Family Medicine – justanoldcountrydoctor

FHO+: The Good, The Bad, and the Reality on the Ground

My thanks to Dr. Wael Guirguis, (pictured inset) who had a superb post on LinkedIN that he’s kindly allowed me to reproduce as a guest blog. Dr. Guirguis got his MD in Egypt in 2003 and has been practicing in Canada since 2011. He’s the lead physician for the Fairway FHO and provides comprehensive care for patients at the Danton Medical Centres. A thought provoking read which I hope you’ll enjoy.

Over the past couple of months, Family physicians across Ontario have started experiencing the reality of the new FHO+ model in day-to-day practice.The goals behind the reform are understandable.

Improve access. Support continuity of care. Encourage after-hours coverage. Create more accountability in primary care.

These are important goals, and family physicians should absolutely be part of improving the system. Some aspects of FHO+ deserve recognition. Organized after-hours coverage matters. Continuity of care matters. Accountability matters. But as implementation unfolds, many front-line physicians are beginning to identify operational consequences that may not have been fully appreciated during policy design.

The Efficiency Problem

One of the biggest concerns is the relationship between productivity and compensation efficiency. Under FHO+, physicians are now heavily constrained by hourly and monthly thresholds tied to direct patient care time. In practical terms, physicians can work harder, see more patients, and still experience a significant reduction in compensation efficiency. The unintended consequence is that the model may discourage efficiency during regular clinic hours.

A physician who develops efficient workflows, uses technology effectively, and safely improves patient throughput may actually feel penalized for doing so. That creates a concerning signal within primary care. Healthcare systems should reward:

safe patient access
continuity
quality
responsible innovation
sustainability
burnout prevention

Not unintentionally encourage physicians to slow down to remain within operational thresholds.

The Hidden Mental Burden

One of the least discussed consequences of FHO+ is the cognitive burden it creates for physicians throughout the day. Doctors are now not only thinking about patient care, they are also continuously tracking:

direct care hours
monthly hour accumulation
reimbursement thresholds
after-hours eligibility
continuity metrics
outside-use implications
whether additional work will still be compensated fairly

That constant background calculation creates mental fatigue. Family physicians already operate in an environment of nonstop decision-making: clinical care, inbox management, staffing issues, documentation, urgent requests, abnormal results, hospital follow-ups, and administrative work. Adding another layer of continuous operational tracking changes the psychology of practice itself. Instead of focusing entirely on patient care and clinic efficiency, physicians may begin constantly asking themselves:

“Am I crossing another threshold?” That is not a healthy foundation for sustainable primary care.

The Bigger Problem: Complexity Itself

This discussion is larger than FHO+ alone, It reflects a broader pattern in healthcare reform. With each reform cycle, the Schedule of Benefits seems to become increasingly complex rather than simpler.

New rules. New modifiers. New exceptions. New thresholds. New formulas. New tracking requirements. Yet very rarely do reforms focus on reducing front-line operational complexity for physicians. And complexity itself has consequences, It increases cognitive load, administrative dependency, billing anxiety, operational inefficiency, and eventually burnout. Complex healthcare systems may be unavoidable. But complex systems still require simple front-line workflows. That principle is often overlooked.

Continuity of Care Should Be Managed by the System, Not Punitive Billing Rules

Continuity of care matters. Family physicians understand that better continuity leads to better long-term outcomes, fewer fragmented records, reduced duplication, and safer patient care. But enforcing continuity through increasingly complicated physician payment penalties is not the right approach. A simpler and more effective solution already exists. If the Ministry of Health wants to strengthen continuity of care within capitation models, the responsibility should sit primarily with the system itself, not through constant billing complexity imposed on physicians.

For example: If a rostered patient repeatedly seeks care outside their enrolled medical home beyond a defined threshold, the Ministry could automatically review or remove the patient from the roster. The patient would be notified directly by the Ministry of Health not by the physician. This creates clear accountability while avoiding unnecessary tension between doctors and patients. Most importantly, it removes one of the major hidden burdens currently placed on family physicians: constantly monitoring continuity metrics, outside use calculations, and roster penalties while simultaneously trying to run busy clinics.

Continuity of care should be encouraged through smart system design and patient accountability not by forcing physicians to navigate increasingly complicated billing formulas and penalties. Doctors should focus on delivering care. The healthcare system should focus on managing the system.

The Human Side Nobody Talks About

Most family physicians are not trying to maximize billing. They are trying to:

keep clinics financially sustainable
reduce patient wait times
manage inbox overload
supervise staff
complete documentation
respond to urgent patient needs
avoid burnout

When systems unintentionally penalize high-functioning clinics for being efficient, morale suffers quickly. And eventually, patients feel the impact.

