Canada – justanoldcountrydoctor

What Exactly is the CFPC Leadership Thinking?!?

My few loyal readers will know by now that I am one of three physicians (along with Drs. Dubord and Conte) who are sponsoring six motions at the College of Family Physicians of Canada (CFPC) annual general meeting (AGM). I genuinely feel that these motions will push the CFPC into a better direction, and will help make it a more accountable organization for frontline members like myself.

Dr. Paul Conte, seen here in his usual lounge wear

I have no illusions, and neither should you, that simply passing these motions will “fix” the CFPC. I’ve come to realize that there is, in fact, no “fixing” of any physicians’ organizations, for a myriad of reasons. But what there can and must be, is ongoing, consistent vigilance and pressure applied by frontline members. These organizations must constantly be pushed to go in the right direction. I believe that passing these six motions will do that.

Having said that, I confess to being completely befuddled by the approach that the current leadership of the CFPC is taking towards these motions. Make no mistake, I fully expected the CFPC leadership to oppose the motions as written. That’s fair. Healthy disagreement and tension are vital for the success of any membership organization. But the strategy they are using honestly suggests that they hope member indifference will stop the motions. (NB – I do recognize there is a large degree of apathy towards the CFPC – but that doesn’t mean that it a GOOD thing).

For example, in the initial emails to the membership announcing that these six motions would be presented at the AGM, the CFPC specifically pointed out that the doctors supporting these motions did not respond to attempts to reach out and work cooperatively on them. Did they not think we would keep receipts? Dr. Dubord clearly reached back and asked for clarifications on what parts of the amendments were felt to be in contravention of Canada’s Not for Profit Corporation Act (NFPCA). We still don’t have a clear answer to that question.

As recently as last week, CFPC president Dr. Sarah Cook (who I will say has done a good job promoting the importance of family physicians in public) stated that our motions “sit uneasily with the law,” and that “court direction may be needed.” But which parts of the motion sit “uneasily”? Which part of the NFPCA will necessitate “court direction”? The specifics have not been provided to the members at large.

Additionally, while the CFPC has developed five alternate proposals that they state could be implemented much more quickly, a review of these alternate proposals suggests that there’s enough leeway for the board to NOT implement them. Remember, this is the same organization that treated a 95 percent vote in favour of access to Board Minutes and a 91 percent vote in favour of an independent review of the PGY-3 mess as suggestions, and declined to implement either. Did the CFPC leadership think we would have all forgotten that? And that we wouldn’t want something with more “teeth” the next time round?

Our six motions are by-law changes that the CFPC would be forced to abide by. Given the unfortunate lack of trust that appears to be there between the membership as a whole and the CFPC leadership, I really don’t understand how the CFPC thought alternate proposals without “teeth” would be acceptable.

Additionally, it would seem that members are expected to forget that last year, the CFPC wanted to institute perpetual annual fee hikes for members (up to the rate of inflation). The argument was basically “we’ve trimmed all the fat we can.” (In fairness they did trim their budget a lot). But suddenly, this year, they don’t need a hike anymore (there is a motion at this year’s AGM presented by the CFPC to keep the fees the same). You mean, membership pressure works? Golly.

All of which is my way of saying that I have the strong sense that members need to continuously push the CFPC to do the right thing. We CAN have a better organization, we just have to put a little bit of effort into it.

It should surprise no one that I’m going to encourage all of you to support the six motions and reject the alternates. As a reminder, members can vote by proxy but MUST register by Sunday October 25 at 11:59 pm.

The directions, once again, for voting by proxy:

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

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

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

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

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

With any luck, we can have a better CFPC on October 29, but only if we are willing to make our voices heard by voting.

