Burnout – justanoldcountrydoctor

It Appears Family Doctors are Giving Up…

Recently, I attended the Menopause Society’s Biennial National Scientific Conference. I’ve long felt that medicine as a whole has done a poor job on women’s health issues, and wanted to learn more about what I can do to better help my patients. The conference itself was packed (over 600 attendees). Half of them were family doctors like myself. As with all medical conferences, not only did I get the chance to learn some valuable information to benefit my patients, I got a chance to network with colleagues from across the country.

Sadly however, a rather large number of family doctors I met were in a similar state of mind. They were tired, burnt out, and were actively exploring ways to stop practicing family medicine. In short, they were all giving up.

A dear friend of mine is taking 6 months off her practice to re-evaluate her work (despite having helped countless numbers of people over the years). Another physician has found happiness working part time at a specialty clinic and occasionally doing locums (vacation relief work). Another is actively looking to find someone to take over his practice. Another is simply going to close her practice after two years of trying to find someone to take over. Another…….ah, you get the point.

About one -third of the family doctors I spoke to were all at some stage of quitting family medicine. Given that Canada has 6 million people without a family doctor – which is already a disaster- it’s safe to say our health care system won’t survive if this happens.

About the only part of the country where family doctors seemed to want to carry on was Manitoba. They cited a new contract that fairly compensated them for their work, and a reasonably positive working relationship with the government. I guess that’s why Manitoba set a new record for recruiting physicians last year. Paying people fairly and working with them co-operatively will attract new talent? Who knew?

(As an aside, Manitoba is also the only province I am aware of that has a specific billing code for counselling women on issues related to peri-menopause and menopause).

But I digress. The question becomes why are so many family doctors planning on giving up? I would suggest it’s a host of issues. There is an increasing level of burnout in the profession. It’s primarily driven by by the administrative workload which has gotten out of hand. For example, I recently went on vacation to Manitoulin Island, and while waiting for the ferry, I couldn’t help but pull out my laptop and check my lab work and messages. I knew that if I didn’t check my labs every day, the workload on my first day back would be crushing.

Me in my car, waiting to get on the Chi-Cheemon ferry to Manitoulin Island, checking my labs and messages on my Electronic Medical Record (dummy chart on screen)

There’s also the constant delays in getting patients tests and referrals to specialists. The most common message I get from my patients is something along the lines of “I haven’t heard from the specialist/diagnostic test people yet, do you know when it’s going to be?”

And of course there is the ever present “But my naturopath told me you could order my serum rhubarb levels for free” and “I did a search online and it told me I need a full body MRI”.

The worst part of it of course, is that the family doctor becomes the brunt of the frustration and anger that patients express when the health care system doesn’t live up to their expectations. I had to tell three patients (while I was on vacation) that, no, I couldn’t do anything to speed up the specialist appointment. Four more were told that I had in fact called the pharmacy with their prescriptions – and I had the fax logs/email logs to prove it. And so on…

So what can be done?

In the absence of anything else of course, the first thing is to pay family doctors more. Recently, the Ontario Medical Association (OMA) and the Ministry of Health (MoH) have rolled out the “FHO+” model of paying physicians. There is a slight bump in pay (about 4% for the next fiscal year over this year). There is also an acknowledgement that administrative work needs to get paid and some other tweaks. It’s perhaps a start, but in the current system, a 4% raise will not stop the haemorrhaging of family physicians.

What really needs to happen is for Ontario to forcibly, quickly and rapidly move to a modernized, province wide electronic medical records system. I’ve been talking about this for years and years and even presented on this to eHealth Ontario (in 2018!). But I have not been able to explain it as well as my colleague Dr. Iris Gorfinkel did in her recent Toronto Star Op-ed. (It’s a really good read and I encourage you all to read it). To shamelessly quote her:

“A fully integrated, province‑wide, patient‑accessible electronic health record system should no longer be viewed as a luxury, but an essential part of the solution to Ontario’s existing crisis…… It would free family doctors to do the work only we can do.”

Secondly, we need to rapidly move towards team based care with family physicians as the lead of the team. While the MoH is announcing teams proudly in the hopes of connecting patients with doctors, the rollout seems kind of uneven. They amount to a call for proposals as opposed to a specific evidence based structure of how these teams should run. There’s also no specific role guarantees for family physicians in these teams (beyond saying they are important). The process seems slipshod at best.

Finally, at the end of the day we must not shame or diminish those family physicians who have given up. Many of them have spent years, if not decades fighting for better care for their patients. The fact that the unrelenting bureaucracy of our cumbersome health care system finally got to them and made them give up should be cause to shame the people in charge of health care, not the individual physicians.

Let’s hope that message gets across.

Study of Family Doctors Choosing “Other” Work Leaves Me with Mixed Feelings

Last week, a study published in the Annals of Family Medicine revealed what those of us in medicine knew all along. More and more, physicians who are trained in comprehensive family medicine, are choosing to do other things. There are a myriad of reasons for this (ranging from poor remuneration, lack of respect from government, incredible admin burden and more). But the blunt reality, which is very very bad for the people of Ontario, is that despite having enough family doctors, not enough of them are practicing comprehensive care family medicine, and more are expected to stop.

There was of course, a large amount of press interest in the study, and rightfully so. Probably the best interview given by one of the studies authors was by my friend Dr. Kamila Premji (who is brilliant) and can be listened to here.

