Health – justanoldcountrydoctor

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

Use AI NOW to Reduce Bureaucratic Bloat in Health Care

On the heels of my last blog on the Auditor General’s report on AI systems in Ontario, I was asked “how then can AI help in health care?” Certainly policy makers often talk a LOT about how AI can help. Better diagnoses! Faster assessments! Better prediction of which patient is more likely to “crash”! Reduced admin time with the use of AI Scribes! Etc.

These are all valid uses for AI technology. I use an AI scribe myself (following the principle of “trust but verify”in signing off on the notes). I access some evidence based AI software to help me with challenging cases. I always have the final word on what to do next of course, but I would be lying if I said that the tools didn’t help me look after my patients.

However, in a health care system as byzantine as the one in Ontario, there is one area where AI can help almost immediately that is not talked about nearly enough. Given the topic, I get why the many government health care planners/bureaucrats/managers don’t mention this. I’m talking of course, about reducing the number of bureaucrats in health care in Ontario.

I’ve talked about Ontario’s health care system being over bureaucratized many times in the past. But there’s never been a better opportunity to meaningfully cut the bloat. It would be impossible for me to search the entire Ontario government data base to find out how many bureaucrats we have. So………I used an AI search on ChatGPT and Claude AI to review how many managers/bureaucrats we have across all government funded health care agencies in Ontario. (I will put the prompt at the end of the blog for those interested).

Both searches suggested the total size of the health care workforce in Ontario was about 500,000 people. Of that, astounding 90,000-130,000 were non-clinical employees (mostly administrative/support staff). The actual management/bureaucratic layer varied between 25,000-45,000. A precise number was difficult to define, because, in the words of ChatGPT:

“……Ontario’s healthcare system is fragmented across hundreds of entities with inconsistent titles and reporting structures.”

However, given all of that, I think Claude’s estimate of having 85,000 admin/management personnel across all Ontario Health care agencies is defensible. Heck, it’s lower than ChatGPTs 90,000 – 130,000. Claude AI further broke this down and suggested 52,000 of these were in Ontario’s 154 hospitals.

Can AI replace some of these jobs? Replace is probably not the right phrase. There can certainly be a consolidation of the actual tasks required from different jobs, and AI can do those tasks much more efficiently and accurately.

For example, AI can, as of today, help with information movement, repetitive analysis, scheduling, policy retrieval, document generation, compliance monitoring, coordination, coding, and referrals to name but a few examples. All of these tasks are currently being performed by bureaucrats, and it’s virtually certain that there is tremendous duplication in the work being done. There is plenty of software than can do these tasks right now (LeanTaas, Qventus, Nuance DAX to name a few). Yes they are mostly American, but surely can be modified to meet Canadian needs.

The cost savings from reducing the number of bureaucrats can be significant immediately, and frankly enormous as AI continues to evolve over the next five years.

For a case study, let’s look at the University Health Network (I’m not picking on them for any other reason then they are huge!). They have approximately 24,500 employees of which an estimated 4,200 are Admin/management of some sort. Many of these positions are people on Ontario’s Sunshine List (i.e. they make over $100,000 a year). Reducing the number of these positions by 10% should be easily do-able if you have the right AI software.

Then the hospital would save the money right? Especially since Ontario’s hospitals are facing massive deficits? I would say no to that. I would instead say if UHN could cut their admin staff by 420 (which should easily be done), then maybe they could hire 210 clinical staff in return (nurses, physio, rehab, RT, Xray techs etc). Instead they just fired nurses. They would still have 210 fewer positions (so some money saved) but they would have 210 more people who would actually, you know – look at a patient. People who could provide compassionate, front line care and assessments to patients and be an invaluable part of the health care team.

Looking forward five years as AI software continues to evolve, I genuinely believe UHN should set its goal for reducing Admin/Management staff by half (at a minimum). This would allow them hire over a thousand (if not more) nurses to provide that front line care that is so essential to patients well being.

From a system wide perspective, the numbers would be even more dramatic. Currently, Ontario has 38% less inpatient staffing than the Canadian average. In order to just meet the average, about 34,000 more nurses need to be hired. The money for that has to come from somewhere, and I can think of no better place than reducing the admin staffing to find those funds.

