Medicine – justanoldcountrydoctor

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

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

Expanded Scope of Practice Will Ultimately Hurt Patients

On October 1, the CBC published an article on how a program to expand the scope of practice of pharmacists in New Brunswick completely fell apart and was cancelled. There’s a litany of reasons why the project died. But the ones that stood out for me were (italicized quotes are lifted from the CBC article):

the project promoted a “a convenient new option” as opposed to to focusing on quality health care first
the project’s hypothesis – “..every patient getting care at a pharmacy would take pressure off the public system — remained unproven..”
there is a lot of focus on the fact that pharmacists need to be able to order bloodwork
There is significant mention of the role of Perry Martin, a paid lobbyist for Shoppers Drug Mart pushing for this change. There’s also this line – “the pilot pharmacists were being deluged with patients prescribed point-of-care tests by Maple, the private company operating the eVisit virtual care service.” Curiously, even though Maple referred patients to Shoppers Drug Mart pharmacies, there’s no mention of the fact that Shoppers Drug Mart invested $75 million into Maple. One would think that if company “A” invests in company “B”, and then company “B” sends business to company “A”, and company “A”makes money from the government for that business (though public health insurance), that should get a mention.
The provinces physicians feared duplication of tests and fragmenting of care
There was significant push back to the statement that letting pharmacists treating minor illnesses led to a 9.2% drop in Emergency room visits in Nova Scotia – “Health officials checked, however, and concluded the drop was because of a combination of several initiatives.“
Unsurprisingly, the government noted “an Ontario report that surveyed pharmacists who complained of corporate pressure to hit quotas and revenue targets“
Most importantly to my eyes: “Nicole Poirier, the director of primary care, pointed out the report contained “no conclusive findings” that it reduced pressure on the public system, and did not show better health outcomes for patients.“

I bring this up because in Ontario, we continue to fail to heed these warning signs. On Sep 17, the Ontario government announced plans to consider expanding the scope of practice of many allied health care professionals (AHCP).

It’s not just this report from New Brunswick that should raise concerns. There has been a growing body of evidence over the years about how the idea of offloading “minor” illnesses to non-physicians doesn’t achieve the benefits intended.

For example a three year study of expanding Nurse Practitioner (NP) autonomy in US Veteran’s Health Administration hospitals found that:

There was a 7% increase in immediate costs to patient care, and an overall 15% in costs for caring for patients when one included downstream costs. This was attributed to NPs taking longer to evaluate patients and ordering more tests.
Sub optimal triage of patients was also noted leading to things like under‐admission when needed (leading to worse outcomes and later, costlier interventions) or over‐referral/overuse
Patients under NP care had worse decision‐making about hospital admissions and increased return ED visits (which cost more)

It’s not just studies that are opposed to scope expansion that have expressed concerns. In Australia, a generally favourable report to having AHCPs work to their full scope of practice, still mentioned the significant need for training, regulation, and funding to support safe expansion. The training part is important because contrary to what’s being put out, many AHCPs are not trained to recognize a potentially serious issue from a minor one. (You don’t know what you don’t know). The same report also mentioned significant concerns about more fragmented care, waste and higher long term health system costs.

Another generally supportive of scope expansion of NPs study purports to show that NP delivered primary care for patients with multiple chronic conditions show similar outcomes to care delivered by family doctors. BUT, a deep dive into the study showed that the models studied often included physician-NP teams, or limited scope expansions. They did not always include fully independent NPs. Training, team collaboration, and oversight often remained intact.

With respect to AHCPs expanding their scope of practice in general, a number of concerns need to reviewed.

First is antibiotic stewardship. This is a big problem as overprescription of antibiotics is increasingly resulting in more and more virulent and drug resistant strains of bacteria. As I’ve pointed out before – CANADIAN provinces which allow pharmacists to provide antibiotic prescriptions- have a higher per capita rate of antibiotic prescriptions than others. That’s just reality.

Secondly the reality is that AHCPs will over order diagnostic testing, particularly if they “are not sure” about the diagnosis. We saw that with the Veterans Hospital study above. We will see that if, as suggested, AHCPs will be able to order more and more tests.

