#ONhealth – justanoldcountrydoctor

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

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

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

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

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

The Efficiency Problem

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

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

safe patient access
continuity
quality
responsible innovation
sustainability
burnout prevention

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

The Hidden Mental Burden

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

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

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

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

The Bigger Problem: Complexity Itself

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

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

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

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

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

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

The Human Side Nobody Talks About

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

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

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

A Better Path Forward

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

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

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

Use AI NOW to Reduce Bureaucratic Bloat in Health Care

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Auditor General’s Report on AI Highlights Failure of Ontario’s Health IT Bureaucrats

There’s currently a lot of talk about the recent report from Ontario’s Auditor General on AI Scribes. The headlines seem mostly to be dealing with the fact that she found numerous AI Scribe generated reports had errors. The errors happened for various reasons, including AI hallucinations, transcription errors, incorrect entry of medications and so on.

Ontario’s current Auditor General, Shelley Spence

However, to my mind, that’s not the real story.

I feel somewhat conflicted in saying this next part, mostly because I think I generally have a reputation for being an advocate for physicians, their views and their well being. However, the blunt reality is that we are all required to check any report that’s generated by an AI scribe before we sign off on them. Physicians, being human, will make mistakes. For example, this past weekend, I got a message from a colleague of mine, pointing out an error that had been made in an AI-generated note on a patient I saw. That was my fault for not double checking. I think to try and blame some software for those kind of mistakes would be inappropriate.

No, the real story is the continued ineptitude of the healthcare bureaucrats at the Ministry of Health who are in charge of health care IT systems today. If one does a deep dive into the Auditor General’s report, there are many, many legitimate question she has, all of which the hard-working taxpayers of this province deserve an answer to.

In particular she found gaps in how these AI systems were evaluated by Supply Ontario, Ontario Health, and to a certain extent OntarioMD. Yes there were three agencies all involved, triplicating the amount of work necessary and adding to the confusion.

Heck the issues began right from the initial procurement stage. The weighting given to different criteria revealed a fundamental misalignment of priorities. The accuracy of medical notes generated by AI scribes accounted for only four per cent of points awarded to potential vendors, while domestic presence in Ontario was weighted the highest at 30 per cent. Data privacy/legal controls were weighted at 23 per cent and system security controls at 11 per cent.

Think about that for a minute. You could have software from a poorly run company, that was completely inaccurate in its transcription and system security, yet still have it approved if it happened to be Ontario based. Yet a company with the best transcription and system security would lose, if it was from out of province. Even Spence was shocked by this, stating, “In my mind, that doesn’t make sense….when we’re dealing with personal information and we’re dealing with artificial intelligence, I think security is of the utmost importance.”

Additionally, the evaluations didn’t actually watch vendors operate the software in real time! There were no live test. Vendors were apparently given recordings and ran the system offline learning. Spence said, “this allowed vendors to potentially overstate their compliance with security and privacy requirements.”

Well, duh!

Worse, 11 of the approved vendors for AI software didn’t actually meet the mandatory submission requirements. They got approved anyway. Five didn’t even submit risk assessments and privacy impact assessments as part of their bid process. They got approved anyway.

This kind of amateurish, ineffectual assessment is supposed to help increase confidence in healthcare IT?

Most damningly, it appears from the auditor general’s report that there is a broad absence of strategic governance. The auditor general benchmarked the AI strategy against Canadian and international public sector organizations and found that there were no specific actionable items, no clear plan to prioritize AI use across ministry areas, and did not identify any prohibited AI practices or areas where technology posed an unacceptable risk.

Essentially, this report paints a picture of Ontario Health/Supply Ontario/Ontario MD approving AI systems through a process that underweighted accuracy, did not require live demonstrations, accepted incomplete documentation and failed to assess bias risk. All while having no clear plan to rectify these gaps going forward.

The thing is, this kind of insanity has been permeating the politics of IT health systems for decades. I’ve written about the bloated and inefficient bureaucracy for years now. The lack of ability to get a truly integrated health care system speaks to a lack of vision and focus in the bureaucracy. It’s incredibly discouraging that it continues unabated after all these years. It seems that no one has the knowledge, wisdom, ability to fire the incompetent bureaucrats, streamline the process by getting rid of multiple agencies, and apply an overarching vision for health care IT.

And yet, instead of fixing the bureaucratic mess first, streamlining health IT infrastructure, and developing on overarching health IT vision, Ontario is instead now going ahead and launching a Provincial initiative to create a province wide primary care medical record system. The people in charge of choosing the software for this? The same bunch who botched the AI scribe issue.

I can’t wait to read the Auditor General’s report on that one in, say 2029.

The OMA’s AGM: Locked Out and Let Down

Old Country Doctor’s Note: In my last blog, I downplayed the technical glitches at the Ontario Medical Association’s Annual General Meeting (OMA AGM) because I only had a couple of issues. Turns out a lot of people had much more trouble. My thanks, to Dr. Paul Hacker for guest blogging for me today about those issues. Please sign his petition linked at the end of the blog.

