NB: My thanks to Dr. Tristan Brownrigg for guest blogging for me today. By his own admission, he never planned to be political, or seek out the limelight. But the situation in Ontario is such that he felt his perspective should be heard. I have a great deal of respect for people like Dr. Brownrigg, who are willing to step out of their comfort zone when necessary, and I commend him for doing so.
Dr. Tristan Brownrigg: I am a family physician, outdoorsman, and rural generalist currently working a mix of clinic, ER and inpatient care in the East Kootenays of British Columbia. I graduated from the University of Toronto Medical School, and did my Residency at Queen’s University (Kawartha site).
I completed family medicine residency in Ontario in 2022 and worked there for 6 months. Prior to this I completed medical school in Ontario, completed my undergraduate in Ontario, and had called Ontario home. Over the years I had watched my goal of working as a comprehensive rural family physician slowly become unsustainable amidst a collapsing system, decades of funding stagnation and poor planning, with a patchwork of good people on the ground trying to do their best in a system that doesn’t seem to value their input. Day after day the insidious march of the family medicine crisis grew closer to the forefront of peoples’ lives and garnered wider media attention, while the government either denied its existence or made no substantive changes that would realistically address it. This has not been the time for band-aids, let alone denial.
Last year I moved to rural British Columbia to try something different for a year, cautiously optimistic about the significant changes to family practice on the back of the LFP model implementation in early 2023. The Longitudinal Family Physician (LFP) model significantly changed how family physicians billed and were compensated in BC, including the ability to bill for the many hours family physicians typically spend on previously unpaid administrative tasks.
My experience has been night and day. For the first time in my medical career I have felt hopeful about the future of family medicine and find my day to day life to be sustainable. These changes have been received positively amongst all other family physicians I have discussed it with. It is not perfect and there are still kinks to be ironed out, but I at least believe my provincial medical association and government are trying to improve things for family physicians. I am not left questioning if government actions are purely incompetent or malicious with the intent to drive privatization.
I had retained my Ontario medical license until now, awaiting the May 2024 renewal deadline unsure if I would return home after a year of trying on a different life out west. Reading the recent government positions and negotiation briefs has been the final nail in the coffin for me. The disdain the Ontario government shows towards the hardworking family physicians who hold up the medical system is nothing short of repugnant. After more than a decade of training and education here, I will now be relinquishing my license to practice medicine in Ontario and stay in British Columbia.
The minister of health thinks recruitment and retention is “not a major concern.” That’s the problem; it should be. If I am not a prime example of this, I don’t know what is.
I wish all of my colleagues still in Ontario who do not have the luxury to vote with their feet the best of luck. If not this government, then I hope the next one learns to value your work and dedication.
My thanks to Greg Brady and 640 am News Toronto for interviewing me today (May 9, 2024) about comments from the Health Ministry that recruitment and retention of physicians is not a concern for Ontario. Posting a link to the podcast of that interview here, as some forms of social media will not allow the actual link to be posted.
On May 6, as part of a needlessly protracted negotiations process, the Ontario Medical Association (OMA) and the Ministry of Health (MOH) began public arbitration hearings to determine a compensation package for physicians for the fiscal year April 1, 2024 to March 31, 2025. Yes, arbitration has begun AFTER the last contract expired, and physicians will need to be given retroactive pay.
This is happening as part of the Binding Arbitration Framework (BAF) between the OMA and the MOH. When the two sides can’t agree on a compensation package after a defined period of time and negotiations, arbitration is invoked. The expectation is that arbitrator William Kaplan will issue an award sometime in August. It’s possible the two sides may reach an agreement before then as negotiations are allowed to continue during arbitration. It’s not unheard of that arbitration can sometimes pressure two sides to get a deal done before a decision is rendered.
William Kaplan, of Kaplan Arbitration Services
One common misconception I hear from my colleagues is that Mr. Kaplan will have to pick one side or another. That’s not the case. The BAF we have is for something called Binding Interest Arbitration. Mr. Kaplan will likely award something in between.
Public arbitration, is just that. It means that the arbitration briefs submitted by the two sides are public, and the arbitration hearings are public. Which means that physicians across Ontario know exactly what the government thinks they are worth. And that knowledge will demoralize an already disheartened profession.
Having gone through this process as an OMA Board member in the past, let me acknowledge a few things right off the bat.
Arbitration is still a lot better than the alternative, which would be unilateral government action. We’ve been down that road before during the Hoskins/Bell years and that was just plain awful for not just physicians, but patients as well.
As part of the arbitration process, the government purposefully put a “lowball offer” forward. Basically they know the arbitrator will likely award more than they offer so of course they try to present a lower version than they normally would expect.
In that vein, I would have expected the OMA to present a higher request. All physicians deserve a raise, and their proposal does address that. But the ask frankly just catches up (barely) for the last few years so calling their brief a “strong” demand is inaccurate.