Thirdly, there is going to be an increase fragmentation of care. Whether one looks at Japan, Norway, Great Britain, or really any other country, it’s been repeatedly shown than having a consistent family doctor will result in better health care outcomes and reduced costs to the health care systems. Central to this is the family physicians ability to provide a medical home where all of the patients information can be consolidated at one spot, and their ability to help patients understand and navigate health care.

In Ontario our system is so disjointed and disorganized that it is not possible for all of the testing/prescribing done by allied health care providers to get to the family physicians easily. This very quickly will lead to fragmentation of care and will eventually come back to hurt patients. To their credit, both OMA Past President Dr. Domink Nowak and current President, Dr. Zainab Abdurrahman have repeatedly pointed this out.

Finally one thing that has not been discussed is the liability concerns. I don’t see any of the people talking about expanding scope of practice acknowledging that there will be increases in the cost of liability insurance. We’ve already seen in the US that NPs have had increased lawsuits against them. I’m positive that this will happen to other allied health care professionals if these changes go through.

It’s fair to note that much literature also finds benefits (e.g. improved access, equivalent outcomes in many primary care settings, especially for chronic disease management), and some cost savings under certain models. The risk is that decision-makers may generalize from settings where allied expansion worked well under supportive conditions to settings where such supports are weaker. Which appears to be where we are heading in Ontario.

All of which means we should expect a newspaper report in about 2029 showing that expansion of scope of AHCPs has not shown the expected results. Say, isn’t that about the time of the next Provincial Election?

It Appears Family Doctors are Giving Up…

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

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

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

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

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

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

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

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

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

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

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

So what can be done?

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

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

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

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

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

Let’s hope that message gets across.

Never Ending Arbitration Seems to Be Our Fate

On September 18, 2026, Arbitrator William Kaplan handed down an award for Ontario physicians in their ongoing and seemingly never ending negotiations process. I imagine rather a lot will be written about this. There are already lots of comments on social media, and many rushes to analysis, sacrificing accuracy for expediency. This is sadly true for any hot button news topic these days. I’m going to take my time to review the ruling in detail and probably have some more thoughts on it later. I would prefer to be accurate, not quick.

Photo of Arbitrator William Kaplan, owner of Kaplan Arbitration — Arbitrator William Kaplan

One thing I will say is that physicians are going to be locked into a perpetual negotiations/arbitration process for the next few years. In a previous blog I had commented that all outstanding arbitration issues would be resolved with this ruling. I based that on comments made by the OMA, and by the arbitrator himself. Being a victim of Murphy’s Law on many occasions, I did go on to say that:

“Of course now that I write this there probably will be yet another process announced after this which will mean more negotiation and arbitration”

Unfortunately, it appears that last part is indeed the case. All this ruling really does is set a (too low) dollar value ruling for how much of an increase (general and targeted) physicians are entitled to for the fiscal years April 1, 2025-March 31, 2028. It doesn’t deal with rather a whole lot of implementation issues.

For example, what exactly is going to be the dollar value of each fee code as of April 1, 2026?. The Ontario Medical Association (OMA) has long stated that current fee codes/billing are temporary and the new permanent values for codes will be implemented this coming April 1. The award defers that to the ongoing Physician Payment Committee (PPC) process that is supposed to have fee codes ready by then.

Additionally, the Award mentions the targeted funds for things like Hospital On Call (HOCC)/Unbundling Surgical Codes/Alternate Payment Plans and more – > but not the specifics of how those funds are going to be distributed or billed. Even the OMA’s own “agreed issues document” doesn’t really offer an agreement. For HOCC for example, it states:

“The parties shall conclude negotiations on the revised burden-based HOCC system bilaterally….If agreement cannot be reached by January 1, 2026, either party may refer the matter to mediation/arbitration ….”

Ok – what about things like the constant delay in physicians getting paid for work they do, supposedly due to the inefficient and ancient OHIP computers. The Award doesn’t set out a specifically penalty. It simply directs the OMA/MOH to make it a priority to fix this issue and if they can’t :

“This Board will remain seized in the event that the parties cannot reach agreement, with either, party having the right to return to this Board after January 1, 2026”

Yup, more negotiations and arbitration if the OMA asks for penalties for delayed payments. I hope there’s a good legal reason the OMA didn’t ask for specific penalties in their Arbitration briefs, otherwise it was dumb of them not to. The MOH asked for penalties in the new FHO+ model for family doctors, and that was awarded.