A Better Path Forward

Primary care reform is necessary. But reforms work best when governments collaborate closely with front-line physicians who actually operate clinics every day. The goal should not simply be measuring physician hours. The goal should be:

maximizing safe patient access
improving continuity
reducing unnecessary administrative burden
supporting sustainable family medicine
encouraging innovation and operational efficiency
protecting physicians from burnout

Ontario has extraordinary family physicians who want the system to succeed. The question is whether the system is being designed in a way that allows them to succeed too.

The Shrinkflation of Family Medicine

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

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

It deserves to be examined plainly.

What Family Medicine Was Designed to Do

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

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

What Has Changed Since the Pandemic

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

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

The Economics of Comprehensive Care

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

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

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

The Systemic Consequences

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

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

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

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

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

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

The Path Back

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

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

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

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

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

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

Dr. Julie Wilson, MD, CCFP, FCFP

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.

About Dr. Elaine Ma: We’ve Been Here Before, and Didn’t Fix It…

My thanks to Dr. Mike Goodwin (pictured inset) for guest blogging for me today. Dr. Goodwin is a retired family physician who held numerous roles in medical politics including (but not limited to) being a member of the Coalition of Family Physicians, a member of the Section of General and Family Practice Executive and an OMA Board Director. He brings a historical perspective regarding medical audits to this blog, and I am grateful for his contribution.

I admire our courageous young colleague Dr. Elaine Ma, she of the seemingly never-ending OHIP billing/auditing dispute with a media savvy beyond her years. Dr. Ma’s impeccable sense of public health propriety during COVID has earned her a growing band of supporters. It has hopefully gained her financial support from both the Ontario Medical Association (OMA) and the Canadian Medical Protective Association.

But what Dr. Ma and younger colleagues may not appreciate is that OHIP’s abuse of doctors, utilizing its antiquated billing payment and auditing processes, has been ongoing for a long time. Between the years 2000 through 2005, a hundred odd doctors every year in Ontario were being subjected to the same sort of unfair retroactive audit, which Dr. Ma is currently experiencing.

Back then, just like now, we had a Schedule of Benefits (SOB) badly in need of an update, a pettifogging bureaucracy unwilling to interpret said schedule with any modicum of common sense… vague auditing rules which conferred the burden of proof upon the accused rather than the province, and the same one-sided authority to claw back payments or garnish future accounts receivable. OHIP even had computers back then, almost certainly the same ancient models they still use today (which they claim can’t possibly be configured to pay doctors in a timely manner after the award of binding arbitrated pay increases).

Administrative abuse of the profession in the very early aughts was rampant. OHIP had enlisted the help of the CPSO, because the College had administrative and regulatory authority, beyond criminal law, over all physicians pertaining to the practice of medicine. Actual auditing and enforcement of decisions was done by an entity of the College called the Medical Review Committee (MRC). It apparently escaped everyone’s notice at the time, and still today, that medical billing to OHIP was and is based upon definitions contained within an official MOH document called the OHIP SOB. The OHIP SOB is, at least in theory, derived from agreements negotiated between the province and the OMA, not the College! One might argue, logically, that any dispute concerning rules and definitions documented within the SOB should always be addressed in the first instance between the Ministry and the OMA.

At any rate, anger and despair over the medical billing and auditing system in that far away time came to a head when a gentle Welland paediatrician, Dr. Tony Hsu, committed suicide. I suspect that Tony felt he had lost face by going public with his own particular auditing horror story. The concept of “face” is important in the Chinese diaspora, and Tony, who worked a one in three (sometimes one in two) on call rota at the Welland County General Hospital (without any on-call stipends in those days), in addition to maintaining a community practice, was forced to repay $96,000. He had to take that out of his retirement savings.

Public and political outrage at Tony’s death, particularly in the Niagara region, was immediate and intense. Then Health Minister George Smitherman was pressed to call for a “public inquiry” into medical billing and auditing. By happy accident, retired Supreme Court Justice Peter Cory was available and appointed to the task. Those of us acquainted with Mr. Cory’s reputation silently cheered.

Former Health Minister George Smitherman

And when Cory’s very comprehensive report was published, nine months later in April 2005, the indecent OHIP billing auditing system finally came to an end.

Or so we thought!

In his report “Study, Conclusions, and Recommendations Into Medical Audit Practice in Ontario,” Mr. Cory did not mince words. “The medical audit system in Ontario has had a debilitating, and in some cases, devastating effect on physicians and their families,” he said. “It has had a negative effect on the delivery of services, and has undermined Ontario’s attractiveness as a place to practice.”