Our negotiations counsel, Messrs Goldblatt and Barrett, frequently told me that it is much better to have a negotiated settlement that both sides agree to, than one that was forced on them by an impartial third party. More chance of the two sides willingly implementing the many nuances in an agreement as complex as the physicians one.
Howard Goldblatt, Negotiations co-Counsel for the OMASteven Barrett, Negotiatons co-Counsel for the OMA
However there is one thing that hasn’t been considered. Arbitration frequently leaves bad feelings amongst the two parties. In the sports world for example, one has to look no further than Toronto Maple Leafs goalie Ilya Samsonov. He took the team to arbitration last summer. The team clearly said some negative things about him to justify their offer to him. While the team has not exactly been forthright about what exactly was wrong with him mentally, there can be no doubt that he had a terrible first half of the hockey season. It was so bad he eventually got demoted (on paper) to the farm team – and his play was so bad no other team in the NHL wanted him (ouch).
Toronto Maple Leafs goaltender Ilya Samsonov
This is why sports teams try to avoid arbitration – they know that the process can be ugly, and can adversely affect the performance of their top athletes who have to listen to negative things said about them. For teams to succeed, the top athletes have to play their best.
Looking at the situation in Ontario, it’s frankly hard, as a physician, to feel anything but insulted and disrespected by how the MOH negotiations team has acted. It’s bad enough that they appear to have, for the most part, stalled the negotiations to the point where arbitration is needed. Contrast this with Manitoba, Saskatchewan and British Columbia, where the governments realized that they needed to retain their physicians due to the current crisis in health care, and made widely applauded agreements with their doctors. But Ontario’s arbitration position is so pathetically inadequate (even when considering they are low balling for arbitration) that one really has to wonder if they want to have good relationships with their doctors going forward.
From 2020 to 2023 – inflation has gone up by 14.8% (with another 2.9% for this year so far). Nurses were given an additional 6.75% (on top of their previous agreements) due to the unconstitutionality of Bill 124. And yet the MOH thinks physicians should only get three percent?? With no recognition of administrative burden? And the MOH claims there are no retention/recruitment issues?? Have they talked to the over 2 million people without a family doctor??
Does their negotiations team truly understand the harm they are doing by putting forward such an insulting and offensive proposal??
Here’s the thing, after a contract is agreed to or arbitrated, physicians and government will need to work together for the benefit of the people of Ontario. Yet how does any reasonable person expect physicians to work with a government team that on the one hand says that “physicians are valued and respected” but then, at the first chance they get, demean them with such a pathetic position.
Remember, many of the bureaucrats who provide supporting information to the MOH’s negotiations team have other roles. They’ll show up on other bilateral committees between physicians and the MOH. And after you denigrate people so badly with such an abhorrent brief, will there really be any trust between the two sides (and yes, they are now sides – this opening position makes it clear we are not on the same “team”).
Just like the Leafs needed Samsonov to, you know, make a few saves earlier in the season, the government needs physicians at their peak to deal with and give their best advice on the current mess that is health care. And while physicians, as is their nature, will genuinely try their hardest to do so – the blunt reality is that Samsonov tried his best to make more saves as well. But when your head is not in the right space……..
At this point there really is only one solution. The MOH negotiations team needs to formally apologize to all physicians for their incredibly repulsive offer. Then they need to look at BC, Manitoba and Saskatchewan, and put together a fair and competitive agreement so that more physicians don’t look elsewhere. This can be done tomorrow.
My thanks to guest blogger Dr. Deepa Soni, an Emergency Room Physician at Credit Valley Hospital. She has written a much more eloquent letter to her MP about the recent tax changes introduced by the federal government, and allowed me to reproduce here as an open letter.
The Honourable Anita Anand,
MP, Oakville,
301 Robinson Street
Oakville, ON
L6J 1G7
April 20, 2024
Dear Minister Anand,
I’m writing to you as a constituent of your riding in Oakville regarding your government’s capital gains taxation measures introduced in this week’s budget.
As an emergency physician for the last 25 years, I and thousands of my colleagues in Ontario, were saving in our medical corporation to be able to fund benefits that many Canadians have available through their jobs: maternity leave, disability, and medical/dental benefits. In addition, and most importantly, incorporation allows us to save for our retirement as we do not have pensions (again, a benefit many Canadians, including government employees and civil servants have as part of their employment). Incorporation was a negotiated benefit that was given by the provincial government in lieu of increasing our fees, with the understanding that the structure would allow us to mitigate some of these factors about our career.
Anita Anand, President of Treasury BoardChrista Freeland, Finance MinisterJustin Trudeau, Prime Minister
When planning for retirement under one set of assumptions, and then finding out that the federal government has moved the goal posts to extract revenue for its budget shortfall, you can understand why so many physicians are bewildered and disappointed by the Liberal government. This would be the equivalent of someone changing the terms of your pension or taking large chunks of it away. For many doctors, this will have profound impacts on their ability to retire when they thought they would.