I get why the bureaucrats have not talked about these uses for AI. Bureaucracy by its very nature is self perpetuating. But we are facing a serious fiscal calamity in health care with our aging population. While it’s nice to have tools that can help physicians like myself make better diagnoses and provide safer care, the blunt reality is we desperately need more front line staff. No matter how good the tool, it will never be a substitute for the compassion or a real human being providing care. The emotional wellness we experience from having real people look after us at the bedside cannot be understated. We need to adopt bureaucracy replacing AI tools now, and put the money saved in front of patients.

For those interested, this is the AI Prompt I used to get this data: “Review the number of bureaucrats/managers in the health care system in Ontario, Canada. Include ALL health care agencies that are government funded like hospitals, Ontario Health at Home, hospitals, community health centres and more – all government funded health care agencies. Get an approximate number of bureaucrats. Then show where AI can result in cuts to management/bureaucrat jobs right now, and in five years. Use the University Health Network in Toronto Canada as an example to show how many bureaucrat/management jobs could be trimmed, allowing them to funnel resources to hiring front line clinical personnel like nurses.”

Why Does The Old Country Doctor Hate Non-Physician OMA Board Members?

My last blog supported Dr. Paul Conte’s four motions that he is presenting at the upcoming Ontario Medical Association (OMA) Annual General Meeting (AGM). At the heart of the motions is a strong desire to course correct the governance changes at the OMA that have gone too far. The OMA is taking physicians authority to govern themselves away. Dr. Conte’s motions are excellent and I am very proud to be the seconder on all four of them.

However, the questions I keep getting asked about in that blog all pertain to the non-physician Board Directors. What exactly do I have against the non-physician Board Directors? Why do I not like them? Is there a grudge of some sort? Do I not recognize that they can contribute skills to the Board that most physicians just don’t have?

I guess that’s a symptom of some of the “spin” that is likely quietly being put out there about the motions and the blog. It’s easier to portray this as someone with an axe to grind rather than encouraging people to read the blog. My previous blog clearly stated that as the founding Chair of my local Family Health Team – I absolutely ensured and supported having non-physician members on our Board. They really provided some valuable guidance during the formative years of the FHT.

To be completely fair, a casual look at the resumes of the current three non-physician Board Directors, suggest some very impressive backgrounds. I’m obviously not on the Board, but on paper it sounds like they could contribute to many of the discussions there and bring different, but important perspectives.

Here’s the thing. The OMA Board ALWAYS has had experts in areas where physicians didn’t naturally have proficiency. The best example would be the negotiations counsel. They are experts in their field. They frequently present to the Board on how things are going with the negotiations process. At the Board level they inform the discussions and yes, they do try to persuade the Board to make certain decisions. All of which is fine as far as I’m concerned. That’s they way things should work and this applies not just to the negotiations counsel, but to a whole host of other experts who present at the Board.

But.

The one extremely important distinction is that at the end of the day, the negotiations counsel does not have a vote at the OMA Board (nor does any other external expert). They can persuade, cajole, entice and coax all they want. But the Board will ultimately have the final authority on whether to accept their recommendation (which is also as it should be). There were times when I was on the OMA Board where we did reject their advice (much to their chagrin).

This to me is the BIG difference. Currently, all three of the non-physician Board Members will not only provide advice based on their expertise, but will then vote, and thus, have a degree of authority and control over physicians.

The OMA Board is currently comprised of seven elected physician Board Directors, the OMA President, and the three non-physician Directors. The manner of how the three non-physician Directors have been chosen has evolved far away from what was intended. Initially there was an election for the position. Then last year we were told that one wasn’t needed for a non-physician Director if it was just a term renewal. Then this year a preferred candidate (preferred by whom??) was presented to the membership for “approval”.

These three NON-physicians, selected and recruited by the OMA as an organization, and NOT by the members, can effectively hold the balance of power in decisions that determine how the OMA advocates for physicians livelihoods. Having been on the Board and seeing diverse opinions amongst physicians, it is not at all hard for me to envision a scenario where 5 physicians oppose a staff recommendation, 3 are in favour, and then the 3 non-physicians would line up as a block to support a staff recommendation. In essence, despite a MAJORITY of physicians on the Board opposing something, it would still get passed.

This is just wrong, and was why I had advocated (and lost) from the start that non-physicians should not vote on the Board. Dr. Conte’s first two motions will correct this mistake.

