OMA 

Dr. Sohail Gandhi, comprehensive care family physician and hospitalist, past-president of the OMA

Dr. Silvy Mathew, comprehensive care family physician and long-term care, past-board director of the OMA