In addition, as a daughter of first-generation immigrant parents, both of whom were physicians, I am certain you had a front row seat watching your parents work hard to obtain their medical degree, residency, and then establishing a practice. This is not to say that other Canadians don’t work hard: the one thing that makes doctors unique is that our fees are set by provincial governments and our fees have not risen to keep up with inflation. Unlike other incorporated professionals such as accountants, dentists, and skilled trades, physicians cannot increase their fees to make up for rising costs. We are locked into the fee schedule determined by provincial governments (who are always employing cost containing measures to balance budgets). The federal government is turning a blind eye to this important point as it does not fall under federal jurisdiction. Nevertheless, the impact cannot be ignored.
As a corporate lawyer prior to being elected an MP, I’m sure you would not have wanted your hard work and education to be characterized with the words ‘tax cheat‘ if you had been using a legal way to save for retirement. This is the narrative being circulated in the media and it is deeply disappointing. It is noteworthy that MPs receive an annual pay raise (this year ranging $8000-11900), along with pension and benefits. This makes an MP salary one of the highest earners in Canada, with guaranteed income through retirement.
Yet, it is doctors who are singled out as being in the wealthiest 1% and rhetoric implying that we are not doing our part for less fortunate Canadians. We pay into personal taxes and contribute to the economy like everyone else. As small businesses, doctors support the economy through employing staff (nurses, allied health, receptionists etc.), paying rent, and financially supporting many Canadian companies providing support services to our practices (electronic medical records, medical office supplies etc.).
We are also entrusted with caring for the population of Canada in the most sacred way. This taxation measure comes at a time when the medical profession in Canada is suffering unprecedented levels of burnout. Millions of Canadians cannot access a family doctor because they have closed their practises and left (in large part, due to rising costs and fixed fee schedules). Why in an era when attracting medical graduates to do family medicine is a priority, would your government eliminate one of the few advantages that help new grads set up comprehensive practices so they can care for Canadians from cradle to grave? Does your government understand the downstream effect this capital gains taxation will have on patients for decades to come?
From watching media interviews recently, it appears that the federal government’s solution to this is “we will just allow in more foreign doctors“. This is deeply hurtful on many levels: it devalues currently practising physicians who have put in their life’s work to bring excellent care to this country’s patients. In addition, it takes many years for a doctor to acclimatize to the healthcare system in Canada. What happens to patients in the meantime? The solution is not to “throw the baby out with the bathwater”. The solution is to step back and really take in the impact of these actions and the message that has been conveyed to the physicians of this country. I hope your government will rethink this and choose to act fairly regarding incorporation for medical professionals.
Dr. Madura Sundareswaran guest blogs for me today. She’s a community family physician who’s resume is too long to print here. She helped found the Peterborough Newcomer Health Clinic and is a recipient of the CPSO Board Award which recognizes outstanding Ontario Physicians. This article originally appeared on her LinkedIn page.
The day people stop asking this question is the day we have fixed the primary care crisis.
I’m a family physician doing community-based comprehensive family practice in Peterborough, Ontario. I currently work in three different primary care models in our community – fee-for-service, a team-based family health organization, and nurse-practitioner led clinics. All of my colleagues work very hard providing excellent care to their patients.
Despite this, the latest figures suggest that 32,000 people living in the Peterborough region do not have a family doctor.
What does that look like?
A woman in Peterborough notices a breast lump today and is very worried about it. She frantically searches google and reddit to learn that there are no walk-in clinics here. She calls a number late in the afternoon for a local clinic for unattached patients, but all the spots are full for the day. Her options are a virtual doctor who will never conduct a physical exam – but she thinks an exam is important – how will they ever know what this lump feels like virtually? She wants someone’s expertise, she wants reassurance. She decides to go to the emergency department for this problem…but leaves after waiting for 9 hours. She is guilt-ridden as she waits there – she is not as sick as the others in the waiting room. No physician or nurse practitioner will have enough of a relationship with this woman to know that she recently lost her best friend to breast cancer and the impact this has on her illness experience. She is freaking out about this lump…alone.
Or…
A 68 year old male has seen a few pharmacists and virtual family doctor for his hemorrhoids over the last year. He decides that he just has to live with hemorrhoids. A google search says his symptoms are classic for the problem; he’s reassured. As a doctor, I know that this gentleman needs a physical exam but this man cannot find someone to do it. After a few months he winds up in the emergency department with terrible pain – a physical exam very obviously demonstrates rectal cancer. It’s had a year to grow.
Or…
George is a 58 year old man who has never had a family doctor. He has been on Health Care Connect for four years but no one has ever called him to say they have found him a family doctor or nurse practitioner. He is in “perfect health” so he does not need a doctor. He has never had his blood pressure checked, never been counselled on smoking cessation, and has never had bloodwork done. What he doesn’t know is that his Hemoglobin A1c is 7.4 (he has Type II diabetes but too early for symptoms), he has hypertension (high blood pressure – which in its most common form has no symptoms or signs), and his cholesterol is really high. George will probably have a heart attack in the next 10 years. The potential consequences of a heart attack are death. This was entirely preventable.
