@OntariosDoctors – Page 3 – justanoldcountrydoctor

The Arbitration Award: The Good, The Bad, The Ugly

On Sep 12, Ontario Medical Association (OMA) Board Chair Dr. Cathy Faulds announced that the Kaplan Board of Arbitration awarded Ontario’s doctors 9.95% for the first year of their Physicians Services Agreement (PSA). Sounds straightforward right? Nope – it’s actually ridiculously complicated.

I’ve looked at the award. I may have some of this wrong (copious documents found on the OMA website induced catatonia, hypersomnolence and cluster headaches). But this is my take.

A simplified (I have a small brain) set of numbers first:

Total award: 10%, approx value $1.6 billion dollars

Amount for general feel increases: 7% or $1.12 billion dollars

Amount for “targeted funding”: 3% or $480 million dollars.

In the past the OMA and Ministry agreed 1/4 of the raises would be across the board, the rest done with “relativity in mind”. IF we do that again then $280 million (1/4 of $1.12 billion) will be in across the board increases. Every specialty would get a 1.75% raise. The rest of the money ( $840 million) would be for raises based on relativity. So all specialties would get 1.75% + X as a raise. The “X” would vary. It would be more for low income specialties, and the X would be lower or even zero, for the high income specialties.

The Good.
There’s a raise. The MOH Team stated that Bill 124 should not impact the deal. The arbitrator disagreed and felt that we were unfairly treated because of Bill 124 stating:

“Bill 124 directly impacted the bargaining even though physician compensation was not subject to its terms.”

Hence, the MOH Team completely lost their argument that there should be no redress, and there was a 6.95% redress given.

There was a recognition that family practice is in crisis. In his ruling the Arbitrator said:

“We accept on the evidence that there is a physician shortage. Somewhere between 1.35 million and 2.3 million people in the province are not attached to a family doctor. These are real numbers. The Ministry’s own documents – which we ordered disclosed–demonstrate that there is a problem to address.”

The arbitrator had to order the Ministry to disclose this?? Jeez. Additionally, the Arbitrator noted:

“Clearly, more family doctors are needed as are more doctors practising comprehensive longitudinal medicine…..it is obvious that the citizenry is ageing – the Government acknowledges this brings with it increased complexity…”

Contrast this with the Ministry’s absolutely laughable position that there is “no concern” about a shortage of doctors. This is frankly a warning shot, and a welcome one, to the MOH’s negotiations team to not say such stupid things again, and to change their position in future rounds of negotiations.

Dr. David Price, member of the Ministry’s negotiations team

In another shot to the now obviously inept MOH Negotiations Team, the Arbitrator agreed that admin burden also needed to be addressed with, you know, money. He stated:

“We have reached the conclusion that targeted increases – not necessarily baked in – should be allocated to the reduction and redeployment of administrative work that can best be performed by others or through digital or other measures.”

Finally, It was quick. OMA Board Chair Cathy Faulds had told us not to expect an award until the end of September. Who knows why Kaplan put the award out so quickly.

The Bad.

This will not be enough. The OMA asked for a 22.9% increase. They got less than half of that. This is not really the big win the OMA is portraying it as.

A 10% increase in gross billings for family medicine will not be enough to stop the haemorrhaging of doctors from comprehensive family practice. The “X” for family medicine (see above) needs to be high, and much of the targeted funding needs to go to family medicine too.

And, while it’s true that the Arbitrator recognized there was a crisis in family medicine, the award given did not really do anything in and of itself to stabilize family medicine. It’s true that was not part of the scope of the arbitrator for this round (this round was for a fee increase). The fact that some practical guidance in how to resuscitate family medicine is missing is still bad for all Ontarians.

The Ugly

The implementation of this award is going to be a nightmare. As I write this, there is no indication that the MOH and OMA have agreed on how to divide up the $1.12 billion in general fee increases based on relativity. In fact, indications are that the MOH will continue to fight the methodology, meaning it could be a very long time before fee increases for specialties are set.