How To Vote By Proxy at the CFPC Annual General Meeting

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

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

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

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

For example, according to their AGM Meeting Materials:

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

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

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

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

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

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

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

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

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

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

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

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

5. Items 11 to 21: I ask that you approve every Member Motion (Items 11, 13, 15, 17, 18 and 20). It is ESSENTIAL to REJECT EVERY Alternative Motion (Items 12, 14, 16, 19, 21). NB. The Proxy Card refers to these as CONTESTS, NOT ITEMS. However, the numbering system still stands. Vote YES on 11, 13, 15, 17, 18 and 20. Vote NO to 12, 14, 16, 19 ,21. Remember, if the alternate motion gets accepted, it will supersede the six member motions, and no meaningful change will occur. You should see something like this:

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

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

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

Preparing for the August Covid-19 Wave in Canada

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

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

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

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

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

What EVERYONE Should Do

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

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

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

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

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

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

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

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

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

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

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

The last word.

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

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

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

Yes. Please don’t move to this area.

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

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

Is the problem the people?

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

Is the problem the growth in the area?

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

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

It’s the healthcare system.

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

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

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

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

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

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

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

But I thought you guys were building a new hospital?

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

You mean like hallway medicine?

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

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

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

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

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

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

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

And don’t move to the Georgian Triangle?

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

Local Medical Schools Will Help Address Doctor Shortages

Old Country Doctors Note: I was a teacher with the Rural Ontario Medical Program for three decades. It was founded by Dr. Peter Wells, and based on the principle that putting trainee doctors in smaller communities will enhance the chance of them working there. It’s been wildly successful. On that same note, Dr. Butt feels that putting a Medical School in Barrie will help increase recruitment to smaller centres, and I think he’s right. His Letter to the Editor appeared in the local press, and he’s given me permission to reproduce as a guest blog here.

Dr. Atif Butt (pictured inset) guest blogs for me today. He’s one of these ultra smart characters who not only has and MBA (McMaster 2003) but also and MD (McMaster, 2011) and a CCFP (EM). He’s retired from the Military (Major) and works in ER in Alliston, and Urgent Care in Barrie and does sedations in an endoscopy clinic in Innisfil. Apparently he’s quite the dancer too.

Barrie has been home to my family and I since the fall of 2013. It is a wonderful area to raise a family and offers everything that a mid-size community requires but also the peace and quiet lacking in larger urban areas. It is also the gateway to cottage country.

I am surprised at how fast the city is expanding as demonstrated by the numerous condo buildings and townhouses being erected, especially on the Barrie/Innisfil border. A growing city will result in many consequences, some positive (e.g., more cultural diversity, more revenues for local businesses, etc.) but also some negatives (e.g., traffic headaches). It will also mean a growing population that will place greater demand on local health-care resources.

I have been practising medicine in several health-care organizations in the Barrie/Innisifil/Alliston area since 2013. I am impressed by how much demand is placed on local health-care organizations, yet they continue to persevere through. The success is fundamentally thanks to the heroic work of the health-care workers including physicians, nurses, and other allied health-care workers who band together to serve patients, often sacrificing their own nights and weekends. But we all have our limits and simply cannot do more.

Currently, almost six million Canadians (out of which over two million are in Ontario) do not have a family doctor. More specifically, it is estimated that over 55,000 people in the Simcoe County area do not have a family doctor. Almost every day, there are news reports of lengthy wait times in the ERs, which are frankly longer than plane flights from Canada to Pakistan. Attempts have been made to address such shortfalls by the use of nurse practitioners, physician assistants, and pharmacists and I am grateful for the work they provide. Nonetheless, physicians cannot simply be replaced by non-physicians and more are needed. That is why I am proposing that either a new medical school be created in the Barrie/Innisfil area or, preferably and more cost-effectively, seats from an existing Ontario medical school be expanded to our area.

I am encouraged to see that some efforts have already been made to expand medical school seats in Ontario. Examples include the 2025 opening of the Toronto Metropolitan University medical school and the upcoming opening of the York University medical school in 2028. I appreciate that such endeavours can be costly. For example, the federal government just announced almost $2 million to expand medical seats and services for the Northern Ontario School of Medicine. While this will greatly support the north, sadly, Barrie and the surrounding area seemed to be left out.