What Dr. Conte’s Motions will NOT do

Just as important to realize is what Dr. Conte’s motions do NOT do. There is an argument to be made that having non-physicians on the Board on an ongoing level is a good thing. It will allow them to see the full dynamics of what goes on at the Board, and provide ongoing advice. Fair enough. The Georgian Bay FHT that I chaired certainly benefitted significantly from just that same concept. And there is nothing in Dr. Conte’s motions that will prevent the OMA from enacting a similar structure for their own Board.

At the Georgian Bay FHT, we called those Directors “ex-officio”. For some reason that I never understood that term was frowned upon by OMA Legal and the consultants that we hired during the governance transformation. Fine. Create a new position. Call it “Board Advisor”. Call it “Board Mentor”. Call it whatever you want. Have three of those positions available. Bind the candidates to Board confidentiality rules. Let them talk at the Board.

But do not let them vote.

Only physicians should have voting authority over matters at an organization whose main goal is to advance the interests of physicians. Only physicians inherently and intuitively understand the challenges faced by physicians. Yes, they should hear out external voices and weigh their opinions thoughtfully. But only they should be making decisions.

Since proxy voting is not allowed, I once again encourage all Ontario physicians to attend the OMA General Meeting and support Dr. Conte’s motions. You can attend virtually. Just click here to register, and let’s correct this mistake and bring voting authority at the OMA back where it belongs.

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.

Springing Forward Into Stupidity: How British Columbia Traded Science for Convenience

There’s a particular kind of modern arrogance required to look a room full of experts squarely in the eye and say: “Yes, yes, very interesting, but have you considered that people find it inconvenient?“

The Government of British Columbia has that arrogance. In a bold act of democratic self-determination, BC has moved to lock in permanent Daylight Saving Time (DST), essentially agreeing, as a society, to spend half the year pretending the sun rises an hour later than it actually does. No more fussing with clocks twice a year! No more groggy Monday mornings in November! Progress, at last!

In fairness, that decision is partially based on some good evidence that there is no need to change clocks twice a year. It does not reduce energy consumption as previously thought. It’s overall harmful to people’s health. BUT, in a trend that has been growing ever since the Covid Pandemic, there appears to be more and more ignoring of the actual science, in the name of convenience.

The scientific consensus on this is about as settled as it gets outside of climate change and vaccine safety. Study after study links permanent DST (as opposed to permanent Standard Time) to increased rates of depression, cardiovascular events, metabolic disruption, and a general dimming of the human spirit that no amount of “extra evening light” can compensate for. The medical community has been remarkably consistent: Standard Time is the one that actually aligns with human biology.

But BC picked the wrong one because the evenings feel nicer.

The 10,000 Lux Future We’re Sleepwalking Into

Here’s a prediction: within a decade, the market for bright light therapy lamps that blast 10,000 lux of artificial sunlight directly into your face, will quietly explode across British Columbia. Families will gather around them at breakfast, bathing in simulated dawn while the actual sun crawls reluctantly above the horizon sometime around 9 AM in December. It will become as mundane as having a coffee maker on the counter. A morning ritual for a society that engineered itself into needing one.

The irony is exquisite. They rejected a scientifically sound way of avoiding clock changes in the name of convenience. Now the next generation will be purchasing expensive medical devices to compensate for what their own circadian rhythms are desperately trying to tell them. The body, it turns out, doesn’t care what the clock says. It cares about the sun. When you spend six months of the year eating breakfast in the dark because a legislature decided that post work golden hours were more politically palatable than morning light, well your body will not be happy. Fatigue, depression, and the nagging sense that something is profoundly off will follow.

Where Were the Adults in the Room?

This, of course, raises the obvious question. Why didn’t anyone listen to the science? The honest answer is that our political culture has largely burned through its reserves of thoughtful, deliberate governance. This was exemplified by the Covid pandemic, when large swaths of people decided to reject the consensus that Covid was airborne , because they just didn’t like wearing masks. Political prices for following evidence that the general public didn’t like were paid. Politicians noticed.

Governments now seemingly use a cocktail of impulsiveness and ideology to make decisions. The boring, unglamorous work of actually reading the evidence, consulting experts, and acting accordingly is rejected. Into this vacuum has rushed something far less useful, the politics of framing. Instead of a straightforward public health question, “which system produces better health outcomes?”, we now have debate on what sells well with the general public. “But I like to golf at night!” “I want to sit on my patio till late!”

In that environment, experts might as well be speaking ancient Incan.