Worse, the OMA and MOH have not been able to agree on how to distribute the $480 million in targeted funds. Which means….more mediation and arbitration. I continue to concede that the OMA states arbitration and mediation will be done by mid- March 2025. I continue to not hold my breath.

Even uglier is that one solution being proposed would be to give “everyone” a 9.95% increase right now, until the relativity and targeted funding is sorted out. But that would mean that some of the higher paid specialties would see a 9.95% for a bit, only to have a relative cut once the final fees are sorted out (also to be arbitrated by March 3-7, 2025). No matter how you message this to warn people – this will cause problems when people see a decrease in income after a rise.

All of which means that the retroactive pay for this year may not come for over a year. If you are a physician who has some decisions to make (eg do you renew the lease on your office at the higher rates the landlord is demanding) – you are going to be awash in uncertainty.

The ugliest part of all of course, is that a bunch of lawyers are going to get really rich as their billable hours go through the roof during this process.

There is a better way.

The government’s main concern should be about expenditures. That decision has now been made for them. The PSB will go up by $1.6 billion. That money will have to be paid one way or another.

The government can now, especially after being told off by the Arbitrator back off from their polarizing and obstructionist path, accept the OMA proposals for implementing the award. They cover what the government states it wanted (pay lower paid specialist more of an increase than higher paid ones). They also covers issues around admin burden which the Arbitrator acknowledged exist, and the shortage of family physicians (which the arbitrator also acknowledged).

The total amount spent by the government is going to be $1.6 billion regardless. Getting rapid agreement on the distribution of those funds will decrease the uncertainty about how much goes where and will shorten the time it takes doctors to get paid, which will stabilize the health care system.

Then, for the love of Allah/God/Yahweh/Great Universal Consciousness – the government now needs to realize that you can’t fix health care without working co-operatively with your doctors. Go look at other provinces. Copy them and get a fair deal for years 2-4 of this agreement.

Or the government can continue to obstruct, obfuscate, delay and impede any real progress towards working together with more protracted, internecine mediation and arbitration. The ball is in their court.

What should doctors do?

The above represent my personal interpretations of the documents I read. I encourage all Ontario physicians to register for the OMA live session on Tuesday Sep 17 from 7:30 – 8:30 pm to hear more details about this agreement.

Never Ending Arbitration a Sign Government Does NOT Want to Work with Doctors

News Item #1: Prince Edward Island agrees to a contract with its doctors. Amongst other things, the deal recognizes that family medicine is a specialty (finally!) and increases compensation to reflect that. It also introduces strong measures to reduce red tape and administrative burdens, and adds what appear to be retention bonuses. PEI joins British Columbia, Manitoba, Saskatchewan and even Alberta (!) in working co-operatively with their doctors.

Dr. Krista Cassell of Medical Society of PEI with Health and Wellness Minister Mark McLane and Health PEI CEO Melanie Fraser

News Item #2: Ontario Medical Association (OMA) Board chair Cathy Faulds announced last week that the Kaplan Board of Arbitration will not deliver a ruling on the fractious contract dispute between Ontario’s doctors and the Ministry of Health (MOH)at the end of August as expected. It is delayed until at least the end of September, if not longer.

Now you, dear reader, are probably wondering why I refer to a one month delay as “never-ending”. Firstly, because I’m not convinced it’s only one month. I don’t recall the Arbitrator ever giving us a timeline for when he was going to give a decision when I was on the OMA Board. Timelines for meetings and hearings, sure – but for the decision, no.

But more importantly, even if there is a ruling in September, it’s nothing but a mere step in a protracted, convoluted process that, at the end of the day, does nothing more than show that the government would rather not engage the OMA in providing solutions for our health care crisis. To understand why, one needs to first appreciate the prolonged nature of the current arbitration process, and just how tortuous it is. (I will do my best).