Despite investments in new medical schools, the demand far exceeds supply. For example, the newest medical school at TMU had 6,416 applications in 2025 but total projected class size in 2026 is 94. That means 1.5 per cent of applicants got accepted. Most medical schools in Ontario roughly seem to have on average about a three- to five-per-cent acceptance rate. While adding medical seats in Barrie/Innisfil maybe a drop in the bucket, it will hopefully lead to an ongoing pool of locally trained physicians that will want to practice in our area. Return of service contracts, where physicians have to practice locally for four to five years after training, can be a condition for acceptance into a medical school here.

Canada in general and Ontario in particular have a lot of talent, yet we are losing out. On a regular basis, I come across undergraduate students who have high GPAs/marks, extraordinary extra-curriculars and experiences, scored high on their MCATs, have applied multiple times to Canadian medical schools, yet are unable to even get an interview (let alone acceptance) into a Canadian medical school. Their families are often spending hundreds of thousands of dollars per year (in U.S. dollars) to send them abroad to the U.S./Caribbean/Europe so that they can pursue their dreams of becoming a physician. Even after they graduate from an international medical school, there is no guarantee that they will obtain a residency spot in Canada since preference is given to Canadian-trained grads. Hence, they may be forced to practise elsewhere like the U.S. Would it not be better if we could retain and train such talent who invested their tuition locally and then stayed to practise?

Intuitively, when medical trainees train in a particular geographical area, many will choose to stay and practise in that area. While in Barrie we have the Family Medicine Teaching Unit for training family medicine residents and the expansion of some ER residency spots at Royal Victoria Regional Health Centre, I believe that the next logical step is to have medical school seats in the Barrie/Innisifil area. This will allow us to recruit and retain future physicians in the local area.

I find that the simplest goals are often the most achievable and realistic. A brand-new expensive medical school with new infrastructure may be a costly pill for any government to swallow. Thus, simply expanding, say, a dozen seats, from an existing Ontario medical school to our area using existing hospitals or other health-care facilities may be much more palatable. Students will be able to virtually watch online any didactic lectures that are delivered at main campuses to obtain theoretical knowledge. Any practical knowledge and skills can be completed with assigned preceptors and through core rotations (e.g., ER, family medicine, obstetrics, general surgery) and elective (e.g., plastics, radiology, etc.) at several of the amazing and existing local hospitals and health-care facilities from Orillia to Barrie and Alliston to Newmarket. After doing three to four years of medical school and assuming they do a two-year family medicine residency in the Barrie/Innisfil area, I suspect many will choose to stay and practise in our wonderful area.

I have already reached out to several governing officials including the Office of the Premier of Ontario and the provincial minister of health to share my proposal. While their offices have provided some appreciative yet general responses of their broader investments, I truly believe that it is through greater and ongoing public support and engagement that expansion of a medical school in Barrie can be achieved. In other words, while I as a physician can write a prescription and explain the risks and benefits of the medicine, it is up to the patient to actually take the prescription. In this case, my prescription is the expansion of medical school seats to the Barrie/Innisfil area and I am asking you, the patient, to engage the government in filling this prescription.

Lettre ouverte au premier ministre François Legault

L’honorable François Legault, député
Premier ministre du Québec
Édifice Honoré-Mercier, 3e étage
835, boul. René-Lévesque Est
Québec (Québec) G1A 1B4

Monsieur le Premier Ministre,

Vous ne me connaissez probablement pas, et vous vous demandez sans doute ce qui m’a poussé à vous écrire une lettre ouverte. J’ai pris cette décision après avoir fait une entrevue à la radio avec Greg Brady, dans son émission Toronto Today. Durant l’entrevue, Greg m’a demandé de commenter la chicane entre vous et les médecins de votre province. Il a mentionné que, dans les dernières semaines, 263 médecins québécois ont fait une demande de permis pour pratiquer en Ontario.

