I’d like to talk to you a little bit about fear.
As many who visit this site are no doubt aware, the Ontario Medical Association (OMA) and the provincial government are in the midst of a fee dispute. The government has decreed that the total physician services budget will be frozen. This means that physicians will be forced to take a pay cut in the form of reductions to various fees. The OMA finds this unacceptable. As a consequence, negotiations between the two sides have broken down and the government has decided to proceed with unilateral fee cuts.
The real determinant of the outcome of this dispute will be you, the public. If the public backs one side or the other in significant numbers, that side will prevail. To that end, both sides have engaged in a pitched battle for public opinion. The doctors, in particular, need you on their side if they are to get their way. This battle may have barely made a dent in your consciousness – and if so, I don’t blame you – but to those involved, the moral combat is ferocious.
The common denominator in this contest is fear. Each side is making ample use of carefully selected information, all of it calibrated to push your fear buttons. Even as a member of the OMA, and therefore something of an “insider,” I find the information coming from both sides to be so logically incoherent and ethically dubious that it is difficult to really know where the truth lies.
What I do know is this:
Ontario is facing a budget crisis of proportions unseen for a long time. The only realistic solution to this problem would be simultaneous spending cuts and revenue increases. No political party is willing to publicly commit to doing both of these things to an adequate degree, but our current government is keen on making some cuts. They have chosen physicians in Ontario as one area where costs could be saved. In order to make their case, they play on your fear of the province’s ballooning deficit. You’d have to have your head in the sand to not be aware of what can happen when deficits run out of control for too long:
If the government has a bachelor’s in fear, however, the OMA has a doctorate in terror. Here is their TV spot:
“…harder to attract and keep doctors…longer wait times. Patients who don’t have a family doctor will wait longer to find one.”
At the end of the spot, they ask the government to help them “put patients first.”
Does no one else see the cognitive dissonance here? How can one threaten to leave the province while simultaneously claim to be putting patients first? This paradoxical behaviour has started to break out at the specialist level, too. Anesthesiologists at one hospital are considering no longer providing anesthesia for cataract surgery. Recently, the Ontario Association of Cardiologists publically threatened that great numbers of cardiologists will leave the province if the fee cuts go through.
I am not as well informed about the situation with anesthesia as I’d like to be, but I can tell you that cardiology remains one of the most sought-after medical fields by people like me. It remains exceedingly competitive to get into a cardiology fellowship. Afterward, it can be quite difficult to find a job as an attending cardiologist, at least in a place of any decent size. In other words, plenty of young cardiologists would be willing to fill the older ones’ shoes should they choose to leave or retire. The threat is a bluff. But until you know that, it sounds awfully scary, doesn’t it?
For the record, both of these specialties are exceptionally well paid. A report released this February by the Institute for Clinical Evaluative Sciences lists the average pre-overhead, pre-tax income of cardiologists in Ontario at around $520 000 a year, and of anesthesiologists at just shy of $400 000 a year.
The McGuinty government, one way or another, will be tested at the ballot box. That is something in which we all get to participate. However, a future physician, I feel particularly embarrassed by the position taken by my professional association. This is not the way to advocate for a better system.
As members of the public, it is important to me that you know that not all of us in the profession breathe so deeply the heady fumes given off by the OMA. There are dissenters, and we make a large minority. My hope is that you are not convinced by the fear-mongering of either side, when neither is willing to do all that it can to improve public health and health care in this province. The only intelligent response is to maintain a healthy skepticism of both parties.
The comments section is closed.
Let me wade in to this pool of extremes. I’m not going to bash teachers nor doctors here. I myself am a physician, family-med trained with addictions specialization- primarily working on a per diem wage and also now working on per fee billings.
My sister in law is a teacher- and my friend works of the Ontario Teacher’s Pension Plan.
I don’t think we should be comparing different sectors of the public work force (teachers, doctors, police officers) . I am not going to try to estimate how much income anyone should make. I am especially not going to tell my sister in law that I deserve to be paid more than her because somehow “I deserve it” nor am I going to tell any doctor “you deserve to make less than you do for reason A, B, etc.”