First, the current arbitration process is ONLY for one PART of the first year of what is supposed to be a four year contract. It will cover April 1, 2024 to March 31, 2025. BUT, it will only cover a percentage increase for that one year. It will not set specific fees for different specialties. Instead, there was general agreement (last I heard) that 70% of the increase would go towards fee increases and the other 30% would go towards targeted areas of high need.

Sounds simple enough to sort out right? If the deal is worth, say $2 billion (this number is totally made up and Mr. Kaplan, if you are reading, this number is much less than the increase should be), then $1.4 billion would go towards fee increases, and $600 million would be targeted towards areas of need.

The problem is that the fee increases are to be distributed along what’s know as a “relativity model”. Essentially lower paid specialists are to be given a bigger raise than higher paid ones. Unfortunately, the OMA and MOH can’t agree on how those raises are to be distributed amongst the various specialties. Worse, they can’t agree on how to distribute the 30% that was earmarked for “targeted funds”.

Which means…..you guessed it, ANOTHER round of arbitration with yet another set of decisions to be ruled upon by the arbitrator. This additional protracted process won’t begin until the arbitrators first ruling and further negotiations and mediations. The information on the OMA website suggests arbitration for those issues won’t happen until March 3, 2025.

But wait, didn’t I say that this was only for the first year of the four year contract? Why yes, yes I did. Which means that after this, we now start arbitration AGAIN for years 2-4 for the doctors contract. And yet again, not only do decisions needed to be made on the percentage increase, but on how that increase is divided up. Which means…….potentially many more rounds of arbitration.

I would concede the OMA websites suggests all of the year 2-4 arbitration, and left over issues from year one can be done at the same time (March 3-7, 2025). However, I will refrain from betting the mortgage on that actually coming to fruition. We are one early election from this timeline being thrown into chaos. The cynic in me thinks that by the time arbitration is all done for this supposed four year cycle, it will be time to start negotiating (and yes more arbitration!) for the next four year cycle.

The government will most likely abide by the initial arbitration award (it’s doubtful they would reject an award prior to an election call). Ontario Health Minister ~~Galen Weston~~ Sylvia Jones will frame this as part of the process for coming to an agreement. She will (probably) claim that by abiding by the award the government is “working with” physicians to benefit the health care needs of the province.

She will be wrong.

I’ve mentioned this before, arbitration is preferable to the days when governments could unilaterally cut physicians income at the whim of the health minister. However, that doesn’t change the fact that arbitration should be viewed as a necessary evil, with emphasis on the evil. Not only can it demoralize people who are going through it, the spill over effects have wide reaching consequences.

What does this mean for the general public? The OMA has come up with some solutions for the various crises our health care system is facing (2.5 million without a family doctors, worsening health care catastrophe in Northern Ontario, overwhelming bureaucratic burden etc). The reality is that many of the solutions require changes that need to be made in a contract with Ontario’s doctors. But we don’t have one, so none of these will be implemented.

Instead of working co-operatively with the OMA to come up with solutions in a fair contract, the current government seemingly prefers to leave it all to the arbitrator. And as a result, patients will continue to suffer.

The government of Ontario has a choice. Follow the lead of BC, Manitoba, PEI and so on and work with the doctors to help patients. Or set up a perpetual conflict with them.

Over to you Minister.

Ontario Health Minister Sylvia Jones, who can start to fix things tomorrow, if she wants.

Reflections on Leaving Family Practice

My thanks to Dr. Ramsey Hijazi, founder of the OUFP, and one of the strongest advocates for improving family medicine that I know, for guest blogging for me today. Unfortunately, the government didn’t listen to Dr. Hijazi, and as a result he left family practice earlier this year. In this blog he reflects on how his life has changed since.

It was a busy Saturday morning at my daughter’s dance competition in April 2024. The family had all got up at 5am to get ready for the day. The morning was hectic getting the kids and dog dressed and fed, making sure we didn’t forget supplies for the day, packing snacks and then rushing across the city to Hull for the competition.