There’s also the fact that this award has funds that should have been already paid to us on April 1 of this year. The award does provide some guidance in terms of saying the increases should be paid retroactively on a lump sum basis, but once again – if the parties can’t agree to the relativity splits for that money – it goes back to……..more Arbitration.

Essentially the award says physicians as a whole are to get 7.3 percent in general increases and 2.2% in targeted increases. The MOH and OMA are to figure out how to split that (mostly through the PPC) – and then go back to the Arbitrator if they can’t agree.

Now the PPC itself is, you guessed it, a bilateral committee of the OMA and the Ontario Government. In fairness to them, they have been working quite hard all this time from what I can tell. They may be further along than we think. But I’m guessing that the government members will have a different overall agenda than the OMA. All it takes is for the government to put their foot down on one issue and the whole thing goes back to Arbitration.

The lawyers are gonna get really really rich……

I will once again state that this Arbitration process is still preferable to having unilateral actions imposed upon physicians by governments. Those of us who lived through the Eric Hoskins/Bob Bell years realize just how much worse things would be with the government acting unilaterally.

BUT – never also forget that this protracted process is also because the current government doesn’t really have the capacity to understand the complexity of the health care system (and the complexity of how physicians get paid). Rather than have a bold vision for transforming health care, and making it clear how they will invest funds to promote that vision, they have opted to simply drag out the contractual process. If the MOH had come to the table in a constructive spirit, all the implementation could be rapidly done. The MOH’s absolute insistence on doing everything in the most drawn out way, regardless of the worsening health care crisis, is where they are really failing the people of Ontario.

Politically, of course, it makes some sense. Instead of negotiating a fair contract right from the start and then getting up and defending that from the usual critics, the government instead has chosen to simply let the Arbitrator make all their decisions . Then the government case say “we did what the Arbitrator told us” and shrug their shoulders if things go bad.

I’m acutely aware that to a certain extent the process benefits the OMA as an organization as well. Look at the new FHO+ model for paying family physicians. Because a couple of elements of the program couldn’t be negotiated – that issue went to Arbitration. Because it’s gone there, family doctors don’t get a chance to actually vote on the model like they would if there was a negotiated tentative agreement. So the OMA can kind of impose a model of payment they feel is acceptable on family physicians, rather than promote it in a free and fair vote.

The unfortunate thing is that I actually do think the FHO+ is a small step forward (not as big as the OMA is making it out to be) and likely would have passed if given to members to vote on. I would have voted for it myself despite my criticism of some aspects of it.

So what does this all mean for physicians? It means that for the next three years (at least) we should all get used to living in an era of constant ongoing negotiations and constant Arbitration, with continual delays in payments because of an intransigent government.

Sigh…

Ten Lessons They Don’t Teach in Medical School (but should)

Dr. Ken Milne (pictured inset), an Emergency Room physician for almost twenty years and an associate professor of medicine at the Schulich School of Medicine and Dentistry (among many other things). He wrote an excellent X post recently, based on an interview with Dr. Ross Prager. He has graciously allowed me to republish here as a guest blog. I think the advice he gives is outstanding, and is a must read for all medical students (and frankly some of us older docs too).

For all the new medical students starting this fall there are 10 lessons they don’t teach in medical school (but should):

One – Patients don’t care how much you know, but how you make them feel.

Two – You’re remembered by your worst moments. When stress hits, your true self emerges…that is what people remember. Grace under pressure matters more than glory during routine.

Three – Stop trying to impress people with knowledge.

Four – Being keen is not a crime. Passion is a virtue, not a vice. Don’t hide your enthusiasm…it’s a sign you care.

Five – Medical School and Residency are long job interviews.

Six – Absence of evidence ≠ evidence of absence. Not everything is backed by RCTs (randomized control trials). That doesn’t mean it’s invalid. Clinical observation and physiologic rationale matter. As always, be skeptical of the lack of evidence, too.

Seven – Character is how you treat people who don’t supervise you.

Eight – Focus on diagnosis first, treatment second. Most medical harm arises from misdiagnosis, not mismanagement. Think ten times harder about “what’s going on” before “what should we do?”