Governance today often seems to attract people operating at an almost feverish pitch. Rather than slow deliberate study of an issue, we have reactive, ideologically committed decisions allergic to nuance. Political culture now treats careful consideration as weakness and impulsiveness as authenticity. In that environment, it’s not surprising that a decision with clear scientific guidance instead got made on the basis of “vibes.”

How Did We Get Here?

That’s perhaps the most unsettling question of all. This is happening in all fields, not just public health. Urban planning, the aforementioned climate change, immigration policy, you name it. Experiences and facts say one thing. Politics, convenience, or ideology says another. Convenience wins. Our society absorbs the consequences.

This has been particularly fuelled by the rise of social media. At its worst, social media is well known to promote a culture of instant gratification. Which has profoundly impacted decision making. “Oh, I may get Covid tomorrow, but I don’t feel like wearing a mask today”. “Maybe I’ll be depressed in six months, but I want to golf tonight.” Etc.

The sad thing is that I think that deep down, most of us know this. We know that good governance requires scientific literacy, patience, and a willingness to accept inconvenient truths. We know that political culture has drifted away from those qualities. We know that we are, collectively, making ourselves worse off.

But we allow governments to do it again anyway.

The Clocks Are Wrong, and So Are We

There’s something almost poetic about using time itself as the canvas for this particular failure. Time is the one thing nobody can argue doesn’t affect them. Every person in British Columbia will experience the consequences of this decision in their own health, every dark winter morning, without exception. The evidence on that is pretty clear.

So go ahead and enjoy your long summer evenings. The light really is lovely. In November, when the alarm goes off and the sky outside is pitch black and your body is quietly staging a protest you can’t quite articulate, you might find yourself idly browsing light therapy lamps from online stores.

They work pretty well, actually. The science on that is solid.

Not that it’ll stop us from ignoring the experts next time.

Which Pharmacy Should You Use?

My patients are increasingly expressing unhappiness with their pharmacy. I’m not surprised. A recent study by JD Power showed a 10-point drop in customer satisfaction with brick and mortar pharmacies in 2024 alone. This is attributed to problems with systemic pressures, health human resources challenges, burnout amongst pharmacists, increasing drug shortages, and competition from online pharmacies. (N.B. I know this was a US survey but I believe the results would be similar in Canada as many of the pressures are the same).

In the past, I would tell patients to choose whichever pharmacy they want. The College of Physicians and Surgeons (CPSO) has some pretty strict rules around who/what I can recommend to patients. They are particularly stringent if there is even a perception of a conflict of interest. This would be why I never insist patients use the pharmacy in the medical centre I work at. Most doctors are very reluctant to run afoul of their licensing body (and I’m no exception).

However, the actual CPSO rules around prescribing drugs states:

“Respecting Patient Choice When Choosing a Pharmacy

13) Physicians must respect the patient’s choice of pharmacy.

14) Physicians must not attempt to influence the patient’s choice of pharmacy unless doing so is in the patient’s best interest and does not create a conflict of interest for the physician“

It seems like I can give some advice to patients. The short version: Stay away from “Big Box” pharmacies.

To understand why I give this advice, it’s important to know what I think of the role of pharmacists. This will surprise those who have been critical of my position on expansion of pharmacists scope of practice, but I actually truly believe that pharmacists are an essential part of a patients health care team. In my area, the smaller, independent pharmacists and their staff all know the patients well. They feel very comfortable messaging me with issues. I often get updates from them about changes to medications a specialist has made (often before I hear from the specialist!). And I’ve always gotten great advice on what alternatives are out there for medications that aren’t unavailable (an increasing problem these days).

The smaller pharmacies always flag drug interactions well (for me and the patient), know which patients react to which medications (even the over the counter ones), have provided great individualized advice on how to take medications. If for some reason, I’m doing something “off label” – they have been very supportive of that.

I (and more importantly, my patients) get that level of support, because the small pharmacies have consistent staff, who have, over time, built up great professional relationships with our mutual patients.

In contrast, dealing with some of the big box pharmacies is getting worse all the time. Some issues are just plain annoying. For example, I generally give a one year supply of medications for patients of mine who have stable medical conditions (three months for diabetic patients). I cannot tell you how many times I’ll get a message from one of the big box pharmacies (the red ones in our area are particularly bad) asking for a renewal three months later, even though we clearly have an electronic record that shows those pharmacies got, and downloaded, a one year prescription. Essentially, the pharmacy refuses to give needed medications to my patients, because of their error inputting my prescription.