Dr. Paul Hacker (pictured inset) is a former Vice-Chair of OMA Council, former co-chair of the GT20 Governance Transformation Committee and former OMA Board Member.

On May 7, a “record turnout” (according to the OMA) of members attended the Annual General Meeting of the OMA. This means that a record number of physicians cleared their weeknight schedule, put clinical obligations on hold, set aside family time and sat down at their screens at the appointed hour. I personally know of emergency physicians who felt attending this meeting was so important that they worked with colleagues, while on shift, to be able to participate in voting on important matters.

And nothing worked.

The purpose of the meeting was to conduct some routine business of the OMA corporation and to consider, debate, and vote on a number of proposals submitted by members.

The routine business went ahead, but the members’ motions were beset with technical snafus.

Even worse, this one annual event where members can hear directly from their leadership, obtain updates and ask questions was blocked for many who had difficulties registering and logging in. They were locked out of our organization’s most important annual event, on their own, with no way in and inadequate help from staff.

The Board’s Response: What It Says and What It Doesn’t

Let’s look at the response from the OMA’s Board Chairs (both outgoing and incoming):

“…we all left the meeting frustrated by the technical and procedural difficulties that occurred as the meeting progressed…”

“The AGM included a significant number of motions and proposals within a limited timeframe, and technical issues related to the hybrid format affected the flow of the meeting and prevented completion of the full agenda before members called for an adjournment.”

Firstly, there is no mention of the registration and login issues. The Chairs completely disregard this as an issue worth addressing to the many members who were shut out completely. (The silver lining for them is that they didn’t have to endure the “procedural difficulties” that have many saying they will never attempt to attend an AGM ever again.)

Second, the email subtly but firmly places the responsibility for the time pressures on members. Those motions were submitted by members, followed all OMA rules, and were duly accepted. The implication that their volume contributed to the problem is a subtle but pointed deflection. Where is the accountability for an organization that has held many members’ meetings in the past and should have a full understanding of how long it takes to properly hear and consider different viewpoints on the issues? Where is the accountability for the unusually cumbersome handling of motions and amendments, when these have been handled well in several past meetings?

A Legal Obligation, Not Aspirational Language

It is important to note that the OMA has a legal responsibility — under the Ontario Not-for-Profit Corporations Act (ONCA) — to ensure that all members can participate reasonably in electronic meetings. This is not aspirational language. It’s a statutory obligation. The OMA is not a tech startup that gets credit for trying. It is a mature corporation with legal duties to its members. The fact that this happened at all, let alone to the extent it did, reflects a failure of preparation, not just execution.

“We Take This Seriously” Is Not Accountability

The OMA, as usual, frames this total failure as a learning moment, with no commitment to report back to members:

“We are committed to working with our CEO, Kimberly Moran, and the leadership team to understand what occurred, identify where improvements are needed, and ensure physicians are well supported for the followup meeting.”

“We want to thank our colleagues for their patience, and continued involvement throughout the evening. Even in moments of disagreement and frustration, physicians continued to demonstrate how deeply we care about the OMA and its governance.”

Well, there is at least that last bit. Members do care about how the OMA goes about its business. Members do care about who represents them at all levels of the organization. And unfortunately, due to the ongoing shredding of the fabric of our health care system, something the OMA has failed to significantly impact, members are quite familiar with disagreement and frustration. We are a resilient bunch, but there are limits. When our organizations are not accountable, not transparent, not fair and truthful about their responsibilities, members lose faith. Many, including myself, have lost faith multiple times.

Members Have Power — And a Petition

But members have power. Members have their own voices. Members have shown, in the debate that was allowed to occur at the AGM, that they can push back on unfair, opaque governance. Similarly, we can push the OMA to own and be transparent about its own failures.

The OMA responds to organized member pressure. That’s one lesson of this AGM. We can apply that pressure to get answers — to ensure the OMA is accountable not just for the things it wants to be accountable for, like ‘technical difficulties,’ but for things like failing to meet its obligation to ensure members can participate in their organization, and then not even acknowledging these issues in its communications.

I have created a petition to demand that the OMA conduct a full survey of members to determine how many had issues, how many were excluded, and how this event has impacted member attitudes towards the OMA. It’s been over three years since the OMA last surveyed members to ask them “how are we performing on your behalf?” If one truly positive thing can come out of this AGM debacle, maybe it can be the resumption of the OMA doing some asking of members, not just telling them.

The petition can be accessed here: https://tally.so/r/44A225

You gave your time. The least the OMA can do is count you.

Local Medical Schools Will Help Address Doctor Shortages

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Former Health Minister George Smitherman

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

Or so we thought!

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

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

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

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

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

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

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

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

Memo to the OMA:

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

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

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

What happened?

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

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

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

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

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

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

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

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

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

How is this hurting health care now?

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

Sign on the door to the Medical Ward of my Hospital

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

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

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

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

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

What should happen (but won’t):

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

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

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

Maybe.

OMA Manipulates Board Elections and Weakens Members Voices

On November 20, Ontario Medical Association (OMA) Past President Dr. Dominik Nowak sent all members an email encouraging them to run for positions in the upcoming OMA Elections cycle. As Past President, his role is to oversee the elections for over 100 positions. He needs to ensure they are fairly run so the voice of all Ontario physicians can be heard.