What we know: attachment to a regular primary care provider (family physician or nurse practitioner) leads to more preventative care, better chronic disease management, and lower rates of hospital admission (ref)
We need a solution ASAP
I eagerly watched as Ontario announced $110 million that will “connect up to 328,000 people across Ontario to primary care teams.” For my community this also translated to a promise for a community health centre (CHC) to connect 11,375 people to primary care. This is much needed but not enough.
Ontario Health Minister Sylvia Jones announcing expansion of primary health care teams
In order to develop a community health centre – a building must be built or set up, policies will need to be implemented, and several primary care providers including physicians, nurse practitioners, social workers, pharmacists, dieticians, etc. will need to be hired. Even if this could be set up within 12 months, where does that leave the other 20,625 in the region without a family doctor? I’ll tell you – scrambling door to door and still knocking asking if anyone is accepting new patients.
But wait! There are other options. A single full-time family physician working in one of Peterborough’s existing family health organizations can roster approximately 1300 patients and join an existing team-based model. We currently have job openings in every one of our five existing multi-disciplinary teams for family physicians. A clinic could be up and running in a matter of weeks. There are family doctors in this community who are very eligible to take on this job – and would likely consider it if they were fairly and adequately compensated.
Learning from British Columbia
I am a firm believer in learning what works and never reinventing the wheel.
In 2023, British Columbia completely revamped its pay structure for family doctors. They paid their doctors better and restructured compensation models – and apparently within a year they got 700 more doing comprehensive, community-based family medicine.
Dr. Ramneek Dosanjh, Past President of Doctors of BC, who called the new funding formula for family physicians in BC a “seismic shift”
I am going to make a few assumptions but I want to illustrate and oversimplify something here.
In the new BC payment model, the pay per full time doctor increased by $135,000/year (assume per full time equivalent). It wasn’t just a pay raise – it involved a few critical changes regarding what doctors could bill for and some restructuring. But the end result was a pay raise.
This resulted in an increase of 700 family physicians (assume full time equivalent) practicing comprehensive family medicine over one year.
Let’s say 1 full time doctor rosters 1300 patients.
If Ontario could get 700 new full-time family doctors to provide comprehensive, community-based family medicine, 910,000 people could now have a family doctor.
The entire rollout for the BC program is budgeted at $708 million over three years but this would include complete restructuring from fee for service care. Ontario already invests over $1 billion annually in interdisciplinary primary care teams and we have a significant head start compared to BC a year ago.
In contrast, Ontario plans to spend an additional $110 million to connect up to 328,000 people across Ontario to primary care teams.
Providing family doctors with the financial support and resources to set up their own practices is the best bang-for-your-buck approach if the goal is patient attachment to a primary care provider.
We need an all hands on deck approach. Support community health centres, nurse practitioner led clinics, but please also support family physician’s practicing family medicine. That is the only way you will achieve attachment for all Ontarians.
Your most obvious solution is pay family physicians better today – so they will hold off retiring for a couple more years and may actually sign on to take a practice.
British Columbia just proved that fair and competitive compensation for family physicians may result in more of them doing it.
Why do I care?
I have been in family practice for five years. I have a roster of patients who have access to a whole range of team-based primary care services – a pharmacist, a social worker, a nurse practitioner, an RPN and multiple other service through our family health team. Every day I get asked if I can take on a friend or family member as they do not have or just lost their family doctor. This simple ask creates a great deal of stress and guilt for me. I know what happens when someone does not have a family doctor or nurse practitioner. They will be sicker, they may die sooner, they will be alone trying to “doctor” themselves.
The moral distress of being made to feel like I am determining people’s fate – giving some people a high standard of care while others are left to fend for themselves will be what ultimately leads to my exit from this profession in this province.Why do I get to give a small handful of people comprehensive team-based care, while the rest (often marginalized, more vulnerable patients) get nothing? It is not fair.
What next?
We are all eagerly awaiting the next negotiation between the Ontario Medical Association and the Ministry of Health.
If we do not see a pay raise for physicians, or worse, we pay them less – everyone in Ontario can accept the reality that they may have a lovely multidisciplinary medical home with a diverse range of primary care providers – but a family doctor probably will unlikely be part of it.
The next time a leader or politician is raving about their new model for care – or pitch a strategy that does not include a family doctor I urge every tax payer and journalist to ask them:
1. Do you have a publicly funded family doctor? (Do you truly understand what it means not to have one? Have you ever had to endure the struggle?)
2. If you are so confident in your plan, would you be willing to give up your family doctor to one of the 2.3 million people in Ontario without one?
3. Why is fair and competitive financial compensation of family physicians not part of your multi-pronged approach?
We are listening to politicians and leaders sell us on an idea of a fully-funded, glorious renovation. Meanwhile the house is on fire. Your family doctors are a dwindling number of people who cannot contain the flames. What are they worth?