It’s gotten so bad that my replies to the pharmacies have, over the past couple of years, gone from informing them of their error, to asking them to fix their internal process, to being rude. I haven’t quite hit unprofessional yet – though the pharmacists may beg to differ.

The big problem with big box pharmacies is that their staff are under pressure to first and foremost, generate profits for their chain. Patient care is actually secondary.

Shot of a mature pharmacist expressing stress while working in a pharmacy

It’s been reported (by pharmacists and staff) that corporate pressure from Shoppers Drug Mart (SDM) head offices led to their pharmacists doing unnecessary MedCheck reviews (and billing the taxpayer $75 per review). Shoppers head office of course denied the accusation and stated all MedChecks were necessary. Yet just one month later the CBC wrote “Shoppers Drug Mart says it doesn’t have medication review targets, but records show it does.“

The Toronto Star had an excellent report in November 2024 outlining just how much pressure corporate pharmacy staff were under. The report showed that:

pharmacists were asked to rush through minor assessments for their new expanded scope of practice in under 5 minutes (Kathleen Leach, a Hamilton pharmacist recognized that this would degrade care)
85% of pharmacists felt compelled to meet service quotas
there was strong concern about how the big chains had stripped back support staff from pharmacists, affecting care
It also outlined how patients were encouraged to have health assessments, even when not necessary, to try and increase revenue

This appears to be a Canada wide problem. The Ontario College of Pharmacists is exploring legal options to address allegations of corporate pressure. The BC College of Pharmacist 2024 report on Workplace Practice clearly showed that pharmacists in corporate and franchise settings experience more time pressure than independent pharmacists. The Toronto Start article above also indicated the Saskatchewan Pharmacy College recognized that focusing on business targets leads to errors and increased patient risks. In New Brunswick a pilot program for expanding pharmacy care fell apart, in large part because a virtual care company that SDM had heavily invested in (Maple), overwhelmed pharmacies with referrals.

Kristen Watt, who’s the current Vice-Chair of the Ontario Association of Pharmacists, wrote a blog in the Medical Post strongly supporting expanded scope of practice for pharmacists. While I have, and will continue to, fundamentally disagree on that, I was struck by her comment in that blog:

“Granted, the government roll-out video, shot in a noticeable big box pharmacy, didn’t help us. There are lots of cries of foul about billings going to shareholders of large corporations.”

It’s the kind of statement that clearly suggests some awareness of issues, without getting oneself into hot water. And certainly left me wanting to know more.

As I mentioned previously, a good pharmacist, and their staff, are integral parts of your health care team. They need to know you as a patient. They need to know some of your medical history. Over time they need to develop a professional relationship with you to provide you with the best advice. At the Big Box pharmacies, you are often getting different pharmacists and different staff every time you visit. Due to some of the corporate pressures above, there is a lot of turnover in those pharmacies.

At a small local pharmacy, you’ll get someone who knows you and says “Dr. Gandhi always gives a one year supply of medications, so I’m sure you’ve got refills.” Whereas at a big box, you’ll get some new staff who mindlessly will tell you “Ok, I’ll message him, you’ll have to come back in 48 hours” because the previous person didn’t enter data properly. Or you’ll get advice from different people at different times, which is NOT the same as having a consistent relationship with one pharmacist.

So my advice, to you dear reader. Find yourself a nice small pharmacy. Make sure they are independently owned. Ensure they have a consistent staff. Build a professional relationship with them. Your overall health deserves it.

Bonus: Red Flags When Searching for a Pharmacy:

Pharmacies that sell groceries.
Pharmacies in department stores or grocery stores.
Don’t fall for “points” schemes – not worth sacrificing good health advice for
They have different pharmacy staff every time you go

Artificial Intelligence is Naturally Stupid

Over the past two years, there has been an explosion in the amount of artificial intelligence (AI) software available, not just to healthcare professionals like myself, but to the general public. In many ways, AI has been quite helpful. I myself have been using AI scribe software in my office for close to a year now. The software listens to the conversation I have with my patient, and automatically generates a clinical note.

The AI scribe has been an enormous benefit to me. My medical notes are much better (also somewhat more detailed). I also save one hour of admin time a day (!) As an aside, this is actually a reason why the government should fund AI scribes for physicians. Under the new FHO+ model, we are paid an hourly rate for administrative work. Surely, saving five hours of physicians time a week is worth the government purchasing a scribe for physicians.