I trained and worked in BC before moving to ON. The B C medical association (BCMA) is not obligatory- I don’t have to join or pay any fees to them. The OMA mandates me to pay. While I agree that the OMA should represent all doctors in the province on important matters- or else who else will- the manner in which they have publicized their campaign is an issue for me. Having said that, the manner in which the government has imposed OHIP fee cuts (though its doesn’t affect me personally as much as it does my colleagues) doesn’t sit well with me either. A negotiated settlement is preferred.
Income, while a huge factor in determining the wort/value of a service, is not the only thing that is important. As they say, its “not all about money.” Though society does need to address the revenues it pays its public workers from the public purse from a fiscal point of view, this has to be taken into context with other neighbouring jurisdictions, contexts within the disciplines, training/education/career investment costs, and in lieu of benefits and other values that are non-monetary in the system.
My sister in law enjoys good benefits as a teacher. Though she must set aside 12% of her income for pension, she gets an excellent pension for life when she retires. That pension sits with the Teacher’s Pension Plan, which is doing extremely well. She has her summers off, allowing her to pursue other hobbies, travel, take care of her family. What value will you put on these things? Though her annual income may be less than a pharmacist, or a doctor, she has these benefits- which are enormous- if you value them- time off, pensions, etc.
As a physician, there is no public pension, no paid time off, and a large annual expense that just to exist (fees to OMA, CPSO, Office Staff, Office Space, CME Courses, EMR maintenance, Hospital Dues, No shows… the list goes on). I once asked a colleague when I was in residency why doctors get paid “quite a bit”, and he replied, “Yes we might, but our costs are higher because everyone knows you are paid at a level to afford them.”
Though I work in both per diem and fee for service settings, I think a true salary system is not helpful- the government would never give us the benefits that other groups are getting, and why would we want them too? Our Health Care system is in need for funds as it is- let the doctors wanting 10 weeks of vacation take it on their own dime. The ones who work harder will be paid more and the system will ultimately get more patients seen- if quality is an issue on this front, then this must somehow be audited.
The best compromise would be a blended system, of per diem plus incentives for care. I’m speaking primarily as a family doc here. I’m not sure the specialists could operate in the same way.
All in all, if all sectors of the public economy need to take a wage freeze (or cut) to help balance the books, the OMA’s the teachers, the police, etc. and everyone else will need to be at the table, all making some sacrifices, and a negotiated agreement- something fair for everyone- would need to reached. We could then at least say the government was not singling out group A, B, etc. Right now, they DO seem to be singling out doctors, primarily because THEY can, and likely because as a complicated lot of individuals they really have NO clue how to go about handling us properly- and since our incomes are higher than everyone else’s (whether that is right or wrong)- we are easier fodder to be picked on. Fair is Fair, and Bullying is Bullying. Nobody deserves to be picked on.
Interesting that the Ont govt spends 10 billion/year servicing the debt, which is the same amount as it spends annually on physician services. No one suggests reneging on our commitments to debtors by forcing them to accept lower interest payments in the name of social justice. While I share your sentiments for social justice and also am concerned about both income disparity and wealth disparity, I do not trust that the state is in the best position to resolve this. Govt has already squandered millions of dollars on hare brained schemes to improve health outcomes with little to show for it. When physicians are told how to practice medicine (which tests will be paid for) and are dictated to about what payments they are going to have to accept, they are no longer professionals. A hallmark of a professional is the ability to set ones own fees (which clients are free to accept or reject) and the ability to execute an agreed upon course, whether that be drawing up a will, filling out tax forms, or doing necessary tests. Absent these privileges, future doctors are simply laborers who should withdraw their labor if they don’t feel they are being fairly compensated. Others will fill the void. Interesting that despite the popularity of cardiology as a residency, only 3 cardiologists in Windsor are graduates of Canadian med schools and residency programs. Where is this line up of unemployed cardiologists of which you speak?
I have read each opinion expressed here. The title of the Ryan’s opinion piece is apt. There is a lot of fear created by the politics of medicine and not only from a doctor’s point of view.
The problem the government faces with needing to save money in their budget angers me because they expect the public to believe that they knew nothing about such problems until post-election. Now all the talk is about “times of austerity”. Hogwash. They needed a scapegoat and now the doctors are expected to willingly hold the title and pay to do so.
This government has wasted so much money due to scandals (ehealth, Ornge, long-term care) and now it expects that doctors should have to accept its unilateral decisions to accommodate for its own ineptitude.