I was fortunate enough to be asked about this issue last week on “Toronto Today” with host Greg Brady. As I explained to him, I personally am left with decidedly mixed feelings about the report.

The Hope

It’s not like people haven’t been talking about this for a long time. Heck I wrote about how Ontario does NOT have a shortage of family doctors, just over a year ago. I pointed out that family doctors were leaving to do other things then.

But now that there is a comprehensive study done on the matter, maybe, just maybe, the bureaucrats at Ontario Health will finally do something positive about the matter. (I won’t bet the mortgage on it – but there is a teensy little bit of hope).

The Frustration

It’s precisely because people have been talking about this for such a long time that I was also frustrated that this issue hasn’t been dealt with yet. Dr. Premji herself warned about this issue years ago. My friend Dr. Mathew (another doctor much smarter than I) pointed out how the system has been deteriorating since 2012 . Dr. Nadia Alam, a former President of the Ontario Medical Association (also a dear friend much smarter than I) wrote in 2018 about the fact a crisis was coming in Family Medicine. And yes, a certain grumpy, miserable and cantankerous old bugger wrote back in 2017 about the need to support Family Medicine and warned that the shortage of comprehensive care Family Physicians was going to get worse if nothing was done.

All of these doctors were ignored. When Dr. Alam wrote her blog, “only” 800,000 people in Ontario didn’t have a family doctor – we are over 2.5 million now.

Thinking about how much better off we would be if the bureaucrats at Ontario Health hadn’t unilaterally ignored these doctors makes my blood boil.

The Fear

Which brings me to my biggest fear in all this. When I look around at some of the Ontario Health staff, and see some of the reports/decisions and directions given by various committees/panels/departments of Ontario Health, I see frankly, a lot of the same old names and faces. The same bureaucrats that ignored Dr. Alam and others for over a decade, and have made bad decisions and recommendations ever since, are still in charge. Many have been promoted. All of them are going to retire with full pensions. And yet now, they will likely be tasked to find a solution to the very mess that they failed to foresee and in many cases aided and abetted in creating.

If I may paraphrase Albert Einstein a little bit, to expect the same people who consistently and repeatedly made wrong decisions over the past ten years to suddenly not make a mistake with the next set of decisions is surely the definition of insanity.

So What’s Next for Family Medicine in Ontario?

As I think most of us know, Dr. Jane Philpott has been tasked by Ontario Premier Doug Ford to lead the new Primary Care Task Force. Her stated goal is to ensure every resident of Ontario has primary care within the next five years. She has a strong relationship with Dr. Tara Kiran, one of the more visible authors of the study on family doctors. Both seem to be working closely together.

Both of them seem genuinely passionate in their support of family medicine. They also understand the foundational importance of family medicine in a strong health care system. I believe they both have the desire to fix this crisis as soon as possible. We should all want them to succeed, because success means a healthier population for all Ontarians.

But…..

To date, I haven’t seen in either of them the willingness/ability/chutzpah/brass necessary to tell off our woefully incompetent bureaucrats at the Ontario Health and tell them which direction we need to go in. As I mentioned above, we just cannot rely on the advice the bureaucrats are giving anymore – nor the processes they have put into place.

One small example of ongoing bureaucratic incompetence if I may. It’s been know for over fifteen years now that our health care IT systems are completely disorganized and don’t talk to each other. The situation is so bad that healthcare is the ONLY major industry in which fax machines are still used (seriously). It’s so wasteful that it’s been estimated that we could save $2.1 billion dollars a year if we unified our health IT systems. (Which ironically is about how much Dr. Philpott has been given to fix the family medicine crisis).

Recently, Ontario Health announced that it would develop an electronic referral system to get rid of faxes. Sounds great. But unfortunately, a deep dive of their plan suggests that each of Ontarios 180+ health teams is to pick their own software. Which means you could have a situation for someone like myself, who has patients from two different areas, being forced to use two different electronic referrals systems. Which will do absolutely nothing to reduce my admin burden, the same admin burden that the study’s authors admit is driving physicians away from comprehensive family practice.

The family medicine crisis desperately needs to be fixed in Ontario. It will take a combination of a seamless electronic record system, processes in place to reduce paperwork, increased pay for family doctors (including pay for admin work and retention bonuses) and yes teams where the family doctors guiding them. But I don’t think any of that can happen until we clean out the bureaucrats at Ontario Health.

Survey on Delayed OHIP Payments

NB: The following is a guest blog, written by the (anonymous) author of the survey I referenced in, “Will the OMA Learn Lessons from OHIPs Latest Attack on Doctors?“. While it’s true these surveys tend to attract negative responses by their nature, the rather large number of respondents (especially compared to some of the OMAs own Thought Lounge surveys), suggests the OMA really needs to pay attention to the extreme dissatisfaction this issue has caused. My thoughts follow at the end.

The purpose of this survey was to highlight to the OMA the need to take this issue more seriously and to outline the impact the delayed payments had on members. The OMA’s response to this has been tepid. At the time the survey responses were collected, the payment timeline for November and December, 2024 retroactive pay was set as November, 2025. This was changed to August, but this does not alter the fact that the MOH has repeatedly delayed payments for physicians over the years.