There are also some significant benefits for patient care. Another piece of AI software I use (that’s restricted to health care professionals) helps me with challenging cases. I am able to put the symptoms and test results into the software and it generates a list of potential diagnoses, and suggestions for next steps. It can also recommend treatments for rare conditions.

The general public can also benefit from AI. I recently had a little bit of trouble with my trusty 13-year-old SUV. I put the make and model of the SUV into a commercially available AI, put the symptoms in, and it generated a list of potential causes based on known issues about my SUV.

To be abundantly clear, I would never attempt to fix a car myself. Just as, with all due respect, patients should never, ever attempt to implement a treatment plan for themselves. What AI did do is give me the ability to have an intelligent conversation with the auto mechanic about the situation. And, dare I say it, allowed me to ensure that the mechanic was not trying to pull the wool over my eyes. (My vehicle is now fixed and running very smoothly.)

But along with the many benefits of AI software, there is, of course, potential for harm. This can range from ludicrous to dangerous.

The phenomenon of AI scribe hallucination is well known to physicians like myself. I have seen it in my own software, and it is the reason why I always read the note before I paste it into the patient’s chart. Admittedly, some of that is laughable :

Hopefully this is an AI hallucination of my skills, as opposed to the software’s judgement!

Additionally, the reality is that AI scribes can’t often put a patient’s lived experience (which is so important to building a relationship with a patient) into a note. My colleague Keith Thompson had a superb post on LinkedIn talking about how the AI scribe failed to recognize his personal interactions with an Indigenous patient, particularly with respect to understanding generational trauma.

Sadly, there have been cases where actual harm has been caused by AI. Grok is currently being investigated for generating sexualized images without consent, including those of minors. This causes severe emotional distress and real harm to the victims. There have also been concerns that AI chatbots are helping or suggesting people harm themselves. No one wants any of this stuff to happen, including the people who write AI software. But it has happened.

All of which reminds me of something that my computer science teacher in high school was fond of saying. (Note to my younger readers, and particularly my sons if they ever read my blog: Yes, there actually were computers when I was a teenager. I am not that prehistoric!)

How I’m viewed by my younger colleagues and my children!

The redoubtable Mr. Williams always implored:

“Do not forget, computers and software are actually very very stupid. They can do some things very fast, but they can only do what they are told.”

It’s a piece of wisdom that still holds true today.

With processing speeds almost infinitely faster than when I took computer science, computers can do multiple calculations very very fast. My desktop computer, which is a few generations old, can run 11 trillion operations a second. Heck my phone, which itself is 4 years old, could probably run a fleet of 1980s Space Shuttles. Speed is not the problem now.

The problem is that these computers and software still don’t actually have the ability to “think” outside of their parameters. They only do what they are programmed to do. If for example, they are programmed to answer questions asked by a user, but they are not given specific rules to avoid illegal answers, well, they will answer the questions directly. If the programming contains an inadvertent error (someone entered a “0” in the code, instead of a “1”), well, then the software will NOT be able to realize that was a mistake, and will carry out calculations based on the wrong code.

It is true that software is increasingly being taught to “look” for errors. But again, the software can only see the errors it is programmed to look for. It can’t find inadvertent errors and it can’t “think outside of the box.” They are, for lack of better wording, too stupid to do so.

All of which is my fancy and longish way of saying that while these new tools are great, at the end of the day they simply cannot replace the human experience. Just as the software couldn’t recognize the generational trauma of an Indigenous patient, there is a lack of “gut instinct” present. That feeling you have when you are missing something, and you know a patient is sicker than they may seem. It’s a trait that seen in our best clinicians, and one that no programming can replace.

Using an AI tool is just fine. But for my part, I’m going to agree with Mr. Spock:

What’s Behind OHIPs Persecution of Dr. Elaine Ma?

In over 3 decades of medical practice, I’ve seen so much stupidity from government bureaucrats that I really shouldn’t be surprised by the dumb things they do anymore. And yet, every once in a while, they do something so colossally, mind numbingly and egregiously idiotic, that I’m still left stunned. Such is the situation with the ongoing persecution of Dr. Elaine Ma. Last week, the general manager of OHIP recommended, and the Minister of Health agreed, to appeal the decision of the Divisional Court that gave Dr. Ma a partial victory in her seemingly endless dispute with OHIP.