Also, and very pointedly, the honourable Cory recommended the appointment of a new independent audit board, while declining to take up an offer from the College to continue auditing medical billings as they had been doing prior to his inquiry. In all, Justice Cory made 118 separate recommendations, and I reproduce only the first four, below, since they were (possibly) the most important:

Jurisdiction and structure: the responsibility for conducting the audits of physicians fee claims should be conferred on a new and independent board. See recommendations (1) to (4).
Purpose of the audit process: The audit process must be employed only for the purpose of determining the appropriateness of physician fee claims. The audit system itself must be accountable. A biennial stakeholders forum should be established to receive reports on the operation of the new audit process and to receive and consider proposals for its improvement. See recommendations (5) to (7).
A new emphasis on assisting physicians to comply with billing requirements: The primary goals of the new audit system should be (1) education to facilitate compliance with billing requirements, and (2) identification and elimination of false, fraudulent, and egregiously erroneous billing in a fair and effective manner. See recommendations (8) to (9).
Schedule of benefits: The schedule of benefits must be revised and adapted. It must also be interpreted flexibly so that a physician is not deprived of payment for a service that is medically appropriate and that complies substantially with the requirements of the fee code. See recommendations (10) to (14).

(NB – as the report cannot be found online, Dr. Goodwin used his own personal copy of the report as a reference – Old Country Doctor)

In the wake of the Cory report, Minister Smitherman ceased audits immediately and promised changes. But no one at the MOH or College lost a job. And ministries or bureaucracies (like the CPSO) are resistant to any change from age-old ways of doing things. That’s particularly true when change might reduce influence, or even more important, authority and funding.

So when I joined the OMA board in 2005 as a newbie director, the ministry was already flooding the zone, as they did, with multiple new issues demanding our attention. Promises made didn’t materialize, and almost none of Mr. Cory’s recommendations, especially the most important, to “confer responsibility for conducting billing audits on a new and independent board,” were implemented. Months became years, and “the Cory report” gradually disappeared from sight, consigned to death by inattention. You can’t find it anywhere today, even with a Google search. Not even on the OMA website: for shame!

I’m convinced that if a significant part of Mr. Cory’s report had been adopted in 2005, much of the shoddy bureaucratic shenanigans from OHIP would have been fixed (including, maybe even their ancient computers). Dr. Elaine Ma would not be undergoing her current marathon persecution. Nor would we be seeing those cases where OHIP seems to let grifters get away with corrupt billing over multiple years before it (OHIP) picks up on the scam. How does that work, by the way?

It’s not every day you get support from a retired Supreme Court justice at your back… particularly such clear, sensible, workable recommendations from arguably the most influential liberal justice of the post-constitutional era in Canada. Peter Cory was famous for his kindness, and for his defence of human dignity at every opportunity…though he definitely had an iron fist in a velvet glove when the need arose. For anyone (like me) who ever had the good fortune to meet him, he was just an unforgettably decent man.

Memo to the OMA:

If you really want to fix this auditing problem, something which I and my colleagues failed to do, Peter Cory’s report from 2005 would still be a great place to start. Dr. Elaine Ma has provided you a good crisis: let’s not waste it.

The Appalling Treatment of Dr. Elaine Ma Is Hurting Health Care in Ontario

I’ve written about the horrific treatment that Dr. Elaine Ma has been subjected to by the bureaucrats at Ontario Health before. The situation is so ridiculous that it could be a story presented at the Theatre of the Absurd.

What happened?

Dr. Ma is a family physician from the Kingston area. During the Covid pandemic she realizes the need to immunize as many people as possible to protect the community. She organizes a number of outdoor mass vaccination clinics, which resulted in Kingston being one of the most heavily vaccinated areas of the province. For her efforts, she wins the very well deserved the praise of many, and an award from the Ontario College of Family Physicians.

There are two billing codes for providing Covid vaccinations. One for physicians who work in a vaccination clinic that someone else set up (e.g. public health). Another for those who set up the clinics themselves, and paid for staff/heating for outdoors/tents/internet etc. Since she paid for all of that, Dr. Ma bills the second code.

Fast forward a couple of years and the callous and unthinking bureaucrats at OHIP decide that she has billed the wrong code and demand she pay back $600,000. I won’t restate all the steps she went through to fight this. I will state that the reasons for them wanting the money paid back varied between the clinic being outdoors instead of indoors, medical students being involved and so on. But eventually the case winds up at Divisional Court.