Nine – Don’t postpone living until after residency.

Ten – Remember the spark. Recall your first patient: the awe, the uncertainty, the honour. When burnout creeps in, revisit that moment. Reconnect with your “why.” Medicine is not just about answers, it’s about presence. Our best tool is our humanity.

Educating the mind without educating the heart is no education at all. Aristotle quote

So, to all the new medical students…get ready for a great adventure. There will be times of joy and sorrow. If you are struggling at some point, remember, it is ok not to be ok. Reach out to friends, families, mentors or counsellors. Your attending physicians may look like they have it all together, but we have all struggled at some point & needed help. You can read my story here. This is another good episode for students and residents to listen to.

Old Country Doctor’s thoughts: On a personal note I want to welcome all of the new entrants to medical school this year. You will have experience incredible joys during your medical journey, and you will have your share of sorrow. To experience those sorrows is not a failure, it is life. But always remember, by being accepted to medical school, you have already proven you’ve go what it takes to succeed and to help others. You yourself may need help sometimes (we all do) but you’ve got this.

“Medicine cures disease, but only doctors can cure patients” – Carl Jung.

Patient Accountability ESSENTIAL for Health Care Systems

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

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

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

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

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

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

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

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

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

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

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

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

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

How does this work in other countries?

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

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

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

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

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

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

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

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

What to Look For in Next Weeks Arbitration Hearings

As I write this, it appears that once again, the Ontario Ministry of Health (MOH) and the Ontario Medical Association (OMA) have been unable to agree on a contract for physicians. We are again heading for Arbitration on June 30, with hearings all next week. A slim chance exists that a last minute deal will be struck – but I highly doubt it.

Up until now of course, the negotiations have been held under a strict cone of silence. There is no public knowledge of what has really been said between the two sides. But Arbitration in Ontario is public. The MoH and the OMA will have to publicly disclose what they are asking the Arbitrator to award.

Some Things to Remember:

These arbitration hearings are a continuation of last years hearings. Last year the Arbitrator only set an award for the total dollar amount to be given to physicians for the FIRST YEAR of a four year contract. This year’s hearings were originally slated for March of this year, but the Arbitrator delayed them until June. He wrote:

“The issues discussed have been far-ranging and include various implementation matters, the allocation of the Year 1 targeted funding, and complex and significant physician compensation issues for Years 2, 3 and 4.”

and:

“…the Board of Arbitration is now directing that the arbitration proceedings over any remaining Year 1 targeted allocation issues, and over physician compensation and all other issues for Years 2, 3 and 4, now take place over four days during the week of June 30. ”

These hearings will be a lot more complex than last years, and will have a lot of moving parts. Not only will the Arbitrator decide on how much of an increase will be allotted to physicians in years 2-4, but he will decide on how the targeted funds are distributed. Remember that 30% of the year one Award (approx $480 Million) was to be “targeted” for areas of health system need. Because of the malignant obstinacy of the MOH’s negotiations Team, the OMA and MOH have not arrived at an agreement on how to distribute these funds. So now the Arbitrator will rule on that.

Not only that, but there is the issue of how much of an increase each specialty should get. There was general agreement between the MOH and OMA the last couple of times that 25% of any increase would be given to across the board raises for all members, and the remaining 75% would go to relativity based increases. But the two sides have never really agreed on how the 75% would be split between various specialties. Reading the statement from the Arbitrator makes it sound like he will decide that too this time. (Of course now that I write this there probably will be yet another process announced after this which will mean more negotiation and arbitration).

Last year by my very rough count, the OMA and MOH submitted over 1,400 pages of documents (ironically called “briefs”) just to determine what percentage increase should be given to physicians. I can’t imagine how big the “briefs” will be this time. I won’t be able to go through them without gouging my eyes out but I do know what we should be looking for.

Has the Ministry of Health’s Team Smartened Up?

Look, both sides are going to “posture” for the Arbitrator. As part of that, the MOH will significantly undervalue physicians and offer a pittance. We should expect that and NOT get all worked up about it.

Unless…..

