#medicine – justanoldcountrydoctor

Animal Farm and the OMA

I was thinking about what to write about the current state of the Ontario Medical Association (OMA). Being of a certain age, my mind went back to the classic George Orwell book, Animal Farm. It tells the story of how a group of animals were not well represented by Farmer Jones. They wound up rebelling against Jones and took over the farm.

In the aftermath of the revolution, attempts were made to reform the farm so it could advocate for and protect all animal citizens. The guiding principles were the seven “commandments” that every animal agreed to abide by. The most important being, “All animals are equal.”

However, some vested interests began to manipulate the situation. The pigs eventually took over the running of the farm and bent the rules to their own advantage. When the rest of the animals went to complain, they found the most important commandment had been re-written to “All animals are equal, but some animals are more equal than others.”

It would of course be ridiculous to suggest that the OMA is a drunken, abusive farmer. It would be even more ridiculous to suggest that the staff of the OMA have the malevolence of Mr. Jones. The staff there are well-intentioned, good people. However, as my friend Greg Dubord pointed out to me, there is something that’s inherent in all organizations known as the “iron law of oligarchy.” Essentially, organizations eventually think of themselves first, not their members.

So it is with the OMA.

Our “revolution” did not have Old Major, or Snowball, or Boxer. We did, however, have Dr. Shawn Whatley, who famously resigned from the Board when he recognized that the association was going off the rails. We had Dr. Nadia Alam who inspired a legion of physicians by her activism. We had 25 brave Council delegates who successfully called for the first ever vote of non-confidence in the leadership of the OMA. There were a lot more but you get the point.

In the aftermath of the revolt that booted out the Board Executive in 2017, there was a strong desire to modernize and improve the OMA. A significant change in the governance structure was enacted. To this day, I support a lot of the principles and rationale behind that change. And there was a strong desire to ensure that the membership had the power to oversee the association and correct it if things went wrong.

We never encountered an evil character like Napoleon the pig. Rather the “iron law” principle itself became our nemesis. Organizational desire to protect itself, not members, began manipulating processes that were put in place into something much different than intended by the rebel physicians.

Nowhere can this be seen more obviously than in the selection process of non-physician board directors. Initially (2021), there was a genuine open election. Non-physician candidates competed alongside physician candidates and were subject to the same member vote.

However, only two years later (!) the process began to diverge. Non-physicians directors seeking a further term were presented for “ratification” as a reappointed director, as opposed to running for a competitive re-election like physician Board Directors are required to. This year the process evolved further. The AGM materials confirm that rather than a standalone ratification vote, non-physician reappointments are woven into the AGM business as a simple “yes/no” matter.

The OMA’s own communications make it clear. What began as a fully competitive open election process for non-physician directors has gradually shifted to a board-managed reappointment track. But physician directors continue to face competitive, multi-candidate elections chosen by the membership. (The physician candidates were also screened by a supposedly independent third party before being “allowed” to run, but I‘ve already gone over that in a past blog.)

In essence, some Board Directors are more equal than others.

The OMA also realized that by changing this process, they could have a stronger hand in selecting non-physician board directors. They could select board directors that on paper had significant skills, but would perhaps be more in line with a corporate philosophy.

One senior OMA executive told me that in the corporate world, there is no running for elections on Boards. The organization recruits who they feel is best and “people of that calibre” don’t submit themselves to votes. “I certainly wouldn’t.” I’m happy for that executive, and wish them luck. However, all those other organizations are not member driven organizations, they are corporate organizations beholden to shareholders.

In a member driven organization like the OMA, there needs to be some degree of political and strategic oversight of the staff. This is not a bad thing. Again, the staff are well-intentioned and want to help physicians. But they need a strong, independent Board to guide them and set strategy. To let them know what will not work for members.

This cannot happen if a block of Board Directors are non-physicians, and worse, have been selected by the OMA (I don’t buy the independent third party bit and neither should you). The voting Board Directors need to be truly independent practicing physicians. This is why Dr. Paul Conte is making four motions at the Annual General Meeting on May 7, with the goal of eliminating the positions of non-physician Board Director, so that once again, all Board Directors will be equal. If successful, this would constitute a sort of “mini” revolution after the big one in 2017. (Full disclosure – I’m seconding all the motions).

Since there are no proxies allowed, I would once again encourage all Ontario physicians to register for the AGM by clicking on this link. You can attend virtually, and make your vote count.

At the end of the book version of Animal Farm, the animals realize that despite their best efforts, they are once again subjugated and really no better off and live in despair. The 1954 movie version changes the ending into something somewhat more hopeful. The animals are once again able to unite, and launch a second “mini” revolution, like Dr. Conte wants to.

Will the OMA follow the path of the book or the movie? We’ll find out on May 7.

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.

Why the OMA Annual General Meeting Matters This Year

I was thinking about what to say about this years OMA Annual General (AGM) meeting. As a die hard Star Trek fan, my thoughts went back to the excellent Next Generation episode, “The Drumhead“. After foiling the ambitions of a Federation official to twist things for her own benefit, Captain Jean Luc Picard reflects that “vigilance is the price we continually have to pay.”

It’s the same for the OMA. Things go off the rails IF members don’t pay attention. Given how big, complex and convoluted the OMA is, well, members do tend to ignore some of the goings on (I am just as guilty of this as other people).