Even with a signed, public agreement, the MOH has not managed to uphold its obligations, yet the OMA seems resigned, on behalf of its members, to accept whatever delays happen, based on whatever excuse the MOH provides. The members are not the cause of the MOH’s problems, yet they pay, over and over, for these deficiencies.

The survey results are summarized below. As a practicing physician, my time is at a premium, so I utilized AI to summarize the main findings of the survey.

Technology willing, the full survey results are here. Survey Monkey dashboard is here.

AI-Generated Summary of the Full Survey Document:

The survey responses reveal widespread dissatisfaction among Ontario physicians regarding delayed payments, systemic issues in healthcare administration, and inadequate advocacy by the Ontario Medical Association (OMA). Key themes include the impact of late payments, financial hardship and impact to personal finances.

Many respondents reported being unable to meet financial obligations, pay taxes, or fund discretionary purchases due to delayed payments. Some had to take on debt or cancel planned expenses like maternity leave benefits, vacations, or home down payments.

Clinic Operations:

Clinic owners faced cash flow disruptions, inability to pay staff, and delayed renovations. Others mentioned the administrative burden of tracking payments and rejected claims.

Mental and Emotional Toll:

Physicians expressed feelings of moral injury, frustration, and discouragement, with some considering early retirement or leaving the province entirely. The delay has eroded trust in the Ministry of Health and the OMA.

Lack of Accountability:

Respondents described the Ministry as untrustworthy, disrespectful, and adversarial, with unilateral decisions that breach agreements. Many called for interest payments on delayed funds and legal action to hold the Ministry accountable.

Systemic Issues:

Complaints included outdated payment systems, rejected claims, and lack of transparency in billing processes.

Weak Advocacy:

Many respondents felt the OMA failed to advocate strongly for physicians, with delayed and insuﬃcient responses to the payment issue. Some called for legal action, media campaigns, and stronger negotiation tactics.

Loss of Trust:

Physicians expressed frustration with the OMA’s perceived lack of power and transparency, with some questioning the value of membership dues.

Declining Appeal to Practicing in Ontario:

Many respondents are considering leaving Ontario or medicine altogether due to poor compensation, lack of respect, and systemic challenges. Some noted that other provinces offer better pay structures and support.

Family Medicine Crisis:

Respondents highlighted the lack of investment in family medicine and primary care, with concerns about burnout, scope creep, and inadequate funding.

Rejected Claims:

Physicians reported valid claims being rejected by OHIP , causing financial losses and administrative burdens.

Delayed Payments:

Delays in flow-through funding, parental leave benefits, and relativity-based fee adjustments were frequently mentioned.

Outside Use Penalties:

Respondents criticized penalties for outside use, especially when patients sought care elsewhere due to hospitalizations or urgent needs.

Recommendations for Advocacy:

Demand Accountability:

Push the Ministry to honour agreements, pay interest on delayed funds, and improve payment systems.

Increase Transparency:

Advocate for clearer communication about payment timelines, rejected claims, and billing processes.

Strengthen Negotiation:

Take a more aggressive stance in negotiations, including legal action and public campaigns to highlight the Ministry’s failures.

Support Physicians:

Address broader issues like rejected claims, outside use penalties, and inadequate funding for family medicine and specialists.

Conclusion:

There have been severe financial, emotional, and operational impacts of the delayed OHIP payment. There is an urgent need for the OMA to advocate more forcefully with the Ministry of Health to address late payments and systemic issues affecting Ontario physicians. Physicians are calling for immediate action, including interest payments, stronger advocacy, and accountability from the Ministry of Health and the OMA. The dissatisfaction expressed by respondents highlights the risk of losing physicians to other provinces or professions if these issues are not resolved.

An Old Country Doctors Thoughts:

While the above was written by my colleague, my personal thoughts on the survey is that I’m not really surprised by the results. I try to “keep my ear to the ground” so to speak, and there is a broad level of dissatisfaction with how the MOH repeatedly gets away with violating its own signed contracts, and the frankly abject level of incompetence at the MOH. The incompetence is unfortunately, not limited to just their payment systems/processes, but also how they run health care in general.

I’m also not surprised by the negative comments towards the OMA. Admittedly (as mentioned before) these surveys tend to cater to negative responses. However, there is a real sense of defeat on the ground about how physicians are being treated by the current government (protracted arbitration, stupid statements about the family physician shortage, and more). My sense is most physicians are resigned to defeat and are disengaging from health care – which is bad for the whole health system.

It does not help frankly, that a few short days after being told physicians would not get paid on time, OMA CEO Kim Moran was quoted in an Ontario Government News release on Primary Care saying:

“Ontario’s doctors are encouraged by this announcement and look forward to working with government to ensure that every Ontarian has access to a family doctor. We will do everything we can to accelerate this goal by collaborating with Deputy Premier and Minister of Health Sylvia Jones, and the lead of the Primary Care Action Team, Dr. Jane Philpott. It’s a long road ahead but this is a positive step forward to protecting Ontario’s valued health care system.”
Kimberly Moran
CEO, Ontario Medical Association (OMA)”

A very well respected physician from another province told me after seeing this: “It’s a bit pathetic. Screw us over and we’ll still be nice to you”. Personally I think Ms. Moran should look up “Stockholm Syndrome“.

I’ve repeatedly said you cannot have a high functioning health care system without happy, healthy and engaged physicians. These survey results suggest that that isn’t the case in Ontario.