Last time, the MOH team went far beyond posturing. They showed nothing but contempt for physicians and an utter and complete lack of understanding of how health care works in Ontario. The MOH teams statement that there was “no concern” about a shortage of comprehensive care family physicians while the media was full of pictures of people lined up for hours for the mere hope of getting a family doctor, set a new bar for stupid government statements. The fact that they lied to the Arbitrator saying there was no crisis in family medicine until being forced to release documents proving otherwise made me wonder if a Court Jester was their spokesperson.

A Court Jester who, given the accuracy they present, could probably be a great MOH Spokesperson

It will also be telling when reviewing the MOH briefs exactly where they feel health care is most lacking in Ontario. Do they propose more investments in family medicine? How much for each specialty? In the last couple of negotiations the MOH has tried to alter the Family Health Organization (FHO) contracts on how family doctors are paid. What changes do they propose this time?

Finally – it will be VERY telling how the MOH wants to spend the $480 million in targeted funds. Will they try to skirt paying physicians for it? For example, will they propose to pay certain physicians to hire an allied health care practitioner, saying “well it will reduce your workload”, all the while demanding copies of proof you are paying that person in triplicate? Or some such thing.

I appreciate the above may sound far fetched, but the MOH Team has proved itself to be so incompetent and borderline vengeful that a scenario like that wouldn’t surprise me in the least.

What About the OMA Briefs?

In comparison, the OMA’s job is relatively easy. They simply have to advocate for increases that will make each of their many sections 100% satisfied and not complain……

OMA Negotiations Chair Dr. Nikolina Mizdrak

In all seriousness, OMA briefs will also tell the profession a lot. I imagine each of the sections of the OMA will pour through the documents and send information to their members. But in short order we should all see how much of an increase the OMA has concluded each specialty warrants, and how the OMA plans to handle the perpetually thorny issue of relativity.

Additionally, the OMA has repeatedly point out that we have a shortage of comprehensive care family doctors. They’ve used the word crisis more than once to describe this. So as a family doctor, I am eager to see what changes they propose to the FHO model as well.

Most importantly, will the OMA be aggressive in defending its members? These last couple of months had seen absolutely unacceptable unilateral decisions by OHIP, delaying payments to physicians and making mistakes on their remittance . The OHIP bureaucrats blame their old outdated computers. Of course, when they plan to recoup the 9.95% they overpaid for the preventive care bonuses this past month – the OHIP computers magically managed to figure out how to get the money back immediately.

Will the OMA finally demand in their Arbitration briefs some sort of penalty for OHIP screwing up? Remember, the fee changes as a result of this contract are to come into effect on April 1, 2026. Given the Arbitrator likely won’t hand down a ruling until the fall, there is no way OHIP will get their act together in time without……..encouragement. Penalties/Interest for delayed payments should absolutely be demanded by the OMA.

All in all, next week, physicians will learn just how both the OMA and MOH feel about them. Buckle up folks……

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

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

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

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

The Hope

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

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

The Frustration

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

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

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

The Fear

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

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

So What’s Next for Family Medicine in Ontario?

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

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

But…..

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

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

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

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

Primary Care Reform Needs More Than a Phone Call

Dr. Madura Sundareswaran once again guest blogs for me. She’s a community family physician who’s resume is too long to print here. She helped found the Peterborough Newcomer Health Clinic and is a recipient of the CPSO Board Award which recognizes outstanding Ontario Physicians. I happen to think she is one of our brightest young leaders.

I was feeling incredibly optimistic after Friday’s SGFP report, which articulated the importance of family physicians in addressing the current primary care crisis. But that hope was abruptly crushed by a recent email I received from Ontario Health East. Ironically, it serves as a prime example of how health systems transformation continues to follow a top-down approach with little regard for the realities of primary care delivery.

In its latest communication to its members, Ontario Health East outlines a two-step strategy for clearing the Health Care Connect waitlist.

Let’s talk about the good first.

Given that the Health Care Connect waitlist has been largely stagnant, the proposal to verify and update the list is reasonable and welcomed.

In its latest proposal, Ontario Health East also commits to providing “interim services” for patients who are not immediately matched to a family physician or primary care team. This is great – and arguably where the new “Care Connector” portfolio should focus. Why? Because this is what many Ontarians need right now: assistance navigating our complex healthcare system without a family doctor.

Now, the not-so-good.