On Dec 16, the court handed down a ruling supporting Dr. Ma. What I had failed to realize before is that the Ontario Health bureaucrats main argument appears to be that there were no extenuating circumstances during the time of the Vaccine Clinics that Dr. Ma set up. Yes, you read that correctly. The whole country was in the midst of a (hopefully) once in a lifetime pandemic. Canada was effectively shut down for business. People were not allowed to visit loved ones in hospital or nursing homes. Travel had ground to a halt. But, in the minds of the soulless and spiteful bureaucrats, none of this constituted “extenuating circumstances”.

Thankfully, Divisional Court Justices Matheson, Varpio and O’Brien were having none of this nonsense. They clearly stated the decision by bureaucrats that there were no extenuating circumstances was “unreasonable.” (I would have, and will, call that decision much worse things). The Justices pointed out the obvious. There was clearly a public health crisis at the time, and that many leaders, including politicians were calling on physicians to get the vaccinations done.

More importantly they stated something the OMA’s legal team really needs to take a deep dive into:

…”that the wording of section 17.5 does not limit relief to unpaid claims; it only requires the presence of extenuating circumstances. Since OHIP typically pays claims first and reviews them later, a restriction on unpaid claims would effectively nullify the provision. The court called this interpretation unreasonable.”

Currently OHIP pays physicians whenever they bill. Later, OHIP decides if it was reasonable or not, and if OHIP feels the situation is unreasonable, they demand the money back. The justices seem to be saying this process is not fair. Which has implications far beyond this one case. Obviously, this would not apply to clear cut cases of fraud. It is a much much needed kick to the slow, incompetent, and spiteful OHIP review process. I can’t possibly understand the potential future implications for this – but I suspect there will be many.

Finally, the justices let their displeasure be known by ordering OHIP to pay Dr. Ma $10,000 in court costs. This strongly suggests to me that they were peeved at the OHIP bureaucrats for taking it this far, and really didn’t think it should have gone there.

How is this hurting health care now?

Ontario is currently seeing an unprecedented surge in flu cases. Flu season has come early. The current variant appears to be extremely strong. It is circulating at “sky high” levels among young people. Three children (at least) have died. Hospitals have declared outbreaks and wards are closed. Visitation has stopped.

Sign on the door to the Medical Ward of my Hospital

You know what would really help? If only some people would come up with some innovative ways of getting their communities vaccinated against the flu. Yes this year’s flu shot is a bit of mismatch for the current strain, but it still provides some protection and keeps you from getting really ill.

Or how about an innovative idea for where to safely look after patients like was done during the Covid crisis. My friend Dr. Bryan Recoskie set up a unique 18 bed ward in our local Legion, to look after non-covid patients while the hospital wards were shut with covid positive patients.

And yet, I don’t see any of that happening right now. Don’t get me wrong, doctors continue to go to work. We continue to care for the sick and continue to comfort those in need. We continue to do our best in these trying circumstances.

But I can’t find any evidence (please correct me if I’m wrong) – of where people are doing unique out of the box things to try and mitigate the currently unfolding nightmare. Given the potential exists that IF you try something unique, you may wind up undergoing two years of pure hell by bitter, ruthless and depraved bureaucrats – can you blame people for not trying?

To quote a good friend of mine, “The damage has been done. Nobody is going to stick their necks out now.”

What should happen (but won’t):

First, under no circumstances should OHIP appeal the decision from Divisional Court. The mercilessly inhumane bureaucrats need back down. Second, Health Minister Sylvia Jones needs to do what she should have done a year ago – and direct the bureaucrats not to seek any recovery at all from Dr. Ma. It’s just the right and decent thing to do.

Finally, it would really help if Minister Jones issued a formal apology to Dr. Ma for how she has been treated by the bureaucrats. It’s not just the OHIP bureaucrats. Jones’ own communications director, Hannah Jensen claimed Dr. Ma had “pocketed the funds“, a statement that clearly suggested malfeasance.

Do that, and maybe, just maybe, physicians would once again feel comfortable coming up with out of the box solutions for crises that are occurring.

Maybe.

Only 25% of members said fees are worth it in 2022. The CFPC hasn’t asked since

My thanks once again to Dr. Greg Dubord (pictured inset) agreeing to post this on my site, (and doing most of the writing). Dr. Dubord is the founder of CBT Canada (www.cbt.ca) and a leading advocate of medical CBT. He completed his training under CBT’s Founder Dr. Aaron T. Beck and was the first Canadian Fellow of the Beck Institute. He has provided medical CBT workshops at many Family Medicine Forums. This blog originally appeared in the Medical Post.