Sunday Snippets: Nov 24, 2025

Another in a weekly series of brief snippets of health care stories that bemused, intrigued and otherwise beguiled me over the past week along with my random thoughts on the matter.

Item: Dr. Sarah Giles writes in the CBC about how she was forced to cut her hours because of the burnout.

My thoughts: Kudos to Dr. Giles for talking so openly about this. Alarmingly few of my colleagues are willing to talk about burnout and how the system is affecting them. Instead they suffer in private, and that’s not healthy for them OR the patients they serve. It’s an important story that needs to be told over and over again.

Item: “Involuntary medical treatment” for people with addiction issues seems to be all the rage. A great article in the “Conversation” shows that this won’t solve anything, and in fact will make things worse.

My thoughts: I really can’t believe we are even discussing this. It has been well known for…..well forever, that people will not get better unless they want to seek help. We have to focus on making seeking help easier, not forcing them.

Item: The always excellent Dr. Katelyn Jetelina, who most of my colleagues know as a superb voice of reason and information during the height of the Covid pandemic, writes about her feelings now that RFK junior has been nominated to lead Health and Human Services in the United States.

My thoughts: My heart goes out to her and all the hard work staff who have tried keep us all safe during the pandemic. They deserve better.

Robert F. Kennedy Jr., a leading American Anti-Vax conspiracy theorist, now tapped to head Health and Human Services in the United States

Item: TV Ontario had a segment suggesting that foreign trained physicians could help tackle Ontario’s physician shortage.

My thoughts: I’ll shout it out again, we already have enough family doctors in Ontario who are already licensed to practice medicine in this province and are familiar with the Ontario Health Care system. The number is approximately 6,000 or so (see the graphs in the linked blog for details). Can we just not make it easier to practice family medicine instead??? If we can get even 1/3 of those doctors already in Ontario to start a practice, we would end this crisis.

Item: Great article on the physician gender wage gap in Health Debate. Clearly shows that the gap is real and needs to be corrected.

My thoughts: One of the best accomplishments of the OMA Board when I was on it was to publish the gender pay gap report. It was arguably too late, but I believe we were the first PTMA to discuss this and to use that as a basis for future negotiations work. While I’ve had some issues with how negotiations have been handled since, I am quite comfortable in saying that positions of the OMA in negotiations would take this into account and that there is likely to be funds demanded to narrow this gap. The blame for the fact that there has been no progress on this lies mostly at the feet of the Ministry of Health. We don’t have an agreement yet on how to divide the arbitration award – and that means the Ministry is not responding to OMA proposals that would close this gap. Shame on them.

Item(s): Alberta announced that it hiring a large number of nurse practitioners to become “primary care providers” to patients who don’t have a family doctor.

My thoughts: The National Health System (NHS) in Britain is under fire for the fact that it too tried to replace the work done by fully trained physicians, with staff who were likely well intentioned, but had less qualifications. It turns out there is significant risk to this, and likely a markedly increase cost in providing health care. The article “My wife died because the NHS used cheap labour” should be, in my opinion, required reading for any politician/health care bureaucrat who thinks they can provide better care by using less trained people.

That’s all for this week. Back next week (probably) with more.

Sunday Snippets – November 17, 2024

Another in a weekly series of brief snippets of health care stories that bemused, intrigued and otherwise beguiled me over the past week along with my random thoughts on the matter.

Item: New reports show that marijuana use is linked to thinning of brains in adolescents.

My thoughts: It’s not just adolescents. And it’s not just brains. I’ve seen a marked rise in people with significant mood issues ever since marijuana was legalized. There has also been a significant rise in people with stomach/bowel issues in my practice that all other tests turn up negative for. Patients with these issues are invariably marijuana users and the blunt reality is they won’t get better until they stop. I continue to be in favour of decriminalizing marijuana and other illicit street drugs if and only if we do it the way Portugal did it and not the haphazard way it is being done in Canada. But we really need to re-think the full on legalization of it.

Item: A survey in Medscape showed that there were two factors critical to reducing family medicine burnout. First would be to reduce the Electronic Health Record burden, particularly the number of times family physicians have to chart from home. Second would be to build stronger physician/nurse teams. Crucially, the teams need to be led by the family physician and NOT a bureaucrat or some other team member.

My thoughts: I hope this finally gets the Canadian Medical Association (which despite over $2 billion dollars in their bank account is amazingly growing increasingly irrelevant to front line physicians) to SHUT UP ABOUT SICK NOTES ALREADY. That’s not going to solve burnout (even though I like every other doctor hate doing them). To paraphrase a political slogan – “It’s the Electronic Health Record, stupid.” My second thought is that I remain extremely concerned that while I do feel Dr. Jane Philpott is well intentioned in her new role (to lead a primary care action team) – the bureaucrats at Ontario Health will sabotage her. They will see “teams help”, then create teams that have the assistant to the secretary to the aide to deputy minister’s attache for the Primary Care Secretariat’s deputy vice president run them. That will be a disaster. Teams need to be led by family physicians. Full stop.

Dr. Jane Philpott, head of the new “Primary Care Action Team” designed to give everyone access to primary care in 5 years.

Item(s): The family physician crisis in Ontario continues to worsen. Tillsonburg lost four family physicians. Wallaceburg is launching a large physician recruitment program to deal with their shortage. Brantford is taking a more hands on role to get more family physicians. Brockville is hiring a consulting firm that employs former health Minister George Smitherman to help tackle their shortage.