Just me again, your erstwhile, somewhat (but not completely) humble old country doctor. Like last time, I would point out that I am really not your harshest critic. I want to recognize that you have done much for health care infrastructure over the past few years.
For reasons that I cannot fully explain, the previous Liberal regime simply stopped building the necessary infrastructure to help Ontarians. Whether it was new (badly needed) nursing homes, new hospitals, or new teams, the Liberals basically did, well, nothing in terms of infrastructure. To your credit, you’ve reversed that trend and are building facilities we in Ontario need. (As an aside, you seem to like building things a lot!)
Ontario Premier Doug Ford
But all of that building will not mean much in two years (when the next election is – nudge, nudge, wink, wink) if, as projected, over 25% of Ontarians don’t have a family doctor. Yes, you can correctly point out that the decline in family medicine was caused by the Liberals (it truly was – Eric Hoskins was by far the worst Health Minister I personally have seen in my time in health care). You can point out that the Liberals slashed the capitation model favoured by most family docs that started the downward trend. You can also point out that their favoured Deputy Health Minister Bob Bell thought family medicine was so easy he could return to it after over thirty years away:
Screenshot
He even tried to mansplain one of the true leaders of family medicine on how the system should work.
Thx Doc Silvy. I suggest that we need fundamental re-think of highly prevalent, poorly managed conditions. Agree that GP focused practices have cropped up in many of these areas, Sports, MH, PC, Chronic Pain- real issue is lack of programmatic care across province. 1/4 https://t.co/hblPVJqDzX
It’s true Bell and Hoskins were completely wrong. That will NOT matter because by 2026, the general public will say – “well you’ve had 8 years to fix this – you haven’t done enough”. That’s just how politics is, and I think deep down you know that.
You can, truthfully, also say that you are listening to organizations like the Ontario College of Family Physicians or the Ontario Medical Association (OMA) and who continue to go on about how team based care is the future of family medicine and how it can help solve the problem. You may not know this but I was the founding Chair of the Georgian Bay Family Health Team . I happen to believe in physician led team based care.
But here’s the thing. It will take a minimum of five years (if we’re lucky) to build out all those teams. That’s assuming the bureaucrats from the Ministry GET OUT OF THE WAY and let front line family physicians be in charge of the teams. But we are losing family doctors by the week. The people of Ontario can’t wait five years.
There is one thing that can be done now however, to stem the tide, and stabilize the system. You need to give comprehensive care family physicians an immediate, and significant raise. How significant? You will need to give an immediate 35% increase to comprehensive care family docs along with annual normative increases for the next four years. If you think that’s outrageous – I invite you to look at Manitoba’s contract or Saskatchewan’s or British Columbia’s. The competition for comprehensive care family doctors has increased significantly, and Ontario is falling behind.
I can pretty well guess what your “advisors” are telling you. They will say you are in arbitration with the OMA, just promise to abide by the result. Honestly, I do believe you will abide by the result, both this year and next.
But…
Arbitration will take months this year, and months if not a year next year. Frankly, I doubt that the OMA, despite their strong words, will advocate for an increase of the amount necessary for comprehensive family medicine (hopefully I’m wrong).
I have absolutely no doubt that the Arbitrator, William Kaplan, will give a raise to family docs, especially after the recent award to nurses. But if the raise isn’t enough, you going out to the general public in two years and saying “we honoured the arbitrators rulings” – will make zero difference to the close to five million people who won’t have a family doctor. They will still blame you for not having been pro active.
William Kaplan, Chair of the Arbitration Board
Listen, I’m on the conservative side of the political spectrum. I’ve always voted for the Conservatives in every provincial election since I was eligible to vote. I live in Simcoe – Grey which is one of, if not the most strongly conservative ridings in Ontario. Heck, in the early 1990s we were the ONLY riding east of Manitoba to vote for a Reform Party MP.
I’m telling you that most of the voices on the ground are really upset about the lack of family doctors. We have about 7,000 patients without a family doctor in our area last I heard. It’s true that when asked who they will vote for in polls, they, like most recent polls, say they’ll vote conservative. However, they always add “I guess, there’s nobody else out there”. That softness in your vote is a problem, and that softness doesn’t show up in the poll numbers.
Listen, I want you to win the next election. I personally think the NDP would be a complete disaster. I have no faith the Liberals, who showed just how much they hate doctors, have changed their tune. But in order to do that, you’re going to need to bite the bullet, and stem the haemorrhage of family docs.
Go to tell your negotiations team to offer up a deal that strengthens family medicine. Mask the increase with things like retention bonuses (like Manitoba) and matching RRSP payments (like BC) and other methods (paid admin time, paid supervision of team members and pensions would be nice). But get it done ASAP.
Otherwise, I genuinely think you will be in more trouble than you might be led to believe by your handlers in 2026.
Lots of talk on the net about how the economic model for family physicians no longer works in 2024. My own blog site has had guest posts dedicated to this issue. There has been some criticism of this position. Dr. Darren Larsen in a reply to the post linked above suggests he is “not seeing or hearing…ideas for solutions“. He further states that all paying doctors more will do is create a “better-paid, unhappy professional. Nothing has changed.”