Je ne prétends certainement pas être un expert du fonctionnement du système de santé au Québec. Je ne me permettrais pas non plus de dire que je comprends toutes les subtilités du projet de loi 2, la législation que vous avez déposée et qui met vos médecins en colère. Et non, je vais le dire d’emblée : je ne sais pas comment se déroulent vos négociations avec les organismes représentant les médecins du Québec (la FMSQ et la FMOQ).

Mais je peux vous dire que mon tout premier billet de blogue (dans le Huffington Post) était une lettre ouverte adressée à l’ancien ministre de la Santé de l’Ontario, le Dr Eric Hoskins. J’avais écrit ce billet parce que son gouvernement parlait d’imposer des mesures unilatérales contre les médecins (ça vous rappelle quelque chose?). Dans ce texte, j’avertissais le Dr Hoskins que des actions unilatérales allaient engendrer le chaos dans notre système de santé :

On ne peut pas retourner à un système où trois millions de personnes et plus n’ont pas de médecin de famille, ou encore à des délais pour consulter un spécialiste (déjà trop longs chez nous) qui deviennent carrément intenables.

J’avais aussi prévenu qu’il y aurait un prix politique à payer en allant de l’avant de façon unilatérale, et que cela nuirait aux libéraux lors de l’élection de 2018. Vous savez peut-être qu’ils ont été complètement anéantis à cette élection-là. Même si une bonne partie de leur défaite s’explique par l’impopularité de la première ministre Kathleen Wynne, je maintiens encore aujourd’hui que les libéraux auraient au moins pu conserver leur statut de parti officiel s’ils n’avaient pas magané le système de santé à ce point.

La raison pour laquelle j’ai pu écrire ces avertissements avec autant d’assurance — et avoir raison au final — ce n’était pas de la clairvoyance de ma part. C’est simplement que j’ai suivi le conseil de Santayana :

A picture of George Santayana, Spanish American philosopher with his famous quote "Those who don't learn from history are doomed to repeat it"

Ceux qui ne peuvent apprendre de l’histoire sont condamnés à la répéter.

Regardez : je comprends que les détails précis des politiques et du projet de loi que vous déposez ne sont pas identiques à ce que le Dr Hoskins tentait de faire. Mais au bout du compte, le message est le même : votre gouvernement affirme qu’il sait mieux que tout le monde comment gérer le système de santé. Vous n’avez pas besoin de l’avis ni de la collaboration des médecins. Vous allez imposer les changements que vous voulez.

Je vous encourage à retourner lire la lettre que j’avais envoyée au Dr Hoskins. Je lui avais souligné qu’il répétait les erreurs (les gestes unilatéraux) du gouvernement néo-démocrate de Bob Rae dans les années 1990. Ils ont détruit le système de santé avec ces actions-là et ont été balayés lors de l’élection de 1995, sans jamais reprendre le pouvoir depuis.

Jetez un œil au gouvernement progressiste-conservateur de Jason Kenney en Alberta, en 2019. Ils se sont mis en guerre avec l’Alberta Medical Association en 2020. La seule façon pour eux d’éviter une défaite à l’élection suivante a été de sacrifier leur chef, Jason Kenney. (Oui, c’est vrai que le mécontentement lié à sa gestion de la pandémie a joué — mais l’essentiel, c’est qu’il n’y avait rien pour le sauver. S’il avait gardé un système de santé fonctionnel…)

Vous en voulez d’autres? Regardez le gouvernement de Gordon Campbell, en Colombie-Britannique. En 2001-2002, ils ont unilatéralement déchiré une entente d’arbitrage conclue entre le gouvernement et les médecins. Cela a été suivi par des années de conflit, un recours fondé sur la Charte (que le gouvernement a perdu), du tumulte politique, un vote de grève des médecins et une majorité gouvernementale passablement réduite. Finalement, devant un système de santé en déroute — un échec dû à leur propre arrogance — le gouvernement a dû conclure une entente avec les médecins en 2002, puis en 2006, rétablissant l’arbitrage exécutoire dans des conditions jugées très généreuses à l’époque.

Comme je l’avais dit au Dr Hoskins, le message est simple :

Tout gouvernement qui agit unilatéralement court le risque de perdre des médecins.