Only 25% of CFPC members believe their fees are worth it.

That devastating verdict emerged from the College of Family Physicians of Canada’s own 2022 member satisfaction survey—unfortunately the last one they’ve published.

When three-quarters of your captive membership says they’re not getting value for money, you’d expect urgent reform and rigorous tracking of improvement. Instead, the CFPC did something remarkable: they stopped asking.

The survey, published by the CFPC’s own CEO Dr. Francine Lemire and executive director Eric Mang in Canadian Family Physician, contained another brutal statistic: Only 39% felt the CFPC was “listening to the opinions and needs of members.” More than 3,000 respondents delivered this indictment of their own professional organization—then watched the CFPC go silent on member satisfaction for three straight years.

Twenty-five percent is not a satisfaction score—it’s a vote of no confidence. In any other context, that number would trigger not just immediate crisis response, but deep organizational commitment to demonstrable change. A product with 25% customer satisfaction gets pulled from shelves. A restaurant with 25% customer approval likely ends up closing. A professional association with 25% approval hemorrhages members unless, of course, membership is mandatory.

When three-quarters of your customers—especially mandatory, captive customers who can’t leave—believe they’re not getting value for money, that’s not a minor problem requiring tweaks. That’s an existential crisis for the CFPC demanding comprehensive reform and continuous monitoring to track whether changes are working. Management guru Peter Drucker put it bluntly: “You can’t manage what you don’t measure.”

The CFPC instead chose this two-part treatment:

stop measuring whether members think fees are worth it; and
ask for more money. No survey in 2023—but a 7% dues increase proposal that 83.86% rejected. No survey in 2024. No survey in 2025—but another fee increase attempt, also rejected.

Imagine asking your boss for a raise while refusing to do your performance review. That’s essentially what the CFPC keeps doing.

This pattern becomes more revealing when you consider the CFPC’s demonstrated survey capabilities. During 2020 to 2022, the College conducted and published multiple iterations of COVID-19 impact surveys—2020, 2021 and June 2022—each with detailed, comprehensive reports and full datasets publicly available. These surveys served important functions, documenting physician challenges and supporting advocacy with government and policymakers.

The CFPC clearly has the infrastructure and expertise for longitudinal research. Yet member satisfaction—the metric showing only 25% believe fees are worth it—gets measured once, summarized briefly, then abandoned. When surveys document external challenges, members receive full transparency and accountability.

Although the CFPC’s 25% rating was horrible, it’s almost certainly a lot worse now. That survey was conducted before the PGY-3 controversy, and before the governance crisis that prompted our ten reform motions.

This brings us to one of our ten governance reforms for the 2026 AGM: Member satisfaction survey transparency. This motion would require annual CFPC member satisfaction surveys with published methodology, response rates and complete results (not curated summaries).

Healthy organizations that genuinely serve their members practice what the Japanese call kaizen—continuous improvement through regular measurement. When Toyota faced acceleration problems, they didn’t just stonewall—they analyzed data, implemented fixes, and reported progress transparently to regulators.

The CFPC has a rather unique accountability problem: membership is mandatory for most, and the dissatisfied can’t leave. Captive dues payers are left to brux in high frustration while wondering if anything will change. Economists call this “moral hazard.” When an organization is insulated from the consequences of poor performance, accountability diminishes. This structural accountability gap—and potential solutions—will be explored in detail in upcoming articles in this series.

Our transparency motion is straightforward: the CFPC will be required to measure member satisfaction annually, publish complete results and let members judge whether their mandatory fees produce acceptable value. If the CFPC is delivering excellence, the data will prove it, and they will have every right to feel proud of it. However, if they’re failing, members deserve to know—with implications for the legitimacy of dues.

Our earnest hope is that this upcoming year we’ll see a highly member-responsive CFPC make genuine changes that demonstrably impact member satisfaction, and they’ll proudly make that public.

Open Letter to Premier Francois Legault

The Honourable François Legault, M.L.A.
Premier of the Province of Quebec
Édifice Honoré-Mercier, 3e étage
835, boul. René-Lévesque Est
Quebec QC G1A 1B4

Dear Premier Legault,

You probably don’t know who I am, and are wondering what propelled me to write an open letter to you. I decided to write to you after doing a radio interview with Greg Brady on his show Toronto Today. During the interview, Greg asked me to comment on the strife between you and the physicians in your province. He brought up the fact that in the past couple of weeks, 263 physicians from Quebec have applied for a licence to practice medicine in Ontario.