The governance changes at the OMA are a great example. What started out as well intentioned (and badly needed) changes to modernize the organization, in the aftermath of the debacle of the mid-2010s, has been turned into something worse than what was intended. For a bunch of reasons, I personally continue to think that it is still better than the previous structure – but a course correction is needed. We’re now in a situation where the staff seemingly control everything, regardless of what members want. Because, let’s face it, as a whole, we physicians didn’t pay enough attention to the OMA. Thus, the organization was able to repeatedly put changes in place that benefited the organization, ahead of the rights of front line physicians.

It’s gotten so bad that two OMA Board members, Drs. Paul Conte and Paul Hacker, resigned their roles early. These are not just ordinary Board Members. Dr. Conte is a former Board Chair, and also Chaired the Governance and Nominations Committee of the Board. Dr Hacker Co-Chaired the Governance Transformation Committee when all of these changes were put in place . They are absolute experts in the field, and if they say something is wrong with what’s going on, well, you can bet it is.

This is why you should all virtually attend the OMA’s Annual General Meeting (AGM). Dr. Paul Conte has come up with four motions (which I am seconding) to present to try and get the organization back to where it should be. There is some wordy legal jargon in the full motions so I’m only going to list what each motion hopes to accomplish and why. The full motions should be in the meeting package you receive when you register.

Motion 1 and 2: Removal of references to non-physician members and increase physician directors to 10

Some background. I was the founding Chair of the Georgian Bay Family Health Team. When we put the team together we knew that there were some skill sets, information and knowledge that physicians just didn’t have. Finances, negotiations, business plans and so on. So we had non-physicians on the Board of the team to help provide those insights. But we also realized that you cannot have a situation where non-physicians governed physicians . As a result, those non-physicians were what we called ex-officio Board Members. They could contribute and offer suggestions at the Board level, but they were not able to directly make decisions.

When the OMA began the necessary governance transformation process, I begged the staff of the OMA and the consultants to do the same thing with non-physician directors. They refused. I was told “Board Members had to vote” under ONCA (Ontario Not for Profit Act). This is twisting things. If you really want a non-voting person on the Board you can create a separate category – say “Board Advisor”. But the staff and consultants just didn’t want to, regardless of what the duly elected representative of the profession said. Then Covid got in the way, and ……….

By passing these motions we will eliminate non-physicians from having voting authority at the Board Level. The OMA can still have them there as consultants if they want – but non-physicians will not have the ability to govern physicians anymore.

Motion 3: Removal of the Screening Process for Board Directors

This year’s election process was an absolute travesty. Not only did the OMA unilaterally screen and short list candidates for Board Director, and only allow members to vote for the candidates THEY felt appropriate, they impugned the reputation of one of the President Elect candidates, by putting up a subjective opinion of their social media posts. It’s up to each individual physician to judge a candidate, NOT the OMA.

By doing so, not only did they harm a reputation, they’ve bastardized the whole election process and by default have tainted the victory of Dr. Haroon Yousuf.

This motion will put a stop to this nonsense.

Motion 4: An end to the Nadia Alam Rule

When I was on the OMA Board, it was quite obvious to me that many of the Board Members were extremely jealous of the popularity of Dr. Nadia Alam, who pretty well skyrocketed to fame because she spoke up and inspired others (including a certain grumpy curmudgeon who was going to sit the dispute with the government out). As a result they forced the implementation of a rule that says that anyone who held the role of President can no longer run for Board, even if they have less than 6 years on the Board (the current term limit).

Dr. Nadia Alam

The stated rationale for this goes something like “we give our presidents all sorts of publicity and it’s an unfair advantage if they run.” This is, of course, a load of cow manure. There are a whole lot of Past-Presidents who got lauded by the OMA and would get exactly one vote if they ran for anything ever again. This rule assumes the membership is too stupid to recognize who can inspire them and who can’t – and really is telling the membership they aren’t smart enough to know who to vote for.

Furthermore, Ontario is THE ONLY Provincial Medical Association that has this rule. (For that matter, no other Provincial Association screens Board candidates like this or puts subjective comments on election packages.)

Time to end this rule as well.

What happens if members don’t show up and the Motions Fail?

As members, we have a choice. We can spend a couple of our hard earned hours investing in and attending the AGM, hearing arguments both pro and con, and voting in the best interests of physicians. Or we can sit passively by, in which case the motions will likely fail, and the OMA will be emboldened, and continue to make choices for us, rather than the other way around.

Since my friend Paul Conte prefers the other, far inferior space franchise, this will be akin to the end of Revenge of the Sith, where Padme Amidala realizes:

Let’s not let that happen

If you are an Ontario Physician, I urge you to register for the AGM here:

https://web.cvent.com/event/c17ccc6c-d186-4ab8-985f-2e48127b4ffb/summary?sfmc_id=7563168

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:

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

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

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

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

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

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

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

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

Former Health Minister George Smitherman

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

Or so we thought!

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

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

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

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

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

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

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

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

Memo to the OMA:

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

Open Letter to Premier Francois Legault

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

Dear Premier Legault,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Yours truly,

An Old Country Doctor

Lettre ouverte au premier ministre François Legault

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

Monsieur le Premier Ministre,

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cordialement,

Un vieux médecin de campagne

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