Tag: @OntariosDoctors

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.

Ontario Health Minister Sylvia Jones

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.

David Price
Bob Bass
Craig Rix

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.

  1. 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.
  2. 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.
  3. 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.
  4. 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
Steven 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.  

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!)

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.

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
Steven 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.

Yours truly,

An Old Country Doctor.

Open Letter to All Family Practice Residents

Dr. Nadia Alam
Dr. Silvy Mathew
Yours truly

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 is no substitute for your expertise. 

Which is why with heavy hearts, we, the undersigned, recommend that you do not start your own family medicine practice in Ontario. Not right now.  

Family medicine is in crisis. Family doctors in Ontario are unable to provide the care they could and should. We face unprecedented levels of administrative burden, unsustainable business expenses, lack of healthcare resources, lack of social and cultural support for our patients and ourselves and finally, a lack of respect. This has led to widespread burnout and exhaustion.

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.

You will burn out and like many others, leave family medicine for good. This is why millions of Ontarians no longer have a family doctor.

The Ontario Ministry of Health can solve this crisis. 

Governments in Manitoba, Saskatchewan and British Columbia have done so. This past year, they made family medicine a priority – and backed their words with targeted funding toward key programs to support both new and established doctors. It comes as no surprise that they have welcomed hundreds of new family doctors into their communities.

If they can do it, so can Ontario.

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

Actually, Ontario Does NOT Have a Shortage of Family Physicians….

You’re probably wondering if I’ve lost my mind. The media is currently littered with stories about how 2.3 million people in Ontario don’t have a family doctor and how that number is expected to double in two years. Family practices are closing down. In Sault Ste Marie – over 10,000 people are about to be orphaned (left without a family doctor). The Ontario Union of Family Physicians just held an event geared towards helping family doctors leave the profession.

How out of touch must I be to make the assertion, as I did on CTV news recently, that we don’t have a shortage of family doctors?

Yours truly on CTV News

Truth be told, there is an important distinction that has to made, which is key to solving the orphaned patient crisis. There are family doctors, and there are family doctors who are willing to work in a comprehensive care family practice like I do. 

According to the Ontario Medical Association (OMA) website, there are over 15,000 members of the Section of General and Family Practice. These doctors have got their medical licence, are qualified to practice in Ontario, and are able to practice family medicine without any further regulatory hurdles (like getting foreign doctors licensed would entail). There are likely many more as some doctors with a family practice billing licence don’t choose a section – but let’s go with 15,000.

What’s really telling is that only about 9,300 are in what’s called a PEM (Practice Enrolment Model – where a formal agreement exists to run a family practice). The number that are in Fee For Service alone (without an agreement) but still run a practice, is likely only a couple of hundred. So at most we have 9,500 comprehensive care family doctors. The other 5,500+ do something else (hospital only work, clinical associate work, walk in, etc).

From the OMA website. PEM + APP is about 9,300. This would be the number of docs with a formal agreement to run a family practice. 

There’s a myriad of reasons why comprehensive family practice is so unappealing, but let’s look at the two main ones.

1)Decreasing net incomes over the years. It is of course, unpopular to talk about the money doctors make. The OMA has historically felt that the general public views doctors as “fat cats” and “part of the rich elite.” So they’ve shied away from talking about physicians incomes or trying to positively frame that discussion – with predictable results.

As Boris Kralj (PhD in Economics, Adjunct Asst. Prof at McMaster and former Staff at the OMA) points out, net income for family physicians has fallen drastically over the past 20 years.

My thanks to Dr. Kralj for allowing me to share his graph.

2) Increasing Admin Burden. I think everybody has heard how family doctors now spend up to 19 hours a week doing administrative work, ON TOP of the time they spend seeing patients. This work is unpaid of course (there is no fee code for admin work). On a personal note, in about 2004, my office, which was already electronic, got a vpn (virtual private network). This allowed me to connect to he office from anywhere in the world. Initially, I thought it was great. I would go on vacation, spend 20 minutes a day taking care of messages and when I got back from vacation – I would not have the backlog of messages to deal with. 

This past summer, I went on a hiking trip with one of my sons. He pointed out that I was now spending over two hours a day going through labs and messages. Essentially, family doctors don’t have any vacation now. I don’t care what your job is or who you are, a life without any breaks is unsustainable.

Me last summer, by a lake, on vacation, checking my office messages and lab work (dummy chart)

What can be done about this? How does one make family medicine more appealing? This may rub some people the wrong way but the first step is simple. Pay family physicians more. In Ontario, the most common fee billed by a family physician is about $37. (The last time I got a haircut, I paid $40). Out of that $37 the family doctor has to pay their nurse, receptionist, rent, cleaning, supplies and so on. Gets used up pretty quickly. 

Additionally, you need to pay physicians for admin work. If there is 19 hours of admin work that needs to be done – it’s only fair that work is paid for. There are people who are skeptical this will work. To them I would point out that British Columbia has gotten 700 more family doctors since increasing the pay to family physicians. 

You mean if you increase the income for a job, more people will apply for it? Who knew?

B.C. isn’t even the province that pays physicians the most. That’s arguably, as I have written before, Manitoba. Saskatchewans new deal is also much better than what Ontario offers.

The second aspect is to reduce the admin burden for all physicians. Many experts suggest this is a process that will take time. They are the same experts that oversaw the increase in Admin work for physicians with “oh it’s just one extra click or it’s just a simple form”. 