Others have made the similar comments. There is nothing philosophically wrong with the argument to reduce workload instead of raising pay. Practically speaking however, history has repeatedly taught us that the Ministry of Health (MOH) bureaucracy is incapable of delivering on that promise.
Some personal stories:
In the mid 2010s I was a Peer Lead for OntarioMD (no really!). I was frustrated by the Ontario Lab Information System (OLIS) because I had to manually retrieve all the lab work for a patient individually in their chart. Hospital Report Manager (HRM) by comparison, sends reports on all my patients directly to one inbox. (why we need two systems – and now more, is another story). The then VP of OntarioMD informed me they were working on “Practitioner Query” – which would allow me to get all my lab work from OLIS in one inbox. This was supposed to be ready in six months. That was over a decade ago.
From 2014-2018, thanks to the vision of my colleague Dr. James Lane, we developed an integrated health portal as part of our Health Links project for South Georgian Bay. For $35K a year, we were able to ensure that nursing homes could message physicians on their EMR. We dramatically reduced paperwork for physicians from nursing homes, improved health care outcomes, and reduced hospitalizations thus saving the entire health system money.
The MOH bureaucracy couldn’t wrap its head around this and wouldn’t allow it to continue.
For those of you who think I should have told people about this project, I wrote an article in the Toronto Sun about it. Afterwards, I got invited to do a presentation on this with the then CEO of eHealth Ontario and her senior team. Heck, when I was a keynote speaker at OntarioMDs Every Step conference in 2019 (no really!) I presented this project. The then head of the MOH Digital Health Team was there and heard it. Still, the bureaucracy couldn’t see their way towards allowing a project that saved physician time (and improved health care outcomes) could continue.
Ok, ok, so this blog is just for me to complain about not being listened to right? Well no, there are multiple other examples.
One workload issue for family physicians is keeping track of which of our patients get immunized for which vaccines. If only there was a central tracking system that sent the information to us directly. Wait, there is! The Covax system for tracking Covid vaccinations. Obviously the easiest and most sensible thing to do is expand the already existing system to add all the other vaccines so we get notified (eg when public health gives Gardasil). Yet 3 years after Covax, the MOH can’t even make this simple common sense change.
More? When I was on the SGFP Executive, one of our senior physicians told us the story of how he was on a working group to make the schedule of benefits (the fee schedule for Ontarios doctors) easier. After six months of meetings, they made a decision to add a comma to the descriptive sentence of one code. One comma in an 800 page schedule.
I could go on but you get the point. It’s fine for the MOH to say that that they promise to reduce the Admin burden for family docs. But frankly to these aged and cynical ears, it just sounds like them saying “This time we really mean it, honest!” – kinda like when Lucy promised to hold the football down for Charlie Brown for real this time, with predictable results.
As with all emergencies, we need to have an effective triage system in place. Deal with the most urgent thing first, then go on to other things. We clearly can’t wait until 2034 for the MOH to implement some of the workload reducing schemes they might have (and no matter how much they promise they really mean it – it will take that long). So the first thing that needs to be done is bring financial stability to family practices so that they can continue to function while we sort out everything else.
Now, given Ontario physicians are in the midst of negotiating a new contract with the Ontario government, I expect the MOH team to say to our own negotiations team something like – “I know you guys want X% increase, but we can only give you 1/2 of that, but we promise to reduce your admin burden so you are working less hard”. I would do the same if I was them.
But, my expectation, and the expectation I think of the majority of doctors in Ontario, would be that the OMA negotiations team looks at the MOH team, and quotes the best engineer in the history of Starfleet to them.
With apologies to Geordi Laforge, B’elana Torres, Trip Tucker, Jett Reno, Andy Billups, and Hemmer – but Scotty was the BEST ENGINEER in the history of Star Trek!
The first step towards fixing the crisis in family medicine is a new physicians service agreement that stabilizes family practices. Once that’s done, work can begin anew on health systems transformation/workload reduction and so on. To try to do it the other way round, or even hand in hand, is a recipe for further collapse of the health care system.
Dr. Alex Duong, a family physician from the Vanier district of Ottawa (which amazingly enough is one of the more underserviced areas of Ontario).
Recently, Maria DiDanieli, the clinical lead for system navigation at the Burlington Family Health Team, published an opinion piece in Healthy Debate that was critical of the decision of Drs. Alam/Mathew and yours truly to recommend that family practice residents bide their time instead of starting up a comprehensive care practice in Ontario. Dr. Duong replies and has kindly allowed me to reproduce his reply here.
I am a full-time community family physician, and I read this article with great disappointment.
I am at the face of our health care system. When patients cannot get a timely breast biopsy or a knee replacement, they come to ask me. I address their frustrations, alleviate their pain, and manage expectations.
I am the backstop when issues are missed during transitions in care and issues that require follow up.