A large part of Ontario Health’s plan is to connect with every primary care clinic in the OHT to determine available capacity. If I am reading this correctly, they want to cold call every primary care clinic in the region and ask if they are accepting new patients. Are they aware that people have been trying to do this for years…?

To their credit, Ontario Health has expressed a commitment to support capacity-building. They’ve emphasized exploring “creative ways” to expand capacity at the individual clinician level — but this language effectively masks the absurdity of the underlying ask. The expectation appears to be that family physicians, already working at or beyond full capacity, can somehow stretch further, simply by reimagining how we work — all while receiving little to no additional resources.

To their credit, Ontario Health has expressed a commitment to support capacity-building. They’ve emphasized exploring “creative ways” to expand capacity at the individual clinician level — but this language effectively masks the absurdity of the underlying ask. It assumes that family physicians already working at full capacity, can somehow stretch further, by simply reimagining how they work — with little to no additional resources.

I’d like to apply the trending analogy of comparing our healthcare system to the public education system.

Imagine 30,000 children in your community suddenly need a place in schools – all at once. Instead of building new schools, adding classrooms, increasing the budget for school supplies, or hiring new teachers – the plan is to call each teacher and ask if they can “accept a few more students.” Not just one or two students– try about 100 each. Now teachers, please brainstorm how you can better meet this need (on your free time, of course).

Parents and teachers – would you allow this to happen?

The dilution of services is not the solution to this primary care crisis. This government’s current focus is entirely on numbers – with little regard for the quality of care being compromised in this process. What happens when each of us have 100 more patients with little to no additional support?

Less time for direct patient care as we dedicate more time to an overflowing inbox.
Longer wait times to see your family physician.
More strict enforcement of rules like “one problem per visit.”
Even fewer family doctors choosing to practice family medicine. More choosing to leave or retire early.

Some argue that teams will offset this burden. Full disclosure: I do think teams can help. But whose responsibility will it be to create medical directives, identify how the teams can best work, and continue to engage in quality improvement and assurance as this new process evolves? Family physicians. Back to the classroom analogy – it doesn’t matter how many other support staff you hire, a classroom of 130 students needs more than one teacher.

This proposal assumes we haven’t already asked—more accurately, begged—family physicians to take on more patients. We have, many times. And with limited success. And before I’m criticized for being negative or dismissing innovation, allow me to share my own experience.

In 2023 I founded the Peterborough Newcomer Health Clinic with the intention of supporting newcomers to Peterborough transition to the Canadian Healthcare system. In this process, I follow newcomers for 6-12 months after which I personally cold call family doctors and primary care nurse practitioners to see if any of them will accept my patients after I have done a great deal of work completing intake assessments and consolidating all previous health records. I have already brainstormed and implemented strategies to make the transition as easy as possible. Have I successfully attached my patients? Rarely. Many of these patients remain unattached.

This is just one story. Many in our community — advocacy groups, primary care providers, and local organizations — have made similar efforts with limited success. And let’s not overlook the fact that this proposed model of attachment completely ignores the issue of inequitable access for marginalized populations (another post for another time).

As I sit here on a Sunday, preparing to enter the week without sounding like a “grumpy physician,” here are my final thoughts.

In this race to reach 100% patient attachment to primary care; we must advocate to ensure that this is not done in a way that dilutes existing resources, compromises existing access to care and devalues family physicians who are currently working at full capacity. We need to protect our existing workforce and support sustainable growth. I encourage every user of our publicly funded healthcare system to advocate for this.
Family physicians – I urge you to continue to advocate for better remuneration and exercise caution when pressed to roster more. Please remember that our contracts exist with the Ministry of Health and Long Term Care. When new opportunities arise – exercise due diligence to ensure that what is being asked of you aligns with the policies of your own practice/organization and the CPSO.
Rushed, expensive, and poorly planned reforms that focus on quantity, not quality is not good for patient care. Failing to address the core issues with primary care – demonstrated by fewer and fewer family physicians choosing to practice comprehensive, community-based family medicine – is resulting in top-down, expensive, and band aid solutions to the primary care crisis. It edges on careless spending on taxpayer dollars. We should advocate for a system that prioritizes sustainable, safe and equitable care – not just a solution for tomorrow.

Disclaimer: The views expressed in this piece are my own and do not necessarily reflect those of any affiliated organizations or institutions.