My thoughts: It’s sad that we are in a seeming “Hunger Games” of one community fighting another for the precious resource that is a family doctor. If only someone had warned people a crisis was coming. Oh, right.

Dr. Nadia Alam, who, like others, warned that the crisis in family medicine (and health in care in general) was coming ten years ago, and was ignored by governments.

Item: Premier Ford promises to correct the mistakes at Ontario Health at Home that led to a large amount of suffering for patients. He also stated that the people who “messed this up” will be “held accountable”.

My thoughts: I’ll believe it when I see it. When I wrote about mismanaged bureaucracy in health care (back in 2015!) I pointed out that no decision seems to get made by bureaucrats without continuously “circling back” to one committee or another. The reason I’ve discovered, is because this way, no individual gets blamed for (the very many) bad decisions made in health care. I’ve yet to see a health care bureaucrat fired – and I’ve met many who deserved to be. I really hope that the comments by Premier Ford signal a return to the old Doug Ford who promised to end the “gravy train” and famously said:

“What drives me crazy is when you have a supervisor in government, and they report into 12 other supervisors. That’s unacceptable.“

Doug Ford, Premier of Ontario for almost 7 years, and the gravy train in Ontario Heath continues unabated

Item: Male doctors are working less hours in a week than they used to. They are still working more than the average Canadian worker, but there has been an unmistakable decrease in how many hours they work

My thoughts: Finally! Proof that men are getting smarter! There’s more to life than work, and good for the younger docs – all of them – for seeking balance in their lives.

Item: A young Ontario mother died of cholangiocarcinoma (cancer of the gall bladder), after encountering multiple road blocks getting a new treatment (Pemigatnib) approved for her.

My thoughts: This story is absolutely infuriating and encapsulates what is wrong with our health care system. Look, there is no guarantee that she would have survived if she had gotten the treatment (it’s an awful cancer she had). BUT – look at all the regulatory agencies involved in getting the drug approved. Health Canada approved the drug in 2021. But the Canadian Agency for Drugs and Technology in Health said the evidence wasn’t clear. (So why then did Health Canada approve it?). Furthermore there are multiple provincial drug agencies involved, which means she could have gotten it had she been a resident of Quebec, but not Ontario (two tier medicine anyone?). It’s the bureaucracy and double speak from having too many agencies involved that angers me greatly. A wholesale streamlining of the process for medication approvals is desperately needed.

That’s all for this week. Back next week (probably) with more.

We Know How to Save Family Medicine. Why Aren’t We Doing It?

I’m honoured to have Dr. Mark Linder guest blogging for me today. I first met Dr. Linder during our time advocating against Dr. Eric Hoskins unilateral cuts to health care. He’s exceptionally well spoken and articulate . He’s a former ER doctor and now full time family physician and clinic owner. His other claim to fame is that got fired from the Kaplan MCAT teaching course after one session – which apparently was a first.

I just wrote this in a flurry this morning. I see stupider and stupider proposals from the government and from newspaper editorials. I see our new grads learn from their teachers that they need to stay away from this job. I then see the domino effect this has on recruitment, job satisfaction and reinforced by absurd government initiatives to save the system. I watch the OMA get pulled in every direction to try and please everyone. So apologies in advance -this is just my take really-and mostly to get it off my chest-not that it will lead anywhere. So thanks for reading.

The Family Health Organization (FHO) is what saves family medicine. It has done it before and it can do it again.

In 2006 something unprecedented happened. It hasn’t happened before or since. And perhaps we didn’t quite appreciate how unique it was. The provincial Liberal government, under Dalton McGuinty and Health Minister George Smitherman, introduced an upgraded payment model for Family Medicine. It built on the existing capitation based Family Health Network (FHN) model to enhance it.

What was so unique about this? It stands out as one of the only times a government has thought beyond their 4 year term to the ultimate health of their population as well as their economy down the road when they may no longer be in power. Sure, it was going to make them look good if everyone got a family doctor out of it-but it was a big expensive risk, a risk based on an assumption that family medicine was critical to the system, AND that practitioners need to be paid fairly for their work if they wish to retain these doctors in the future. A different time to be sure!

It worked. Look at the stats from 2008 to 2018. Look at how many Family Doctors gladly embraced the new system. Look how the number of orphaned patients dropped.

The system had flaws. I mean this was the second iteration of what was described as an experiment. The “outside use” enforcement rule made little sense in most cases. The calculation of capitation payments wasn’t always a fair representation of how much work it took to look after the patient in front of you. Certain “in the basket” fees were bizarre and should never have been part of the package. Doctors were actually more incentivized to send people to the ER over a walk in clinic!!! But all in all, it was a great innovation, a great idea, and saved family medicine. It also, no doubt saved the province millions in treatment dollars and ER visits as family doctors made themselves available to look after patients.

And then, In 2015 Kathleen Wynne and Eric Hoskins, the health minister at the time, effectively shut down enrollment in FHOs And that was the beginning of the end. I presume they just wanted to control the immediate budget – paying for family medicine up front meant huge savings down the road. But it resulted in a pretty big chunk of budget going out the door NOW. And the Wynne liberals didn’t have a health care crisis, didn’t heed the warnings that we as physicians laid out pretty starkly at the time, and decided, nah, we’ll just “pause” the experiment.