My wife helped bring my daughter and her sister backstage to get dressed and prepare for practice. I watched my 2 year old son run tirelessly down the hall of the venue screaming in pleasure. I watched with a sense of calm and patience that I hadn’t felt in a very long time. More than I can remember I felt….present. The previous day I had left my family practice to pursue a position as a hospitalist. In less than 24 hours (and to my own disbelief) I noticed a distinct difference in my frame of mind.

Leaving family practice was not an easy decision. It is a rewarding and challenging career where you can make a positive difference in the lives of your patients. You get to know your patients better than anyone else in the medical system as you care for them from birth to old age. Their journeys in the medical system can remain with you forever. I became a family doctor because I loved family medicine and I am grateful for having had the opportunity to practice and take care of my patients. It is also part of the reason I started the Ontario Union of Family Physicians in July 2023 to help advocate for changes to improve the working conditions of family doctors. I had hoped to continue this work.

However, over the last several years the landscape of family practice has deteriorated significantly. The administrative or paperwork burden in family medicine has ballooned to almost 20 hrs/week. It is a constant barrage of work that is being downloaded or dumped on to family doctors from specialists, insurance companies and pharmacies. There’s also the extraordinary duplication of lengthy and sometimes irrelevant hospital reports that come in daily for review.

In essence, you supervise every single step all of your patients take in the medical system whether you have seen them recently or not. You ensure that tests and follow ups are completed and that nothing falls through the cracks. If my patients did not have me overseeing their journey in the system, countless tests and follow ups would get missed and never take place.

Like it or not, family physicians have been unofficially assigned the responsibility to make sure things actually get done when no one else will. It is mentally exhausting. There were days I would come home from work feeling so overstimulated I could do nothing more than sit on the couch and keep silently to myself for the rest of the night (although young kids make that a difficult reality to realize).

In an age where patients can simply email their family doctor you are never unplugged from your job. Despite trying to convince myself that I wouldn’t think or worry about work on vacation, I couldn’t help but have intrusive thoughts that occupied my mind. I would drift away from the present moment I was trying to enjoy. Often I would use the first and last days of my vacation as a desperate attempt to try and be caught up.

On weekends when not much was happening, such as watching TV with the kids or supervising them in the backyard I also couldn’t help but have the same intrusive thoughts of thinking my time could be better spent trying to catch up on the paperwork that was piling in. I very much resented having these thoughts.

Now add this to the stress of running a family practice. Business expenses have steadily increased with a dramatic spike in the last 3-4 years without any real increase in OHIP revenue. Running a business can be a stressful, but worthwhile endeavour. Unfortunately, this couldn’t be further from the reality of running a family practice. Revenue from OHIP continues to pay less year over year relative to inflation and expenses.

The OMA has kept track of OHIP rates relative to inflation to show current rates are only 37% of what OHIP used to pay physicians to run their practice. For the newer family doctors entering practice the future stability of the profession is truly grim. They enter practice with huge loads of debt and an almost guarantee they will take home less and less money every year despite the workload contrarily increasing year over year. With no pension, benefits, paid sick time or vacation to top it off, the reality for recent grads is that without significant changes to help the profession, it is no longer a viable career option.

Many family doctors work side jobs to help financially subsidize their practice. Granted, the entire medical system is plagued with poor working conditions, underfunding and increasing burdens of work, however, the situation is particularly magnified in family medicine. But you don’t need to take my word for it, just look around to see what is going on in your community and in our province. Despite the OMA showing statistics that we have more doctors trained in family medicine per capita than ever before, we are in one of the worst shortages ever.

Family doctors simply don’t want to do family medicine any more.