Et quand ça arrive, le système de santé en souffre. Les patients en souffrent. Les délais augmentent. Les soins se détériorent. Et dans ces situations-là, les gens ne blâment pas les médecins. Ils blâment les politiciens.

En bref, un gouvernement qui impose des mesures unilatérales aux médecins fait du tort aux patients de sa province et paie toujours un prix politique. Au final, il finit toujours par payer plus cher que s’il avait tout simplement négocié de façon juste avec ses médecins dès le départ.

Écoutez : je n’ai pas d’intérêt particulier pour vous ou votre gouvernement. Ça m’est complètement égal que vous gagniez ou non la prochaine élection. Mais mes collègues médecins, je m’en soucie. Et je sais qu’ils sont très, très fâchés (et avec raison). Je me soucie aussi des citoyens du Québec, et je sais qu’ils vont énormément souffrir de vos décisions. En ce moment, 28 % de la population n’a pas de médecin de famille. Imaginez ce qui va arriver si 263 quittent. Et pensez-vous vraiment qu’un médecin sensé voudra venir pratiquer au Québec quand votre gouvernement agit de cette façon?

Croyez-moi : si vous ne changez pas de cap immédiatement et si vous ne recommencez pas à travailler avec vos médecins, les dommages causés à votre système de santé — et aux gens que vous êtes censé servir — seront immenses.

Et si vous ne me croyez pas, relisez la citation de Santayana.

Cordialement,

Un vieux médecin de campagne

Patient Accountability ESSENTIAL for Health Care Systems

Canadians want a high functioning health care system. This requires (but is not limited to):

appropriate funding
a seamless electronic medical record
strong support for Family Doctors (the back bone of a high functioning health care system)
a “Goldilocks” level of oversight to ensure the needs of Canada’s diverse areas are met
and much more

But one essential feature that is not talked about nearly enough is patient accountability.

Doctors diagnose and treat patients. More of us (thankfully) are also discussing proactive measures to prevent people from getting sick (appropriate screening, lifestyle tips, advice on menopause/andropause etc).

BUT patients also bear a vital responsibility in their own health outcomes. When patients are accountable—meaning they are informed, engaged, proactive AND use the health system appropriately—health systems perform better. In contrast, passive, non-adherent patients who misuse health care will strain health systems.

What exactly is patient accountability? Partly it’s the degree to which individuals take responsibility for managing their health. This encompasses adherence to prescribed treatments, lifestyle choices, attending medical appointments, following preventive care recommendations and so on. Certainly patients who adhere to current guidelines for, say, diabetic care, will have fewer complications and wind up in hospital less and use health care resources less overall. This is why investing in proactive teaching for diabetics has been shown to not just improve health care outcomes, but also the cost to the health care system.

Patient accountability cannot exist without adequate health literacy. Patients must understand medical terminology, navigate health systems, and assess risks to make informed decisions. Without health literacy, patients cannot be expected to manage their care effectively. A diabetic patient who learns to read food labels, monitor blood sugar, and adjust insulin levels exemplifies accountability in practice. When one looks at just how disjointed our current health care system is, it is clear we have much work to do to improve health literacy amongst our patients – and that dollars spent to promote this, will be money well spent.

But patient accountability also refers to how patients use the health care system. Our health system is under pressure from growing demand, finite resources, and rising costs. Patient accountability plays a pivotal role in mitigating these challenges.

Non-adherence to treatment alone is estimated to cost billions annually in avoidable hospitalizations, emergency room visits, and disease complications. For example, failure to take antibiotics properly can lead to resistant infections requiring more intensive care. Likewise, patients who frequently miss appointments or use emergency departments for non-urgent needs place undue strain on systems designed for more acute care.

By contrast, when patients manage minor issues at home, access preventive care on schedule, and comply with physician recommendations, they reduce unnecessary utilization of high-cost services. This not only frees up resources for patients with more serious needs but also ensures that funding is directed toward value-based care rather than avoidable interventions.