Now, I certainly don’t pretend to be an expert in how the health system functions in Quebec. Nor would I assume to know all of the intricacies of Bill 2, the legislation that you’ve introduced that has your physicians so angry. And no, I’ll say right off the bat, I don’t know what negotiations between you and the representative bodies of physicians in Quebec (FMSQ and FMOQ)have been like.

But I will tell you that my very first blog ever (in the Huffington Post) was an open letter to Ontario’s then health minister, Dr. Eric Hoskins. I wrote that blog because his government was talking unilateral actions against physicians (sound familiar?) In it, I warned Dr. Hoskins that acting in a unilateral manner would result in chaos for our health system:

“We cannot return to a system where there are three million or more people without a family doctor, or wait times to see specialists (already too long in my area) get prohibitively longer.”

I also warned of the political consequences of proceeding with unilateral actions and how this would hurt Liberals in the 2018 election. You perhaps know they were absolutely decimated in that election. While its true a large part of that defeat was because the feckless Premier Kathleen Wynne was so widely disliked, I maintain to this day the Liberals could at least have maintained official party status had they not botched health care so badly.

The reason I could make those statements in my blog with such absolute certainty, and have them proven right in the end was not because of any prescience on my part. It’s because I followed the advice of Santayana:

Look, I understand that some of the specifics of the policies and legislation that you are bringing in are different from what Dr. Hoskins tried to do. But at the end of the day, it amounts to you as a government saying that you know how to run healthcare. You don’t need advice or co-operation from doctors. You’re going to impose the changes you want.

I’d encourage you to go back and read the letter I wrote to Dr. Hoskins. I pointed out to him that he was repeating the mistakes (unilateral actions) of the Bob Rae NDP government in the 1990s. They destroyed health care by those actions and were wiped out in the 1995 election, never to see power again.

Take a look at the Jason Kenney PC government of 2019. The went to war with Alberta Medical Association in 2020. The only way they were able to salvage a victory in the next election after that, was to dump their leader, Jason Kenney. (It’s true unhappiness with how he handled the Covid pandemic played a role – but again, the point is there was no saving grace for him – if he had kept health care functioning…..)

Want more? Look at the actions of the Gordon Campbell British Columbia government. Between 2001-2002 they unilaterally tore up an arbitration agreement between the BC government and their doctors. Years of discord including a Charter Challenge (that the BC Government eventually lost), political strife, a strike vote by physicians and a vastly reduced majority followed. Eventually, given a failing health system caused by their own arrogance, the BC government had to come to an agreement with their doctors in 2002, and again in 2006 that restored binding arbitration and was viewed as extremely generous at the time.

As I pointed out to Dr. Hoskins the message is simple. Any government that takes on unilateral action will run the risk of losing doctors from that province. When that happens, the healthcare system suffers. When that happens patients suffer, wait times go up, care deteriorates. When that happens, people don’t blame the doctors, they blame the politicians.

In short, a government that imposes unilateral actions on physicians not only hurts the patients of their province, they always pays a political price. They always have to pay more in the long run than if they just worked fairly with their physicians in the first place.

Look, I don’t particularly care about you or your government. I could not care less whether you win or lose your next election. But I happen to care a lot about my physician colleagues and I know that they are very very angry (and rightfully so). I also care about the residents of Quebec, and I know that they are going to suffer a lot because of your actions. As of now, 28% of your population does not have a family doctor. Can you imagine what will happen if 263 leave? And do you really think any doctor with half a brain will actually come to Quebec when your government behaves like this?

Trust me on this one, if you don’t immediately reverse course, and start to work with your doctors – the harm done to your health system and the people you are supposed to serve will be enormous.

And if you don’t believe me – go read that quote from Santayana again.

Yours truly,

An Old Country Doctor

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

From Aloof Oligarchy to Professional Partner: Ten Motions for CFPC Reform

My thanks to Dr. Greg Dubord (pictured inset) for offering to co-authour this blog with me (and doing most of the work). His resume is too long to list but briefly Dr. Dubord is the founder of CBT Canada (www.cbt.ca) and a leading advocate of medical CBT. He completed his training under CBT’s Founder Dr. Aaron T. Beck and was the first Canadian Fellow of the Beck Institute. He has provided medical CBT workshops at many Family Medicine Forums.

In 1911, sociologist Robert Michels observed that most democratic organizations drift toward oligarchy. Given enough time, leaders insulate themselves from member accountability, prioritizing institutional preservation over their founding mandate—thereby betraying the founders’ intent. This is mission inversion: institutions founded to serve a profession end up prioritizing institutional interests over member needs. Michels called this the “Iron Law of Oligarchy,” predicting it would afflict even the most well-intentioned groups.