Changing my career path to work in the hospital as a hospitalist was a big risk and required a leap of faith (I hadn’t worked in a hospital since I finished residency). But unfortunately, in family medicine I had become increasingly unhappy professionally and personally. As it turns out, becoming a hospitalist was the best decision I could have ever made. Working in hospital means I am responsible only for the patients on my ward and not 1500 patients in the medical system. I must round on and see each patient to review their medical problems, perform examinations and order any tests or investigations. I follow up with family when needed and appropriate for medical updates. At the end of the day unless I am on call, I walk through the door to go home and my work is done until I arrive again the next morning. There is no appointment schedule to rigidly follow and I can take as much or as little time that is needed for each patient. If something unexpected occurs, I can deal with it and get back to my work without the worry or stress of being behind schedule and having irritated patients. It is also challenging and extremely rewarding.

No longer do I have all the stresses of running a business or see up to 40% of my OHIP billings go towards business expenses. No longer do I need to reconcile rushing several patients in and out of the clinic for appointments to stay on schedule and maintain a reasonable availability while also trying to give the appropriate time to address their concerns. No longer do I leave work at the end of the day, eat dinner with the family and go back to the computer to tackle the never ending pile of paperwork. No longer do I need to worry and stress while on vacation about all the work that is piling up in my absence. No longer do I have the intrusive thoughts of working on paperwork while watching the kids ride their bikes or to watch my son run down that venue hall aimlessly in pleasure.

I am more present and at peace. I am a better person, husband and parent because of my decision to leave family practice and that is perhaps the saddest and scariest thing about this entire journey.

This Must Be the Health Care System Canadians Want

Patients lined up to register for a family physician in Kingston (image first published on CBC.ca)

For this blog, I will be telling some patient stories. They are not all my patients, but people in my area. The stories are real – the identities have been anonymized.

Last week, I received yet another rejection letter from a specialist, in this case a neurosurgeon. He declined to see my patient because his practice was “too busy to see the patient in a timely manner”. Which of course means more admin work for me as I try to find another neurosurgeon for my patient. I do a lot of procedures as a rural family physician, probably more than the average doctor – but neurosurgery is a bit beyond my skills.

All of which got me wondering (again) how our health care system, which in Ontario was once rated the best in the world (no really) came to fall so far that a certain grumpy curmudgeon has openly said if he gets sick, he would go to Turkiye. The only answer to my mind, would be that it’s because Canadians are okay with it.

LC, early 40s, seen in emergency for sudden abdominal pain. CT scan sadly shows advanced cancer. Specialist refuses to see her until she goes to a “screening clinic”. Three weeks to get to the screening clinic, that agrees it’s cancer. Refers to specialist who orders more tests. Treatment doesn’t begin until 12 weeks after the diagnosis.

Why do I say Canadians are ok with this? Because for all of the noise on social media, and for all of the news reports highlighting ER closures, delays, and lack of health care staff, I don’t really see people organizing to demand change.

Look, if ten years ago, someone had told me, hey, in 2023 in Ontario there would be over 800 times when an Emergency Department has a partial shutdown, 2.3 million people would no have a family doctor and wait times would be forcing people to consider leaving the country to get health care, well, my first thought would have been “I need to avoid Queen’s Park, there’s gonna be a protest there every day”.

KX, 85 years old, in good health, debilitated by arthritis pain in his hip. Can’t get a fluorscopic cortisone shot to his hip for 5 months, and a specialist who does this in office under ultrasound is over 100 miles away, and has not responded to a referral request yet. Has been limping and on addictive painkillers for 3 months with no appointment in sight.

I see people protesting and demanding change for any number of issues (and I stress many of these are important causes that I support). I have yet to see the kind of sustained pressure on government needed to force drastic change in Health Care.

I’m not the only one to suggest this. Dr. Stephen Major, now the President of the Newfoundland and Labrador Medical Association (NLMA) suggested that the public has become “complacent” about health care. He correctly points out that while fish harvesters protested and shut down Confederation Building in May, he has yet to see a protest about the fact Newfoundland has over 100,000 people without a family doctor.

ET, severe sciatic style back pain. First sees the family doctor who correctly diagnosed this clinically. MRI ordered – which took 5 months to get, confirms sciatica. Referral made to back surgeon. 6 months later – still no word from back surgeon. Currently 11 months of waiting in daily pain to be assessed by surgery – still no operative time booked.