During my time in practice, I have only seen one government paper that talked about patient accountability – the (in)famous Price-Baker report of 2015. Written by lead authours Dr David Price and Elizabeth Baker, and including luminaries like Dr. Danielle Martin on their expert committee, one of it’s ten principles stated:

“The system is built on joint accountability: Each primary care provider group is responsible for a given population and their primary health care needs. Both provider groups and citizens are expected to use the system responsibly.”

Since then of course I have yet to hear Drs. Price/Martin or any of the other authours talk publicly about patient accountability.

How does this work in other countries?

In Finland, patients are told they have the right to good care that respects their opinions and ensures that there is informed consent with treatment. This onus is on the doctors. BUT, Finland also puts accountability measures on the patients in the form of user fees. They are generally nominal, but they are there, and I would suggest, serve to make patients think about whether they are using the health system wisely.

In Norway a similar concept applies. Health care is heavily subsidized by public health insurance. However there are user fees up to a prescribed annual maximum (currently around $250 if I’ve done the currency conversion correctly). After that, all your health care needs are covered (nobody goes bankrupt if they get cancer).

Then we have the Netherlands. There you are required by law to purchase health insurance (there are many providers apparently). There are various packages from basic to more comprehensive and the costs vary. There is also, unsurprisingly, a deductible, known as Eigen Risico, which you have to pay, before your insurance kicks in. It’s mandatory.

I picked these three countries as examples because not only do have a reputation for providing excellent health care, but because they are often talked about in glowing terms by the two physicians who seem to be driving the change in Primary Care in Ontario, Dr. Jane Philpott (Chair of Ontario’s Primary Care Action Team) and Dr. Tara Kiran (principal investigator for the ourcare.ca project)

Dr. Philpott frequently mentions countries like Finland/Norway, not just in her book (Health for All) but in various interviews. Dr. Kiran has frequently mentioned the Netherlands. They have generally spoken in glowing terms about how well the health system works in those countries and how almost everyone has a family doctor there.

I’ve also never heard them talk about how those countries require patients to be accountable for how they use the health care system.

Currently, our health care system is poorly rated compared to its peers. Canadians want, and deserve a better system. But in order to get that, we need to recognize that preserving our health care system is a shared responsibility. Despite what the politicians say, you should NOT be able just to walk into a health care facility and automatically expect it to be perfect. Rather, we should all recognize that we taxpayers own the system. As owners, we have a responsibility to use it fairly, wisely and appropriately. And yes, that means putting in mechanisms like deductibles to ensure people think about how they use health care.

Or we can carry on with a health system in a perpetual state of crisis. The choice really is up to us.

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.

It’s (Well PAST) Time to Review the Canada Health Act

The Canada Health Act (CHA).

Written by former Federal Health Minister Monique Begin, and passed into law forty (!) years ago, it transformed health care in Canada, and in many ways transformed the country.

Former Federal Politician and Health Minister Monique Begin

Viewed as sacrosanct by many pundits, it has now reached a status amongst politicians where health care is widely viewed as the “third rail” of Canadian politics. To question the reverential status of the CHA is to invite political ruin, and to be forever labeled as un-Canadian. I guarantee that I will be accused of being a proponent of “two-tier American style health care” simply for suggesting that the CHA should be reviewed.

Yet review it we must, because the reality is that a LOT has changed in health care in the past forty years. The CHA was written before the explosion of medical knowledge we have experienced. To expect it to still be appropriate is naive at best, willfully neglectful at worst. My much smarter friend Dr. Mathew pointed out: The CHA was written when health care was “episodic”. You got sick, you went to the doctor. You usually had a small co-payment. You got treated for the illness you had.

But since the CHA, health care has been massively transformed to focus on prevention. Whether with the explosion of screening tests for cancer, a focus on control of chronic illnesses, or a recognition of the benefits of being able to afford prescription medication, health care is different than 1984. In a big way. This is why the government is again promising pharmacare.

While there will always be a paper, or plan or policy on how to improve health care, very few people have the courage to address the root cause that is stagnating and impeding change, namely the CHA.