The iron law helps in understanding the behaviour of the College of Family Physicians of Canada (CFPC). When PGY-3 proposals drew overwhelming opposition at the annual meeting of members (AMM), when member motions achieving 94.78% support were later treated as non-binding, when members face detailed behavioral codes while the bylaws contain no published reciprocal standards, when automatic fee increases are proposed while “only 25% felt annual fees were worth the expense,” and when basic records requests under statutory rights receive no response addressing the request—these aren’t random frustrations. They’re textbook iron law symptoms of an organization completing its evolution from member-serving to self-serving. These observations reflect structural patterns common to many long-standing organizations and are not personal criticism of current leadership.

Which brings us to ten specific reforms. We are submitting ten governance motions for the November 2026 CFPC AMM. Each addresses structural gaps enabling oligarchic drift:

1. Board and committee minute transparency: CFPC bylaw is silent on minute access beyond requiring an annual report. This motion requires board and committee minutes be posted within 30 days of approval, with redactions only for privileged matters requiring board vote and logged publicly. This directly implements Motion 9a from the 2023 AGM, which passed with 95% support but appears unimplemented after two years.

2. Member portal for governance documents: Transparency requires accessibility. This motion creates a searchable digital portal for board minutes, committee records, policies with version history, redlined comparisons showing changes, and board voting records on contested matters. Modern technology makes this standard practice—if CFPC can build CFPCLearn, they can build member transparency.

3. Corporate records access policy: Section 21 of the Canada Not-for-profit Corporations Act (CNCA) grants members statutory rights to corporate records, but CFPC has no public policy operationalizing these rights. This motion establishes response timelines (acknowledgment within two business days, substantive response within 10 days), fee structures capped at reasonable copying costs and appeal mechanisms for denials.

4. Leadership code of conduct: CFPC leadership adopted a detailed member code of conduct in 2025 governing member behaviour toward staff. However, the bylaws contain zero reciprocal standards governing how leadership and staff interact with members. This motion creates a reciprocal leadership code requiring good faith, respect, courtesy, procedural fairness, and timeliness.

5. Member satisfaction survey transparency: CFPC’s January 2022 member satisfaction survey (as reporting in Canadian Family Physician) showed 25% satisfaction ratings. This survey is no longer publicly available on the CFPC website (but is archived at the National Library of Medicine at this link). No member surveys have been published since. This motion requires annual member satisfaction surveys with published methodology, response rates and complete results, ensuring members can assess whether their mandatory fees produce acceptable value.

6. Policy change documentation and impact analysis: Major policy changes significantly affecting member time burdens or costs currently proceed without documented consultation, needs assessment or alternatives analysis. This motion requires red-lined comparisons showing exactly what’s changing, impact analysis quantifying time and cost implications, documentation of alternatives considered and 90-day member consultation periods before implementation.

7. Member complaint tracking system: Members who raise governance concerns have no way to track whether complaints were received, reviewed or resolved. This motion establishes a tracking system (with anonymized quarterly summaries published) ensuring acknowledgment, investigation timelines, outcome notification and appeal rights. Transparency prevents complaints from disappearing into administrative black holes.

8. Electronic voting for annual meetings: The current annual meeting voting system restricts participation to those who can either attend in person or can navigate proxy procedures. The CFPC’s Lumi platform has supported secure, real-time electronic voting for member meetings for many years—yet CFPC has not consistently activated this functionality for member motions. This motion requires the permanent activation of electronic voting with real-time results display, expanding democratic participation using existing technology.

9. Member motion submission reform: CNCA Section 163 grants members statutory rights to submit motions 90-150 days before AGMs, but CFPC’s practice has stretched this to 140+ days—effectively disenfranchising members who observe problems after the extended deadline. This motion reduces the submission window to 60 days prior and creates emergency procedures for urgent matters arising after the cutoff, ensuring responsive member democracy.

10. Independent ombudsman with enforcement authority: The nine preceding motions mean nothing without enforcement. This motion establishes an ombudsman structurally independent from CFPC management, with authority to receive confidential complaints, investigate with full document access, issue binding recommendations, and report publicly on systemic patterns. Real accountability requires independent oversight—not self-policing by the same leadership structure these motions address.

These motions aren’t attacks—they’re the structural reforms many organizations need after 70 years of the iron law doing its mischief. A transparent, accountable CFPC could become the powerful advocate physicians need—championing educational excellence, defending professional autonomy, and ensuring Canadian families have access to well-supported, continuously learning family doctors. Details will follow here in the new year, and CFPC members will decide at the November 2026 AGM whether their college serves them—or itself.