I like very much Ryan’s suggestions that the OMA consider adding some key points to a negotiation between the OMA and the government, but that would assume the government is even interested in fairly and openly negotiating in order to have any of these good suggestions considered.
From what I read, and from my own experience in dealing with the MOHLTC, it is not interested in transparent, honest and accountable communication, and it is not interested in how patients are negatively impacted by its unilateral decisions. It is evident to me that the government is certainly not sympathetic to the position doctors are in as well. When the public and/or any specific group feels it is under the power of a dictatorship, that is bound to create animosity among those who feel tethered by power abused.
It is very telling in my opinion that the health minister re-tweeted this opinion piece as I interpret that move to mean that she is pleased to see so many doctors in disagreement with one another. The disagreement would seem to add to the strength of the government’s position which I have no doubt they will try to exploit.
As a patient, I never consider when I need to see a doctor how much the doctor will be paid and I don’t perceive doctors to be in an elite category. No doctor has ever discussed with me the costs of my visit, but I have heard many doctors and nurses express that healthcare cuts to the system fuel frustration for them and their patients and that these cuts affect directly the quality of care given and received.
I totally support the OMA in its efforts on behalf of Ontario doctors. When I need medical attention in the middle of the night I want the best care possible, and I am grateful for the doctor who shows up to provide it. If I need a specialist I want one available to help me. Doctors do make a lot of sacrifices that the average citizen would not find appealing much less acceptable and I think that they deserve to be compensated accordingly. The years doctors invest in education and intense training, the heavy debt they incur, the loss of time with family and friends, not to mention the loss of sleep when in residency must be considered in the big picture when considering how much a doctor is worth (financially).
A good doctor’s worth is beyond measure to me as I recall as I write those doctors who saved the lives of my family members. I am willing to pay (via taxation) for my doctors’ expertise and I support them and the OMA in trying to have their voices heard by the government. I abhor the politics of medicine and the unfortunate fear and imbalance of power it creates.
Doctors cannot strike and the government takes advantage of this fact. Doctors have demonstrated integrity and most would never consider putting their patients in harm’s way to make a point with the government, but I urge all doctors to stand up and unite because there is much more public support for you and your cause than you may realize. That’s my opinion.
Catherine Richards
Thank you Catherine. As a physician I appreciate your clear-minded support.
And bless you, it’s getting lonely and demoralizing out here.
Thank you Catherine for eloquently and powerfully sharing your voice.
All the best
The strongly held belief that only fear tactics will prevail needs to be reconsidered by all parties. In the long sweep of time hope has been shown to prevail over fear time and time again on an individual level as well as larger organizational and systemic levels. Collectively we need to find a way to steer this necessary debate to one considering alternatives for reconstructing health care which includes proper remuneration of doctors for the huge responsibility they carry but also in a way that patients, doctors, other health professionals, the broader community, ‘public servants’ and politicians… can see has a longer term potential for addressing the long standing issues threatening health care sustainability.
Thank you GJ and BigDuke6 for your kind comments. I am happy to support Ontario doctors on the record.
Andrew, I am not a proponent of fear tactics but I have been on the receiving end of them by this government via the MOHLTC and I sympathize when anyone is up against this agency’s enormous and immovable power.
If negotiations were possible where both sides are willing to listen, contribute ideas and solutions to come to a compromise, I would have more hope as I am an eternal optimist, but I don’t see that willingness on the part of the MOHLTC in the case of doctors. The arbitrary decisions by the MOHLTC regarding doctors will also affect public healthcare. Even the fact that so many doctors feel unsupported, unappreciated and undervalued while the MOHLTC seems intent on making them out to be the villains in the healthcare ‘crisis’ must cause people to question their motives.
Where has the MOHLTC been for the past several years? Why now must doctors be made to bear the brunt of their own lack of insight and foresight and accountability, and why should the public be forced to accept its decisions that will see the morale among doctors lowered along with the standards of healthcare?
The reality is that those with the bulk of the power don’t in my opinion use it appropriately and nor do they use it to instill hope or goodwill. There is a lot of mistrust in the top bureaucracy of the MOHLTC and while that is unfortunate, it is in my opinion, justified.