Which they did. And the fall out was obvious. As a clinic owner and a family doctor, I had a front row seat. The residents and new grads had all been trained in the new system, and now were unable to access it. If they wanted to work, they’d be taking a tremendous risk setting up a clinic in a Fee For Service environment using a Schedule of Benefits that had failed to keep up with inflation for 20 years. They were screwed. The aging Family Doctor population continued to retire at a predictable rate, and the aging population continued to get more desperate to find doctors with increasing difficulty.

By the time the FHO’s opened up again in 2021, it barely mattered–The reputation of family medicine among new grads had been thrashed for 6 years.
With the new rules, new grads would have to gather 6 like-minded individuals (instead of just 3 like in the old days), or find a bigger FHO that was already established and could fit them in. Not so easy. Opening up your own shop had become increasingly more expensive with post pandemic inflation, so the debt would be crippling just to get started if you wanted your own clinic. And these are graduates who already had a huge amount of debt coming out of school.

Couple this with the insane increase in administrative burden as we become more and more efficient at having hospitals and labs forward us copies of paperwork. In theory, amazing, in practice hugely burdensome, time consuming and unpaid. Arguably, if the FHO rates had increased at the level of inflation, there’d be no complaints about this additional work. But the FHO rates had more or less remained static relative to the cost of doing business. Still better than FFS, still paid a lot less than the actual market value of doing the job as proven by the lack of uptake that continues today.

The thing is: The FHO is still the answer. It absolutely needs some significant tweaks. The rates need to go up. The outside use concept needs to go. Minimum size and shared EMR requirement needs to be softened so that smaller groups can join together in nearby geographic areas. Some sort of separate funding will be essential to help clinic owners to keep up with inflation. But it still achieves by far the best mix of physician autonomy, clinic management, and long term government savings. And it’s evidence-based! We have a recent history we can look back on to demonstrate efficacy!

Other solutions, such as having lesser-trained individuals diagnosing and managing patients give the appearance of short term gains at a huge future cost as more referrals to specialists are made and more referrals to the ER are made. Another concept of having government run all clinics is clearly so expensive as to be dead at the gates-Doctors currently pay for rent, administration and their own retirements out of their incomes. It’s not great for us, but it’s a heck of a lot cheaper for the taxpayer to do it that way, and simply pay the doctors more.

I recognize that my FFS colleagues are not helped at all by an enhancement and advocacy for the FHO approach. And I’m sorry. I obviously think there’s a lot of work that could be done to improve FFS rules and individual payments. No doubt.

But we actually have the evidence that the FHO saved family medicine when it was introduced. It was stunningly effective, and if nursed back to health, will absolutely work again.

CFPC Blows it AGAIN. Insults All Ontario Physicians.

Jeez. I thought the Board of the College of Family Physicians of Canada (CFPC) had learned its lesson following the ham fisted attempt to raise members dues and extend the residency to three years. In the aftermath of that debacle, CFPC President Dr. Mike Green promised a full review of the organization, and stated that the CFPC will be a “humbler and more transparent organization” going forward.

Turns out that letter was worth as much as an IOU from Donald Trump. The CFPC has once again insulted a good chunk of its members, and showed an incredible disconnect between those who run the organization, and the front line members whose dues pay them.

I’m referring of course, to the incredibly insensitive and frankly, downright insulting decision on the part of the CFPC to ask Dr. David Price to be one of the keynote speakers at the Family Medicine Forum (FMF). The FMF is their biggest continuing medical education event.

I will certainly agree that Dr. Price can be credited with a whole list of accomplishments. His resume alone would exceed the self imposed word count on my blogs. I would also completely agree that as someone who has done a lot work studying primary care models, he would, in fact provide some thought provoking ideas. While I wouldn’t agree with all of them, I would find them worth discussing.

But.

He is also a member of the Ontario Governments negotiations team. This is the team that has refused to provide a reasonable proposal for compensation for family doctors (and specialists) and has instead referred the matter to a protracted arbitration process.

Worse yet, the public proposal that the team put forth at the Arbitration hearing could very charitably be defined as inadequate. Not being in a charitable mood, I would rather describe their proposal as what it really is, insulting, out of touch with reality and frankly, downright offensive. Since Price has chosen to continue to be on that team, the blunt reality is that he is beholden to support the governments arbitration position. (Members of teams like this often will have varying view points internally – so who outside of him knows what he really thinks – but externally – he has to toe the party line).

The CFPC has taken the position that family doctors need to get paid more (good on them), and has lauded provinces like British Columbia who have chosen to do just that. Yet they invite someone whose team has told Ontario physicians that all they deserve (despite the runaway inflation of the past two years) is 3 per cent more.

The CFPC has also strongly advocated for a reduction in the admin burden and health system transformation (good on them). Yet the team Price is part of has essentially refused to acknowledge these as big issues. They’ve refused to pay for admin work. And those 2.5 million people without a family doctor in Ontario alone? The official position, which again, Price has to support as a team member, is that there is “no concern” about the supply of doctors in Ontario.

Yes, that’s correct. Publicly, Price has to say:

3 per cent raise is enough for all doctors (despite inflation being 15% from 2020-2023)
no retention or recruitment bonuses
no payment for admin time
no recognition of the harm caused to physicians morale by such an offer
no significant investments in Primary Care
there are enough family doctors for Ontario

As I wrote previously, his position is a slap in the face to Ontario physicians.