To reduce the Admin burden significantly, one needs to drastically revamp digital health care. Get rid of eHealth Ontario and OntarioMD, and run all decisions through the Digital Health Branch of the Ministry of Health. It’s too late to unify all of our electronic medical records, but you can approve one (and only one) patient app that will allow patients to access and transfer their records to the physician of their choice to reduce duplication and waste. That’s the kind of bold steps that we need to take, not just crowing about the fact that doctors don’t have to sign hearing aid forms any more.

Look we already have 5,500 licensed family physicians in Ontario able to open up a practice. If 40 per cent did so, it would end this crisis immediately without having to resort to years long plans of modifying licensing and training requirements for foreign graduates (who in fairness are generally very good).

Do our leaders have the boldness and vision to do the right thing?

OMA Needs to Communicate Better About Status of Negotiations

Negotiations between the Ontario Medical Association (OMA) and the Ministry of Health (MOH) on a new Physicians Services Agreement (PSA) began this past fall. The first set of bilateral meetings were in mid-October. This years negotiations present a particularly complex challenge as not only is the OMA trying to negotiate a new four year agreement for physicians, but it also has to determine how much of an increase physicians will get this year (more on that later).

Given that we are a few months into the process – I think the OMA as an organization is really not doing a very good job of communicating the status of the Negotiations with its members.  The OMA really needs to increase some of the transparency around the negotiations process.

In fairness, there are somethings about negotiations that simply can’t be divulged (and I fully support this and members do need to accept this):

  • The mandate for negotiations must be confidential, to prevent the other side from knowing what our bare minimum acceptable increase is
  • The detailed discussions between the Negotiations Task Force (NTF) and the MOH must also be confidential (a lot of stuff that goes back and forth is hypothetical – and to protect the integrity of the process – you can’t disclose this to 40,000 + people)
  • The briefings presented to the Board and the Section Chairs must stay confidential as well (for the same reasons above).
  • NB – If we wind up in arbitration, the asks at arbitration are public.

So what should the OMA be informing members about then, given what’s usually a “cone of silence” around negotiations? Well, put simply, there are a number of things that are part of the negotiations process, outlined in public documents readily available to all members. The OMA needs to recognize some members (not just me) will read and wonder about these. (Although I’m probably one of the few loudmouths who’ll publicly write about it).

The Cone of Silence, from the classic series, “Get Smart”

For example, the Binding Arbitration Framework, under which negotiations are now held, is posted on the OMA website for all physicians to see. The framework is pretty clear. After 60 days of negotiations, either side can ask for mediation. They don’t have to, but they can. 

We are over 60 days. Perhaps mediation is not needed yet (which would be a good thing). But the OMA can, without compromising the negotiations tell members something like “while we have been negotiating for x number of days, at this time the process continues and we neither side has called for mediation.” It would at least let members who follow this closely know what the stages are.

Similarly, it would be quite reasonable for the OMA to list the dates of the meetings with he MOH and a general list of what they are talking about. Eg Oct 19 met with MOH to discuss Primary Care models, Oct 21 to discuss backlog in radiology etc. (I have no idea when the meetings with the MOH were or what they talked about btw – I’m just pointing out what could be said).

Finally, there appears to be radio silence about the part of the last contract that directly affects this year. This contract was completed and ratified by members and is public knowledge. The parts of concern are:

21. ….the parties will establish a committee that will meet on a quarterly basis…..to review the expenditure calculations. Through this committee, the parties will agree to a best estimate of the year 3 (2023- 2024) PSB expenditures in accordance with paragraph 6 by December 15, 2023.

22. Any agreements reached by the Government with respect to any new physician payment program or addition to an existing program which was not the subject of a proposal by the OMA during the negotiations leading to the agreement for the 2021-2024 PSA will not be included in calculating the total PSB expenditure …..”

It’s obviously past December 15, 2023. Which means we should have an agreement on the PSB expenditures by know. This information is critical to determining how much of an increase we get this year. The OMA had told us that:

“Conservative OMA projections indicate an expected Year 3 increase of 2.8 per cent, with a range of 2.1 per cent to 3.6 per cent”

But if the expenditures are too high, then we potentially get a zero percent increase. My friend Paul Hacker did an EXCELLENT job of explaining this here:

Paul Hacker’s Analysis

As an aside, some of you wondered why I endorsed him for OMA Board Director. It’s because of stuff like the above link. He knows the Board needs to provide proper oversight on the process and ensure it’s explained to members.

Anyway, perhaps this date got pushed back. This wouldn’t surprise me. The MOH Negotiations team was never able to get data on time in the past (there was always an excuse, except for the truth – that they are generally incompetent).

But the OMA should simply tell members this. Remember last year when it was announced to primary care docs that the repurposing of the preventative care bonuses couldn’t be mutually agreed on, and so was delayed for a year? Do the same thing and say the deadline couldn’t be met and you continue to work on it. But don’t just ignore the deadline and hope no one will notice.

Communicating better would also be beneficial for the NTF. There is no task force at the OMA that is more controversial, and gets more….attention…from members than the NTF. Yet what’s missed is that the NTF works really really hard. I remember some of the 18 hour days they put in when I was in various roles at the OMA. 

But when communication about the process, and the work they are doing is substandard, members won’t appreciate all that. They’ll simply blame the NTF for what goes wrong (e.g. if we were to get zero percent this year). It would be foolish in the extreme to suggest everyone will love the NTF if they just communicated better. But better communication would at least blunt some of the criticism that will come their way.

Hopefully, the OMA as an organization will recognize this.