The MOHLTC had/have many opportunities to inspire hope and trust but they consistently squander these opportunities. I have a lot of hope for the healthcare system in Ontario, but my hope depends on public engagement in the issues that affect us all and it requires a concerted effort to challenge the injustices imposed on the public and certain groups ie doctors in order to see hope translate to change.
Hope is a beautiful thing and I highly recommend it, but I am often afraid as well – yes fearful – that those with the power to move mountains are not willing to climb them with us.
Catherine Richards
“Why now must doctors be made to bear the brunt of (MOHLTC’s) lack of insight and foresight and accountability, and why should the public be forced to accept its decisions that will see the morale among doctors lowered along with the standards of healthcare?”
Word.
Catherine
I think you are articulating many of the requirements for constructively building a health care system for the future – one built on hope … not fear. I have taken the liberty to selectively adapt some of the characteristics that you have outlined including: a) negotiations were where all sides are willing to listen, contribute ideas and solutions to come to a compromise; b) all parties feel supported, appreciated and valued; c) all parties are motivated to constructively resolve any and all issues at hand; d) issues will be proactively addressed in a constructive and accountable manner that enhance the standard of care; e) people in positions of authority throughout the health system use there positional authority to best of their ability for the higher good it was entrusted to each person to uphold; f) stakeholders and the public are active participants in their health care and g) the broader face validity of decisions is seen to be used to ‘move mountains’.
I agree fear is there for a purpose – at it’s basic level it makes sure we are paying attention. Moving beyond fear and deciding to act constructively across the many thousands of people who hold positions from front line care givers of all sorts, support staff, volunteers, managers, boards, public servants … all the way through to the Minister of Health and beyond is our current challenge. I am hopeful that rational minds will prevail.
BigDuke6 thanks for clarifying that I meant the MOHLTC in the quote from my previous post, as I realized after I posted it that the sentence could have been construed otherwise.
Andrew, thank you for sharing your thoughtful remarks; I appreciate your feedback. If hope is contagious and an antidote to cynicism, your optimism may have a chance of catching on to inspire a fairer conversation about doctors. I have a very rational mind, and while fear is still present, hope is a constant in the mix of my thoughts and feelings about Ontario’s healthcare.
If I felt all hope was lost I would not bother to speak out, nor would doctors I suspect. I hope the MOHLTC will respect, respond to and reward our hope by agreeing to genuinely begin anew with a fresh perspective in negotiations with Ontario doctors. This is the kind of opportunity I was speaking about and I hope it will not prove to be another example of opportunity squandered by the MOHLTC. There is no shame in admitting a mistake in strategy, but it is inexcusable when mistakes are neither acknowledged nor corrected.
Today I came across an article in the Ottawa Sun entitled: ‘Medical cuts out of the hands of doctors’. I haven’t yet commented about this particular issue, but the news piece got me thinking again. I think the public should be very wary of the MOHLTC’s power over our doctors’ decisions to order diagnostic tests for us. If a doctor sends someone for a test the MOHLTC can decide whether or not the test is/was necessary and at its own discretion based upon its decision it could make the doctor pick up the cost of a test. Is that not among the most serious policy changes in this debate? How will this work? If a doctor thinks his patient requires an EKG to confirm or rule out heart problems, and the test rules out the existence of a heart problem, will the doctor then be expected to pay for the patient’s good fortune? I know that if my doctor must err I would prefer it be on the side of caution.
The potential danger to patients in numerous such scenarios is disturbing. I must trust my doctor’s judgment or in an emergency situation another’s, and in fact I rely on the judgment of doctors to help diagnose and treat me when necessary. I think the MOHLTC should demonstrate that same level of trust in doctors instead of questioning their daily medical decisions.
When our actual healthcare is placed in the hands of MOHLTC bureaucrats as a way for the government to save money, as a consequence it loses face, but even more worrisome than the risk of lost confidence by the public in the management of the healthcare system, is the potential that lives may be lost.
I don’t wish to live in a state of fear but I am realistic, and if I cannot trust that a doctor has the autonomous authority to order a test for me or a loved one based upon her/his experience, expertise and judgment, trust will be compromised and I don’t see that situation as being the fault of doctors.
In the end, I hope justice in healthcare for all concerned will prevail.
Catherine Richards
Thank you all for your comments. Certainly I seem to have sparked a lively and wide-ranging debate. I would, however, like to clarify my position a little further.