For example, Dr. Tara Kiran (Fidani Chair of Improvement and Innovation in Family Medicine at the University of Toronto) had a four part series on health care in the Medical Post where she compared Canada to Denmark. She looked at how Denmark organized their family doctors, how they pay physicians, their EXCELLENT health IT system and so on. All of which is wonderful and really should be emulated here in Canada.

Similarly, former federal Health Minister Dr. Jane Philpott has been in the news a lot with her new book “Health Care for All” in which she talks about the “right” to have a family doctor. In an interview with the Medical Post she glowingly references Norway, and how they build in health care infrastructure, much like they build schools, when planning developments. A lot to like about Norway’s health care system.

But, did you know that Denmark has a parallel private health care system (despite their high taxes) that allows faster access to care along with access to more specialists and other services? Did you know that in Norway, you actually pay for you health care at the point of service until you reach your deductible (2,000 Krone, about $250 Canadian)?

You mean Drs. Kiran and Philpott never mentioned that these countries whose health care systems they have been talking up had defacto co-payments for medical treatments (gasp!) and parallel private health care (gasp!). Gee, I wonder why….

Here’s the thing. EVERY single country that has a better health care system than Canada’s has TWO main features:

A universal health care system that is funded by taxes
An element of private care, usually some combination of a deductible for taxpayer funded services, and, a private system.

To deny the above is simply to deny the facts. To cherry pick what other countries do and to think we can do it here in Canada without also recognizing that much of what they do would contravene the CHA is naive at best, and disingenuous at worst.

Canada had a health care system that was ranked very highly in the mid-1980s. Ontario used to boast of having the “best health care system in the world”. It’s undeniable that since the CHA, health care in Canada has deteriorated markedly when compared to the rest of the world. This is not a coincidence.

What can be done? I believe the CHA should be changed to allow the federal government to have strong controls to ensure a fair universal health AND pharmacare program that functions like a true insurance plan (yes that means deductibles). It should also empower the feds to enforce a Canada-wide health IT system that allows patients to access their own data.

Why deductibles? Why not have the taxpayers pay for everything? Because without them you take away the responsibility for using a service properly. People feel as if it’s something they deserve as opposed to something they have a joint responsibility to manage and care for. By making deductibles illegal, the CHA has created a society of entitlement, instead of one of empowerment.

If you think I’m un-Canadian for suggesting that there should be a deductible on taxpayer funded health insurance, then I would ask that you be fair about it and also call the guy who said this un-Canadian:

“I want to say that I think there is a value in having every family and every individual make some individual contribution. I think it has psychological value. I think it keeps the public aware of the cost and gives the people a sense of personal responsibility.……there is a psychological value in people paying something for their cards……… We should have the constant realization that if those services are abused and costs get out of hand, then of course the cost of the medical care is bound to go up.“

That fellow? Why none other than the “Greatest Canadian” himself, Tommy Douglas.

Health care in Canada is at crisis. Patients are suffering terribly. One third of physicians are thinking of leaving the profession in then next two years, just when Canadians need them most.

A crisis demands you look at all options. The first step is to revisit the CHA.

“Health Care for All” Policies Will HURT Physicians and Patients

Recently, physicians leaders have been in the media promoting the right to primary care. I generally refer to this as a “Health care for All” policy, as it is reflective of one of the tenets of former Health Minister (and current Dean of Queens Medical School) Dr Jane Philpott’s new book. Dr. Tara Kiran has also promoted the same through her “Our Care” project. These proposals seek to guarantee a family physician for everyone in a certain geographic area, just like children in an area are guaranteed a school.

While these policies sound nice (for reasons I’ll go over later) – they are doomed to failure. To understand why, let’s look at just two other situations – The Barer Stoddart Report and the move toward safe injection sites and decriminalization of illicit drugs. I appreciate my three loyal readers (I actually gained one!) might be wondering what this has to do with primary care. Bear with me, it hopefully will make sense later.