It’s no secret to the general public that Ontario physicians are demoralized and burnt out. It’s no secret that more and more comprehensive care family physicians are closing their practices and that most are finding joy elsewhere. It’s no secret that many are leaving the province.

But apparently, all of this is either a secret to the CFPC Board and the FMF Team, or they just don’t care. By blindly ignoring the harm that the Ontario Governments Negotiations Team is doing, and inviting David Price to talk anyway, the CFPC and FMF team are basically giving the finger to all of their Ontario doctors.

It just amazes me that when even a young physician can realize that the position that Price’s team is taking is repugnant and shows disdain for family physicians, how can the CFPC Board not seen that??

What’s worse, usually keynote speakers at events get a stipend (having been a keynote speaker I can tell you it’s pretty nominal) and their travel/accommodations paid for. Well where does the CFPC get the money to pay Price? You guessed it, from the very dues collected by the members for whom Price’s negotiations teams has shown nothing but contempt.

Talk about rubbing salt in the wound.

It would be different if Price was not on the Negotiations Team. (If I was on that team and been forced to accept their proposals publicly, I would have resigned in disgust. Only Price can answer why he chooses to continue to stay on). Then, even though many will disagree with Price’s views, it would be fair to have a robust discussion about his ideas and why they may or may not work.

But to invite him to talk despite his association with the negotiations team shows that the complete disconnect between the Ivory Tower mentality of the CFPC and its hardworking frontline members persists despite the embarrassing fiasco of last year. One can only wonder what it will take for them to realize that as a membership driven organization, the CFPC really needs to be more sensitive to the feelings of their members.

Never Ending Arbitration a Sign Government Does NOT Want to Work with Doctors

News Item #1: Prince Edward Island agrees to a contract with its doctors. Amongst other things, the deal recognizes that family medicine is a specialty (finally!) and increases compensation to reflect that. It also introduces strong measures to reduce red tape and administrative burdens, and adds what appear to be retention bonuses. PEI joins British Columbia, Manitoba, Saskatchewan and even Alberta (!) in working co-operatively with their doctors.

Dr. Krista Cassell of Medical Society of PEI with Health and Wellness Minister Mark McLane and Health PEI CEO Melanie Fraser

News Item #2: Ontario Medical Association (OMA) Board chair Cathy Faulds announced last week that the Kaplan Board of Arbitration will not deliver a ruling on the fractious contract dispute between Ontario’s doctors and the Ministry of Health (MOH)at the end of August as expected. It is delayed until at least the end of September, if not longer.

Now you, dear reader, are probably wondering why I refer to a one month delay as “never-ending”. Firstly, because I’m not convinced it’s only one month. I don’t recall the Arbitrator ever giving us a timeline for when he was going to give a decision when I was on the OMA Board. Timelines for meetings and hearings, sure – but for the decision, no.

But more importantly, even if there is a ruling in September, it’s nothing but a mere step in a protracted, convoluted process that, at the end of the day, does nothing more than show that the government would rather not engage the OMA in providing solutions for our health care crisis. To understand why, one needs to first appreciate the prolonged nature of the current arbitration process, and just how tortuous it is. (I will do my best).

First, the current arbitration process is ONLY for one PART of the first year of what is supposed to be a four year contract. It will cover April 1, 2024 to March 31, 2025. BUT, it will only cover a percentage increase for that one year. It will not set specific fees for different specialties. Instead, there was general agreement (last I heard) that 70% of the increase would go towards fee increases and the other 30% would go towards targeted areas of high need.

Sounds simple enough to sort out right? If the deal is worth, say $2 billion (this number is totally made up and Mr. Kaplan, if you are reading, this number is much less than the increase should be), then $1.4 billion would go towards fee increases, and $600 million would be targeted towards areas of need.

The problem is that the fee increases are to be distributed along what’s know as a “relativity model”. Essentially lower paid specialists are to be given a bigger raise than higher paid ones. Unfortunately, the OMA and MOH can’t agree on how those raises are to be distributed amongst the various specialties. Worse, they can’t agree on how to distribute the 30% that was earmarked for “targeted funds”.

Which means…..you guessed it, ANOTHER round of arbitration with yet another set of decisions to be ruled upon by the arbitrator. This additional protracted process won’t begin until the arbitrators first ruling and further negotiations and mediations. The information on the OMA website suggests arbitration for those issues won’t happen until March 3, 2025.

But wait, didn’t I say that this was only for the first year of the four year contract? Why yes, yes I did. Which means that after this, we now start arbitration AGAIN for years 2-4 for the doctors contract. And yet again, not only do decisions needed to be made on the percentage increase, but on how that increase is divided up. Which means…….potentially many more rounds of arbitration.

I would concede the OMA websites suggests all of the year 2-4 arbitration, and left over issues from year one can be done at the same time (March 3-7, 2025). However, I will refrain from betting the mortgage on that actually coming to fruition. We are one early election from this timeline being thrown into chaos. The cynic in me thinks that by the time arbitration is all done for this supposed four year cycle, it will be time to start negotiating (and yes more arbitration!) for the next four year cycle.

The government will most likely abide by the initial arbitration award (it’s doubtful they would reject an award prior to an election call). Ontario Health Minister ~~Galen Weston~~ Sylvia Jones will frame this as part of the process for coming to an agreement. She will (probably) claim that by abiding by the award the government is “working with” physicians to benefit the health care needs of the province.