Current Past President of the OMA, Dr. Dominik Nowak

Unfortunately, the current Board has sabotaged this process and rather than listen to the members, will only present pre-approved candidates for Board Director, the most important role. They have the responsibility of ensuring the OMA speaks for, you know, the members. Buried in his email were the following statements:

A streamlined shortlisting process for board candidates, with two to four candidates, whose skills and experience align with the board’s needs, being presented on the ballot for each open position
Stronger screening and evaluation for consistency and fairness of candidates
More transparency about how the board performs and what gaps are in the skills-based matrix

There is no explanation of what exactly this “streamlined” process is. But it’s clear that there will be now be increased vetting of candidates and some candidates will be found wanting and not allowed to run. Now, there always was some vetting of Board Candidates. Candidates had to be in good standing with College of Physicians and Surgeons, the OMA, pass background police checks etc. Some basic stuff.

But now, undoubtedly based on the fact that something like 38 people ran for Board last year, the OMA Board has determined to vet candidates even more and reject qualified people if they don’t meet these nebulous criteria. Importantly, the criteria will be to pick candidates who align with the BOARD‘s needs, not the MEMBERS. This is of course, all in the name of “fairness” and “transparency” and to make decisions “easier” for physicians.

But here’s the thing, the Board will NOT do the vetting. Board’s don’t actually do any operational work. Their job is to set policy, and then let the staff of the OMA implement it. So it will be up to the staff of the OMA to vet the Board candidates, and then approve whoever is acceptable……..to the staff.

Colleagues, we have a big problem.

The OMA staff are generally good people who work quite hard on behalf of physicians. They get a lot of unwarranted criticism for decisions that are actually made by physician leaders. Our elected leaders that should bare the blame.

But, at the end of the day, the OMA staff are only human, and prone to human tendencies and failures. My friend Dr. Greg Dubord, who I was honoured to pen a blog with, introduced me to Robert Michel‘s “Iron Law of Oligarchy“. It would seem to apply just not to the CFPC, but to what is going on at the OMA. From Wikipedia:

“… all organizations eventually come to be run by a leadership class who often function as paid administrators, executives, spokespersons, or political strategists for the organization. Far from being servants of the masses…. this leadership class, rather than the organization’s membership, will inevitably grow to dominate the organization’s power structures.^[3]“

Robert Michels, a sociologist who described the political behavior of intellectual elites in the early 1900s

And that is exactly what is going to happen with these new changes. The OMA staff (not physician leaders, but employees of the OMA) will review the candidates for Board. THEY will decide who meets certain criteria. THEY will determine how many candidates run for each Board position, hiding behind a policy the Board has set.

Will they do their best to pick some good people? Sure. But their definition of “good” may not be what the members want. For example, someone like Shawn Whatley was openly critical of the OMA prior to being elected as President. Would he have passed these criteria? How about Nadia Alam? Prior to getting involved in medical political activism she was a relative unknown with little leadership experience (even though she is arguably the most well respected President of the past 25 years).

pictures of Dr. Shawn Whatley and Dr. Nadia Alam, both of whom are past presidents of the Ontario Medical Association — Dr. Shawn Whatley

Nope. My guess is they would have been found wanting. A total guess on my part would have been Dr. Whatley would be deemed “too disruptive” (he famously resigned from the OMA Board prior to being elected President). Dr. Alam would like be viewed as “too inexperienced.”

Worse, the blunt reality is that the staff will likely decide who is “best qualified” based on how well they can work with them (that’s just human nature). Not necessarily those who can, you know, push them and challenge them to do better.

The staff, generally being very nice people, always had a tendency to try to work co-operatively with the various government bureaucrats on bilateral committees. This is despite the over 30 years of evidence that always trying to be nice and reasonable just isn’t working. Cynics have suggested that its in part because they realize if they want to advance their careers – one of the places they can go after working in the OMA is the government, and it doesn’t help to burn bridges there. So why would they approve a candidate who had a reputation for being less than reasonable?

Want proof? Just look at how badly the OMA as an organization handled last year’s elections. I asked potential Board Directors to commit to filing a Freedom of Information Act request, to determine just how many patients Nurse Practitioners saw in a day and how much they cost the health care system per patient (easy to do with billing numbers). The goal was to get proof that they were more expensive overall (by a lot) than family physicians and slow down scope creep.

Not only did the OMA put a stop to that, they threatened the careers of people who signed that with a Code of Conduct violation. Can’t have people on the OMA Board who will be too aggressive can we? (Psst – hey Kim Moran, CEO of the OMA – how is sending strongly worded letters to the government asking them to stop scope expansion working out? Oh, right.)

Do you really think with that history, the current staff will allow someone even remotely controversial to run?

The OMA Board has shamefully allowed this to happen. As a result there will not be a diverse Board with many viewpoints that focus on members. Rather a bland, non-controversial Board that will be limiting to speaking in political jargon speaking points in response to all issues.

Physicians will truly be hurt by this short sighted decision.

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.