I am the navigator that helps patients, and their families orient themselves to housing resources, mental health and financial resources.
I am the advocate for my patient’s health when they deal with their employer or insurance companies.
I do all these things and more, alongside everything from newborn care to palliative medicine.
I, like the great majority of family physicians, take pride in our work, and in what we contribute to our patients and the community at large. But Banks do not grant loans for a new clinic based on my contributions to Ontario’s healthcare system. My rent payments do not decrease because of the positive impact I make on my patients’ lives. The salaries of our exceptional staff are not funded by the sound of clanging pots and pans.
Today, to outfit a new clinic with the minimum number of physicians for a FHO requires high 6 figures to 1 million dollars, loaned at 6.95% interest. We guarantee our own lease – we are on the hook for ensuring it gets paid for the entire term. We are responsible for hiring and ensuring our staff are paid a living wage. We invest our own time in making sure the clinic runs. For many community family physicians like me, there is no assistance for any of this from any level of government. No money for staff, no incentives for starting up, no support for logistics. We are in a precarious, failing business model with ever growing administrative burdens patching the system equal to a part-time job. We have been trying to expound on this, and frankly have been completely unsuccessful in this.
You realize that “… there does not seem to be much political will to improve this situation at this time.” Yet, you ask family physicians to work harder expecting a different result from the government.
You state that “With these current barriers and shifts, any new practice can feel fragile or vulnerable to imminent obsolescence.” Yet, you expect new graduates to take on a massive financial risk: long term lease, EMR contracts, and double their already tremendous debt in start-up costs.
You lament that “Instead of acting as beacons of wisdom, encouragement and level-headed advice, we see a growing shift toward inciting everyone to walk out!”. Do you apply this standard to the teachers in Quebec who recently concluded a strike? Are they less dedicated to their students? Do you apply this standard to all groups who organize to make their voices heard?
The authors, Drs. Alam, Gandhi and Mathew made it clear that there are many options available to new family doctors. They warn of the current state of specifically locking into comprehensive family medicine, to ensure that new grads do not put themselves in a position where they will be burnt out early in their career. To me, leadership requires honest conversations, not empty promises, or exploiting the ideals of new family doctors. I find it unethical to sell a romantic vision of what it is like to start and maintain a Family Medicine practice in the current environment. It is a recipe for moral injury when those ideals run flat into the economic realities, as I have experienced.
And frankly, to say to those of us, like myself, still practicing longitudinal family medicine we should be working harder, or we are just doing family practice wrong is demoralizing. It is grossly offensive to my early-mid career family medicine colleagues who have burnt out through great moral struggle and guilt. Disillusioned family physicians who leave longitudinal family practice will not return. The greater harm to the public and to patients is not the Star article that speaks truth to the issue, but the issue itself: that family physicians, whose concerns are being gaslit, continue to leave longitudinal practices.
Just me again. The grumpy, aged quack with a history of being a bit of a thistle in your obliques. Well intentioned I assure you (although I’m told some may not see it that way).
Negotiations with the provincial government on a Physicians Services Agreement (PSA) continue and mediation began on February 20th. That’s all great and part of the process. However, things HAVE CHANGED a lot since the last time I wrote to you and urged you to set a strong mandate.
I am asking you to revisit the negotiations mandate at this time, in light of threenew key pieces of information that are very relevant to Ontario doctors.
To recap – the negotiations mandate is the bare minimum ask that the Negotiations Task Force (NTF) can accept on behalf of the Board. If the government makes an offer that meets or exceeds that – well, then they accept it on behalf of the Board and the Board is compelled to endorse it. The mandate is, quite correctly, confidential (you can’t let the other side know your bare minimum ask any more than they would let you know their mandate). But it’s up to the Board to determine if the mandate is enough (not the NTF).
Now to be clear, I’m not saying you should revise it, just revisit it. Perhaps the mandate is already sufficiently strong. That would be great. But things are different now.
The first reason to revisit the mandate:
Other provinces have surpassed Ontario physicians in terms of income. BC and Saskatchewan have significant deals to stabilize the physician work force. Manitoba’s deal with physicians appears to be the best of the bunch. Manitoba has not only a well deserved increase for all physicians, but significant steps towards gender pay equity.
As an aside, while I applaud the fact that DoctorsManitoba made steps towards gender pay equity, I’m forced to wonder what happened to Ontario? When I was on the OMA Board we were proud of the fact that although it was too late, we were the first PTMA to report on the issues around gender pay equity. We proved that the pay gap was not because “women work less hard”. What happened ?
Also, to be clear I want to acknowledge that the negotiations counsel (Messrs Goldblatt and Barrett) are very well aware of any topic that could affect negotiations. I remember Darren Cargill, who at the time was on our NTF, told me “they read everything.”