She will be wrong.

I’ve mentioned this before, arbitration is preferable to the days when governments could unilaterally cut physicians income at the whim of the health minister. However, that doesn’t change the fact that arbitration should be viewed as a necessary evil, with emphasis on the evil. Not only can it demoralize people who are going through it, the spill over effects have wide reaching consequences.

What does this mean for the general public? The OMA has come up with some solutions for the various crises our health care system is facing (2.5 million without a family doctors, worsening health care catastrophe in Northern Ontario, overwhelming bureaucratic burden etc). The reality is that many of the solutions require changes that need to be made in a contract with Ontario’s doctors. But we don’t have one, so none of these will be implemented.

Instead of working co-operatively with the OMA to come up with solutions in a fair contract, the current government seemingly prefers to leave it all to the arbitrator. And as a result, patients will continue to suffer.

The government of Ontario has a choice. Follow the lead of BC, Manitoba, PEI and so on and work with the doctors to help patients. Or set up a perpetual conflict with them.

Over to you Minister.

Ontario Health Minister Sylvia Jones, who can start to fix things tomorrow, if she wants.

Dr. Soni Writes to her MP About the Recent Tax Law Changes

My thanks to guest blogger Dr. Deepa Soni, an Emergency Room Physician at Credit Valley Hospital. She has written a much more eloquent letter to her MP about the recent tax changes introduced by the federal government, and allowed me to reproduce here as an open letter.

The Honourable Anita Anand,

MP, Oakville,

301 Robinson Street

Oakville, ON

L6J 1G7

April 20, 2024

Dear Minister Anand,

I’m writing to you as a constituent of your riding in Oakville regarding your government’s capital gains taxation measures introduced in this week’s budget.

As an emergency physician for the last 25 years, I and thousands of my colleagues in Ontario, were saving in our medical corporation to be able to fund benefits that many Canadians have available through their jobs: maternity leave, disability, and medical/dental benefits. In addition, and most importantly, incorporation allows us to save for our retirement as we do not have pensions (again, a benefit many Canadians, including government employees and civil servants have as part of their employment). Incorporation was a negotiated benefit that was given by the provincial government in lieu of increasing our fees, with the understanding that the structure would allow us to mitigate some of these factors about our career.

Anita Anand, President of Treasury Board

When planning for retirement under one set of assumptions, and then finding out that the federal government has moved the goal posts to extract revenue for its budget shortfall, you can understand why so many physicians are bewildered and disappointed by the Liberal government. This would be the equivalent of someone changing the terms of your pension or taking large chunks of it away. For many doctors, this will have profound impacts on their ability to retire when they thought they would.

In addition, as a daughter of first-generation immigrant parents, both of whom were physicians, I am certain you had a front row seat watching your parents work hard to obtain their medical degree, residency, and then establishing a practice. This is not to say that other Canadians don’t work hard: the one thing that makes doctors unique is that our fees are set by provincial governments and our fees have not risen to keep up with inflation. Unlike other incorporated professionals such as accountants, dentists, and skilled trades, physicians cannot increase their fees to make up for rising costs. We are locked into the fee schedule determined by provincial governments (who are always employing cost containing measures to balance budgets). The federal government is turning a blind eye to this important point as it does not fall under federal jurisdiction. Nevertheless, the impact cannot be ignored.

As a corporate lawyer prior to being elected an MP, I’m sure you would not have wanted your hard work and education to be characterized with the words ‘tax cheat‘ if you had been using a legal way to save for retirement. This is the narrative being circulated in the media and it is deeply disappointing. It is noteworthy that MPs receive an annual pay raise (this year ranging $8000-11900), along with pension and benefits. This makes an MP salary one of the highest earners in Canada, with guaranteed income through retirement.

Yet, it is doctors who are singled out as being in the wealthiest 1% and rhetoric implying that we are not doing our part for less fortunate Canadians. We pay into personal taxes and contribute to the economy like everyone else. As small businesses, doctors support the economy through employing staff (nurses, allied health, receptionists etc.), paying rent, and financially supporting many Canadian companies providing support services to our practices (electronic medical records, medical office supplies etc.).

We are also entrusted with caring for the population of Canada in the most sacred way. This taxation measure comes at a time when the medical profession in Canada is suffering unprecedented levels of burnout. Millions of Canadians cannot access a family doctor because they have closed their practises and left (in large part, due to rising costs and fixed fee schedules). Why in an era when attracting medical graduates to do family medicine is a priority, would your government eliminate one of the few advantages that help new grads set up comprehensive practices so they can care for Canadians from cradle to grave? Does your government understand the downstream effect this capital gains taxation will have on patients for decades to come?

From watching media interviews recently, it appears that the federal government’s solution to this is “we will just allow in more foreign doctors“. This is deeply hurtful on many levels: it devalues currently practising physicians who have put in their life’s work to bring excellent care to this country’s patients. In addition, it takes many years for a doctor to acclimatize to the healthcare system in Canada. What happens to patients in the meantime? The solution is not to “throw the baby out with the bathwater”. The solution is to step back and really take in the impact of these actions and the message that has been conveyed to the physicians of this country. I hope your government will rethink this and choose to act fairly regarding incorporation for medical professionals.

Sincerely

Deepa Soni MD CCFP(EM)

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.