The Barer-Stoddart report is infamous in Ontario medical politics. It’s the report that is widely viewed as suggesting Ontario had too many (!) doctors in 1990s and led to the reduction of the number of medical school positions. However, what is not commonly appreciated is that was the last recommendation in the report. The first recommendations were to support the current supply of physicians by adding a large number of allied health professionals and making many health systems modifications. If and only if all those recommendations were carried out, then medical school enrolments could be cut. The bureaucrats and politicians looked at that, went through the report, decided that all the other recommendations were too expensive or complicated, and just cut med school enrolment. “The report told us to.”

Similarly, when it comes to drug decriminalization, the idea is best implemented in Portugal. The top line read is “addiction rates fall 40%” after Portugal introduced this policy. BUT a deep dive shows that before decriminalizing drugs, Portugal made a number of legislative changes, ensured that the court systems were educated, ensured that addiction therapy and counselling was available for addicts, and then implemented the decriminalization policy.

In Canada, our bureaucrats looked at Portugal, and figured all the rest of the changes were too complicated. But hey, maybe just decriminalizing will be enough without the other stuff! The result is a disaster when it comes to safe injection sites and an obviously failed policy.

So let’s look at the right to primary care that Drs. Philpott/Kiran and others propose. At their heart, ideas like this are reasonable, make sense and will help improve health care for the general population (I bet you didn’t think I’d say that did you?). They speak to a fairness that just isn’t apparent in the current system. One of the reasons that people pay taxes is so that those taxes can fund health care. How is it fair then, that one taxpayer has a family doctor, and another does not? How is it fair that one quarter of Ontarians can access team based health care, but the rest cannot? And so on.

Well then, what’s the problem and why do I think “Health Care for All” type policies will hurt physicians and patients?

Because I simply don’t believe that our politicians/health care bureaucrats will be able to implement all the work necessary to support this, prior to implementing this change.

Look at the other items I mentioned. Do you really think that the bureaucrats who mucked up so badly will get it right this time? Do you really believe that those bureaucrats are going to provide the admin support, the additional allied health workers, the organizational and structural backing first, before just writing out “everyone gets a family doctor” in the funding contracts?

Not a chance. Zilch. Zero. They will look at the need to invest in teams and say “too expensive.” They will look at the need to add administrative support first and decide that’s not feasible. They will look at the need to build healthcare infrastructure and be confused as to how to do it properly. They will be aghast when they come to the part that says for teams to be successful, they must be physician led. “But I’m the aide to the executive secretary of the assistant to the assistant deputy minister’s attache for the chief regional officer of the Primary Care Branch of the Ministry! I should run the team!”

Then they will come to the part of the policy that says ensure every patient in a geographic area has a family doctor. And those bureaucrats will say “oh that’s easy to do with just some changes and regulation”. And they’ll do just that without any of structural changes needed.

I did some rough calculations for my neck of the woods. Each family doctor in my area would have to take on 200 unattached patients to make this work. The problem is we’re all working at 110% capacity right now. There’s no way we can do that.

So, once “health care for all” comes in what’s going to happen? Physicians will stop doing comprehensive family medicine, myself included. You can only ask a person to work so hard before they get frustrated and quit. Which increases the burden on the remaining physicians, which will cause more of them to quit. And so on.

What’s worse, presenting these policies now deflects from the main issue. Basically, family medicine is no longer economically feasible. Without some immediate stabilization funding, family medicine will collapse. By the time people figure out how to implement “Health Care for All” and reduce admin burden, you won’t have any family physicians left. By introducing the “right to primary care” now, the laser like focus on just what is needed to make family practice economically viable is lost and this hurts everyone, patients included.

I genuinely have a great deal of respect for Dr. Kiran and Dr. Philpott in particular (she was the one who sacrificed her political career to warn us that our Prime Minister was an effete, vacuous ninny who for the sake of all Canadians needs to go back and teach drama classes). But as well intentioned and well thought out as “Health Care for All” may be, now is not the time to talk about it.

Economically stabilize and support family medicine first. Then let’s talk.