Dear Specialist, You’re Awesome, but PLEASE STOP Calling Me A Provider

To my specialist colleagues,

In over 30 years of family practice, when I have been uncertain about a diagnosis you’ve been there. When I needed some advice on best treatments, you’ve been there. You’ve helped me and my patients, and you deserve many many thanks for that.

As with all things, there have been some ups and downs over the years (we really need to talk about the “go see your family doctor to have your staples/sutures removed” thing). Perhaps it’s because I work at a fairly small hospital with generally collegial colleagues, but I genuinely have positive feelings about our relationships and interactions.

There is, however, one thing that is starting to creep in to the vernacular that needs to be addressed before it goes too far. I’ve noticed it increasingly in reports from specialists. It seems to be particularly endemic in notes from the Emergency Medicine specialists and younger specialists.

It is the unfortunate tendency to use the highly offensive and derogatory term “provider” when referring to the family physicians. As in “the patient should follow up with their primary care provider.”

A couple of months ago, I attended the biennial menopause society update (yes, the same one where I discovered family physicians were giving up). At one of the small breakout groups, I happened to sit with a couple of my specialist colleagues. We were talking about how to handle various clinical scenarios, when I noticed both of them using this abhorrent term.

My personal observation (and I suspect I’ll get in trouble for saying this, but I’m going to say it anyway), was that the two of them looked like they weren’t even born when I entered medical school. It’s a credit to them just how involved they were in their hospital and community and patient advocacy at such a young age. As I understand it, they had been told that “primary care provider” was the appropriate new terminology to use.

I don’t really fault them. They were not aware of the negative connotations involved in that term or how objectionable it was. In fact, I credit both of them with being very open to change when I spoke to them about this.

What exactly is the problem you may be wondering? What’s the big deal about using the term provider?

Because language matters. Words matter. Definitions matter. Just as it is highly reprehensible and dehumanizing to use the word “client” when referring to a patient, it’s pretty offensive to use the term “provider” when referring to a family physician.

The term “physician” has meaning. It denotes a person who is entrusted to help you heal. It signifies a sacred bond between the healer and the sick that dates back to Hippocrates. It infers respect and dignity. It attributes professionalism, honour, and morality. It automatically speaks of the implicit trust that patients have.

The term provider, in health care, is egregious and appalling. To quote an excellent article by Jonathan Scarff:

“The word provider does not originate in the health care arena but from the world of commerce and contains no reference to professionalism or therapeutic relationships.”

He goes on to state:

“This terminology suggests that the clinician-patient relationship is a commercial transaction based on a market concept where patients are consumers to be serviced”

I could not agree with him more.

One of the things that the bureaucrats who run health care have long resented is the respect that physicians have from patients. Despite all of the attacks against physicians on social media, and even from official government types like RFK Jr in the States, physicians consistently continue to be shown to be among the most respected professionals out there (yes we are behind nurses). We receive these high rankings based on the proven belief that we are honest and adhere to ethical behaviours and high standards.

I firmly believe this is why bureaucrats have tried to bring in new terminology to describe physicians. They know that if we speak out against their brilliant ideas to “fix” health care, physicians will inherently get more trust than bureaucrats. I’ve seen the resentment of physicians first hand at a bunch of bilateral meetings between the OMA and the Ministry of Health. Trust me, it’s there, both implicitly and in some cases, very explicitly.

So the bureaucrats, under the guise of “inclusivity” or “patient centredness” or some such thing, are now introducing the term “provider” to diminish the significance of our roles. Their goal is to curtail our value in the eyes of the public, so when we call out their (many) mistakes, there will not be implicit trust in what we say. Think about it, which sentence below has more impact:

“Ontario’s providers speak out against government’s health proposal “

“Ontario’s physicians speak out against government’s health proposal”

Get the point? I beseech my specialist colleagues to not fall into this trap. Being a physician (as you know) is a sacred responsibility that all of us take seriously. We routinely make life altering suggestions to patients, and have a strong bond with them. Our role in their lives is not a commercial transaction. We do not treat patients as consumers who need to be managed. As the Section of General and Family Practice points out:

This term (provider) devalues the training, expertise, and vital role we play as physicians in the healthcare system. Family physicians are not providers; they are physicians.

So I ask you my specialist colleagues, the next time you write an Emergency Department note, or a consult note, be mindful of what you write. Recognize and respect the value of the person you are sending it to. Ignore the bureaucrats self serving machinations when they try to change the terminology.

Tell the patient to follow up with their FAMILY PHYSICIAN. (Except for the staple/suture removal – you can do that yourself).

Yours truly,

An Old Country Doctor