Picture of Dr. Elaine Ma, family physician from Kingston, Ontario — Dr. Elaine Ma

I’ve written about this before, but a brief summary follows. Links are provided for people who want more detail. My three loyal readers can just skip the next paragraph.

Dr. Ma organized, set up and paid for dozens of Covid Vaccination clinics in 2021. She billed the codes for organizing the clinics to OHIP (since she paid for all the overhead). A couple of years later OHIP told her that she should have billed an hourly rate and demanded over $600,000 in fees back. Their reasons for saying she inappropriately billed varied seemingly from week to week. The clinic was outside, not inside! She used Medical Students! Different people injected! etc.

The case eventually made its way to Divisional Court. I never thought I’d see a more laughably ludicrous comment from bureaucrats than when the Ministry of Health’s negotiations team announced there was no concern about a lack of comprehensive care family doctors. But, as Einstein once said, stupidity is infinite and these OHIP bureaucrats outdid the MoH crew by suggesting that there were “no extenuating circumstances” warranting the setting up of these Covid Vaccinations clinics. The whole country was in the midst of a pandemic, there was the largest public health crisis in my lifetime, the country was locked down, travel had ceased and so on. But these were not extenuating circumstances in these eyes of these rigid, automaton bureaucrats.

However, it was also at the Divisional Court hearings that I personally feel that we may finally have seen why OHIP is so intent on tormenting Dr. Ma. The court did scold the bureaucrats for the absurd suggestion that extenuating circumstances didn’t exist. But, as I mentioned in my last blog, the court also found:

“…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.”

Section 17.5 of the legislation that governs OHIP (which in it’s current form is found buried in Bill 138) states:

“The General Manager shall refuse to pay for an insured service if the claim for payment for the service is not prepared in the required form, does not meet the prescribed requirements or is not submitted to the General Manager within the prescribed time. However, the General Manager may pay for the service if, in the General Manager’s opinion, there are extenuating circumstances.“

I mentioned last time that OMA lawyers really need to take a deep look at this ruling as it likely had implications for other billing disputes. And, indeed, the court’s interpretation of Section 17.5 appears to be main basis for OHIPs appeal.

According to a report by Michelle Dorey Forestell (who has done an excellent job reporting on this issue over the years), the General Manager of OHIP is appealing because:

“section 17.5 contemplates discretionary payment decisions only before funds are issued, noting that other provisions of the act expressly address recovery and reimbursement of payments already made……the court’s broader reading will make physician payment disputes more complex and uncertain.”

AND

“the case raises issues of public importance, given the potential impact on how physician billing disputes are assessed and adjudicated and on the administration of OHIP.”

This, in my personal opinion, is the real reason that OHIP is fighting Dr. Ma tooth and nail now, despite having (deservedly) lost at Divisional Court. It may have started out as bureaucratic ineptitude. But it’s no longer about recouping the money. Heck bureaucrats have wasted far more on various schemes.

No, the clear sense I’m getting is that OHIP bureaucrats, having botched their attempt to bully and harass Dr. Ma, they now find themselves in a position where they may be forced to make changes to their review process. If the Divisional Court ruling holds, it means that OHIP would have to modernize how they review payments (gasp!). Who knows, they might even need to buy some new billing computers that can more efficiently review physicians claims (double gasp!). But worst of all, it means OHIP bureaucrats will actually have to do real work (triple gasp!) to develop new processes.

Dr. Ma deserves better. By acting so quickly during the pandemic she ensured Kingston was one of the most highly vaccinated areas in Ontario. She not only saved lives, she prevented many hospitalizations. She undoubtedly saved the health care system far more than $600,000 by her actions.

Unfortunately for her, rigid thinking bureaucrats were unable to use some basic common sense and recognize how urgent things were in 2021. She has been egregiously wronged as a result.

But the sliver of hope is that she may actually have the last laugh. If the appeal is denied, or she wins at a higher court again, the bureaucrats will be forced to confront their own incompetence. They will need to develop a fair, modern and rational review process. If they don’t many other physicians will use her case as precedent by saying OHIPs review of their billing comes from an unreasonable process.

By not yielding to common sense, the OHIP bureaucrats may have wound up giving themselves much more headaches. And as far as I’m concerned, it’s entirely well deserved.

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.

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