Canadians have a well deserved reputation for being “nice.” The BBC implies we can teach the rest of the world to be nice. We are polite to each other, polite to tourists and we have a habit of saying “sorry” to just about everybody – regardless of whether it’s our fault or not.

Perhaps it’s this inherent niceness that keeps us from protesting daily at each and every one of our Provincial Parliament buildings. Perhaps it’s because of an attitude that “at least our health care is free” (even though it is definitely not – your taxes pay for it). I don’t know. But I do know that for those of us in health care it really seems like the general public is content about the state of the health care system.

DD, 4 years old. Significant behavioural issues compatible with Autism Spectrum Disorder. Referral to paediatric team for assessment. Message returned informing there is a two year wait to see the paediatrician.

But wait, aren’t doctors and nurses organizations advocating for better health care? Of course they are. But the blunt reality is that there are about 43,000 members of the Ontario Medical Association, and 190,000 or so nurses in Ontario. To truly enact change – millions of people need to demand it because millions of votes will matter to politicians.

I’m not seeing that happening.

BC, 40 years old. Complex psychiatric situation. Referred by family doctor to psychiatry. Two months later a message back that this is not suitable and should be referred to Ontario Structured Psychotherapy. Six months after that an intake assessment is finally done, and was told will be entered into the program, but wait time to start the program is twelve additional months.

Our health care system continues to collapse all around us. Governments across the country appear to be making mild to moderate changes to the health care system. But the kind of bold, truly transformative change to health care (like has been done in other countries) will require Canadians to stop being so complacent about health care and protest regularly, repeatedly and with perhaps a little less niceness.

Will they?

Dear Minister Jones – Fire Your Negotiations Team.

Dear Minister Jones,

Just me again, a certain crotchety and increasingly cantankerous geezer offering you advice in an open letter that you are not likely to take. But you would be better off if you did. More importantly, so would the people of Ontario.

First, I would once again suggest that you have done some good work in the health ministry. Moving surgical procedures to outpatient clinics, increasing the number of diagnostic testing facilities, starting a new medical school focused on training family doctors and more are all good moves. While the effects of some of those decisions will not be felt for many years – the reality is that somebody had to do this to help health care down the road and you’ve done that.

Unfortunately however, the past couple of weeks have been catastrophic for your Ministry’s relationship with Ontario’s doctors. It’s funny how one dumb decision or comment can completely wreck a relationship, but that’s exactly what happened when your Negotiations Team stated that there was “no concern” about a diminished supply of doctors. Therefore, they refused to negotiate money for retention of physicians or admin work, like other provinces have (cough BC, cough Manitoba, cough EVEN Alberta!)

In essence, your Negotiations Team has been a disaster, first by militantly dragging out negotiations into a very adversarial arbitration process (when all the other provinces above figured out a way to, you know, respectfully negotiate with doctors) – and then by making a statement about the supply of doctors that is so comically stupid and out of touch that Ontario has become a laughing stock.

Three members of the Ministry’s Negotiations Team pictured above.

This will not bode well for health care in this province.

Look, I know there may be a temptation to say “Ok this was a mistake” and to try and walk back the comments.. While it’s abundantly true that the people of Ontario are a good and kind people who will forgive politicians if they own up to their mistakes (cough greenbelt, cough enhanced police powers and closing playgrounds during covid) – one thing that politicians can’t survive, is being made a laughing stock. Except Donald Trump of course. I still haven’t figured that one out and I don’t think I ever will. (N.B. Donald Trump is not someone you should try to emulate).

Anyway, the reality is that at this point you really only have one path left to turn this thing around. You have to fire your negotiations team. All of them. I’m not just talking about the seven who were appointed to lead that team, I’m talking about the multiple bureaucrats who give them supporting data and have influenced their position.