Howard Goldblatt, Negotiations Counsel for OMASteven Barrett, Negotiations Counsel for OMA
Therefore, I know they read the Manitoba Schedule of Benefits which is available online and reported back to you. I’m sure you are fully aware of the retention bonuses in that deal. I’m sure you know about the significant changes that decrease the gender pay gap. I’m sure you know about the fact that Manitoba pays physicians for Admin time. And that their capitation model has no negation (although a lower base rate). And that they have an age premium. A pelvic exam premium (gender equity again). And that they allow extra payments for dealing with more than one problem at a visit. I have absolutely no doubt that our negotiations counsel has fully and thoroughly advised you of this, along with the benefits of the deals in BC and Saskatchewan.
The second reason to revisit the mandate:
The crisis in family medicine is spiralling out of control, faster than I thought possible. Not only is it badly affecting patient care, but the health, well being and morale of physicians is sinking like a stone. Last September, I never dreamed that I, along with Drs. Alam and Mathew, would write a letter to Family Practice residents telling them to stay away from comprehensive family medicine in Ontario. I never dreamed that there would be story after story after story of individual family physicians openly talking about how they were burning out. This situation has gone form bad to desperate frighteningly quickly.
The third reason to revisit the mandate:
Bill 124, the piece of legislation that limited increases to the public sector, was used to promote a low ball PSA to us the last time. You even, admittedly and embarrassingly, convinced a guy who should have known better. It’s ruled unconstitutional and the government will not appeal this. In fact they will repeal the Bill entirely. In light of that, many other public sector workers will be asking for catch up pay.
So it really is time for you to re-visit the negotiations mandate. Just double check to make sure it’s as strong as it should be given the above factors. Make sure it takes into account that the the BC deal has attracted over 700 physicians to comprehensive family practice. Make sure it recognizes that Manitoba will likely be showing a net growth in physicians shortly, and can reasonably attract physicians from out of their province. If you have to revise the mandate upwards after looking at it, then do so.
NB – IF the NTF were to push back if you do revise the mandate upwards, then make sure you hold your ground. Remember, YOU are the Board and YOU give direction to ALL committees and task forces, including the NTF. I’ll be careful how I say this so as not to divulge Board confidentiality, but the NTF in my day did have a proposal on one particular issue (not the whole PSA) that they told us to approve and our Board pushed back and said no. We had to listen to some (quite eloquent) speeches about how hard they worked and this undermined their work and so on and so forth – but after that they went back and kept negotiating as directed. Don’t do any less this time.
These negotiations are likely to make or break the profession for decades to come. They are that important. You owe it to your members to take another look at the mandate.
The following letter was jointly written by the three of us and published in the Toronto Star on February 20, 2024. It is being reproduced below so that we can share the letter on Facebook as we believe it will be of interest to physicians across Canada.
To All Family Medicine Residents,
We are writing to say congratulations! You are nearly at the end of a decade of hard work, perseverance and sacrifice; ready to start your career and “real life”. You have joined a beautiful and unique specialty. You will be the key to the healthcare system. You will find answers when patients arrive with ambiguous symptoms. Others will tag in and out of a patient’s health journey. You will stay and be an essential part of the beginning, middle and end of every patient’s story. You will save lives.
Your skill and knowledge are unparalleled, and there isno substitute for your expertise.
Which is why with heavy hearts, we, the undersigned, recommend that you do notstart your own family medicine practice in Ontario. Not right now.
In short, it is becoming frankly unsafe to run a family practice in Ontario, especially for those just starting.
We are family doctors with decades of experience. We are also physician leaders, past-presidents and board directors of the Ontario Medical Association (OMA), academic faculty, and health policy experts. We understand the situation well.
Do not sign that contract. Do not sign a lease, hire staff, buy equipment, contract with an EMR or any of the million things that must be done so that you can start a comprehensive care family practice.
Starting a practice at this time will require you to continue to sacrifice everything else in your life. If you have debt, you may not be able to pay it down, let alone start living the life you and many others have postponed for so long. You will struggle to spend time with your family, buy a home, care for vulnerable loved ones and more. You will continue to work at a non-stop pace, this time with no end in sight.
What can you do in the meantime? Work in hospitals, hospices, operating rooms and long-term care. Work in obstetrics, anesthesia, as a hospitalist, in emergency or palliative care, oncology, sports medicine etc. Be a locum. Bide your time.
You are skilled, smart, and adaptable. Your knowledge is extensive, demonstrating an unmatched depth and breadth of training. Use it.
When people leave comprehensive care family medicine, they almost never come back.
We don’t want that to happen to you. When the government of Ontario recognizes family doctors as the foundation of medical care, negotiates a fair contract and improves health policies to reflect patient needs in 2024… well, when that happens, we will write a different letter and welcome you to the world you were meant to be in.
We hope by then it is not too late.
Sincerely,
Dr. Nadia Alam, comprehensive care family physician and anesthetist, past-president of the OMA
Dr. Sohail Gandhi, comprehensive care family physician and hospitalist, past-president of the OMA
Dr. Silvy Mathew, comprehensive care family physician and long-term care, past-board director of the OMA
justanoldcountrydoctor 