The only rational explanation I can think of for those bureaucrats promoting a position of “no concern” about physician supply, and saying doctors are not working hard enough, is that they hate doctors. Many of them were likely hired at a time when it was fashionable to bash doctors for billing “too much”. (BTW how did that attitude work out for the people of Ontario?) They’ve clearly carried on with that belief in the arbitration proposals.

I get that in arbitration, there will be some posturing. If your Negotiations Team had said “we’ll pay you $50 a month as a retention bonus” or “admin work doesn’t involve seeing patients, so we’ll pay you $20 an hour” – I honestly would have shrugged my shoulders, recognized it was part of the arbitration “game” and said nothing.

But to say retention and recruitment of physicians is not a major concern, when people line up for hours on end just for the faint chance of getting a family doctor?? That thought process can only be due to a pathologic hatred of physicians, or a delusional mindset totally divorced from reality. Either is a cause for termination. Can the whole team now.

A long line forms outside CDK Family Medicine and Walk-In Clinic in Kingston, Ont.. It was the first day of ‘rostering’ at the clinic, where four doctors will take as many as 4,000 new patients. (Jamie Corbett) – from CBC News

But what of negotiations with the OMA you may ask?

Actually, that’s not hard either. Your ministry has an appointee to the Arbitration Board, just like the OMA does. I believe your appointee is one Kevin Smith. The job of the appointee is to tell you and your team what the lead arbitrator, William Kaplan is thinking and how he is leaning. How they do that is beyond me. When I met Kaplan it was like talking to a Vulcan. There was absolutely no emotion or hint of what he was thinking – but apparently Kevin Smith is better than I am at figuring this out.

One of the above is William Kaplan, Arbitrator, and even after meeting him I’m not sure which is which.

What your appointee will tell you, and what the OMA appointee to the Board will tell the OMA is – Kaplan is wondering “this” or thinking “that” or leaning towards “X percent”. Find out what that X per cent is, offer it to the Doctors for the first year of the new Physicians Services Agreement (PSA). That solves things for one year, which gives you time to pick a brand new negotiations team for year 2-4 for the PSA.

Note to my three loyal readers, yes, this arbitration is ONLY for the percentage increase of the first year of the four year agreement. Worse, while the OMA and Ministry have generally agreed to a 70/30 split of whatever the amount is with 70% allotted to raises, and 30% to be given to targeted programs, they haven’t been able to agree on how the 30% is to be targeted. This means…..more arbitration for that piece. Then, it begins again next year for years 2-4 of the PSA. In essence, we appear to be locked in a perpetual, never ending antagonistic arbitration process (which is still better than unilateral government actions but really frustrating nonetheless).

As I told Premier Ford recently- if health care doesn’t get fixed – I don’t care what the polls say now, or how many by-elections you seem to have won, this is going to be a real problem in 2026. With health care in the crisis it is in now, you need all hands working together and co-operatively. Locking Ontario’s doctors into two more years of extremely adversarial arbitration shows that we are not co-operating and not working together. This is why graduates are leaving the province. And we can’t afford that.

It’s time for you to do the right thing for Ontario, and cut bait with your current negotiations team.

Yours sincerely,

An Old Country Doctor.

Ontario Government’s Arbitration Position a Slap in the Face for Physicians

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 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.

Otherwise, I genuinely fear that we are going to continue to lose physicians, not only in fields where they are desperately needed, but to other jurisdictions as well.

Open Letter to Premier Ford: Fix Family Medicine or Risk Losing the Next Election

Dear Premier Ford,

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!)

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:

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
— Bob Bell (@drbobbell) January 27, 2019

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.

Your sincerely,

An old country doctor.

About Asking for Reduced Admin Burden From the MOH….

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.

Look, we have a five alarm crisis in family medicine in Ontario. Just about every week brings a story of another physician who is struggling with the economics of running a practice, and is considering quitting.

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: The Challenges Facing an Early-Mid Career Family Physician

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.

Another Open Letter to the OMA Board: Re-visit the Negotiations Mandate

Dear OMA Board Member,

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 three new 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 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.

Yours truly,

An Old Country Doctor.