To be clear, I am no supporter of the government’s position. To my mind, both parties in this dispute need each other and the government’s unilateral action will likely cost them in the long-term. I can certainly understand the anger some of you feel at the way that these changes are being brought about. From my perspective, however, that is the more obvious side of the story and therefore the less interesting one.
As for the OMA, it is an organization that has long stated that it has a double mandate: it advocates for physicians and it advocates for patients. I have no doubt that the people who run the OMA are well-intentioned, hard working, and genuinely try to represent the diverse views of the physician community while simultaneously advocating for changes to the system that will benefit patients. This must be a challenging task.
However, the fact is that the OMA are my representatives. At present, they are representing my views poorly. Therefore, I feel I have no choice but to represent myself.
So that addresses the first part of the mandate. As for the second part, while I believe that most people involved want to see good outcomes for patients, I think that some of the information being put out by the OMA is intellectually dishonest. I know for a fact that the OMA employs polling firms who do research for them on what “works” in terms of pushing the public’s buttons. I am simply saying that I do not like the approach that the OMA has taken – on the advice of these pollsters – in an attempt to win over public opinion. The OMA can advocate with honour or it can advocate with fear. It has chosen fear, and this embarrasses me.
Much of the intellectual dishonesty that I see comes in the form of claims about the impact that this will have on physician retention and on patient care. Undoubtedly some patient care will be affected. Undoubtedly some physicians will choose to retire or leave the province. But will it be to the extent that the OMA proclaims? I doubt it. I have carefully read every press release, every fact sheet, and every description of every proposed fee change. In addition, I attended a recent OMA meeting where details of the negotiations and the proposed fee changes were discussed. I asked OMA president Dr. Doug Weir to please explain to me how this is going to have such a dramatic impact on patient care.
None of it has convinced me, nor have any of the comments posted here. While I suspect that I will not sway those who disagree with me, I will not be silenced either. Mine is a view not often heard in public and I hope to continue expressing it.
Ryan – I would suggest for all of the reasons debated here, that the OMA has no other lever than public opinion and that is changed only when the public is AFRAID that they will lose something. Doctors can’t and shouldn’t strike, most doctors feel a compulsion to do their work and for many of them even if there were many jobs available elsewhere, they wouldn’t move bc of spouse/children/parents etc (Im far more interested in why people don’t leave places that are un healthy rather than why they stay)
I guess I’ll conclude with this – almost every player in the health game wants to make you their servant and employee and remove your autonomy and voice in the system. That is to the detriment of all, including your patient. Believe me as president of the OMA for the year the discussion anticipating a difficult negotiation always centred around how we might find levers to represent the needs of the doctors in the province. They are few, and government knows it
Now this is the conversation that I thought we would be having!
I think I will have to agree to disagree with you, Dr. Macleod. If I was “dictator” of the OMA, with full control of its actions and statements, here’s the sort of thing I would say.
“To the Ontario government:
We recognize that as physicians we have done incredibly well over the last 10 years or so. Further, we recognize that the province is in dire economic straights and that as well-paid public servants it behooves us to be responsible and accept a true pay cut (not just a fee freeze). Further, we recognize that the gap between the highest and lowest earners in Canada is growing and that as top earners we bare some of the responsibility to help shrink this gap, not least because a less stratified society is a healthier one.
However, we are not willing to take this pay cut for nothing. In exchange we would like the savings to be directly invested into addressing the social determinants of health and in improving the health care system in general. This would include, but not necessarily be limited to:
-the implementation of a public drug plan for all Ontarians who are not covered by the current Ontario Drug Benefit or a plan linked to their employer
-an expansion of long-term care and eventual public takeover of the long-term care system in order to make it both more equitable and to save the system money by getting patients out of expensive acute care beds
-a vast expansion of the grant system for people who can’t properly afford post-secondary education
-re-regulation of professional school tuition, as current medical school tuition is so high that it discourages low-income individuals from applying, thus de-diversifying the pool of doctors and thereby reducing the quality of care available
-improvements to the “Ontario Works” (welfare) system, which currently is so ungenerous that no human being can live a remotely healthy lifestyle on its payments
-an expansion of home care
-an expansion of palliative care
-an expansion of the use of teams in delivery of primary care
-OHIP coverage for cognitive behavioural therapy in a wider range or circumstances
We recognize that this is a long list of improvements. We do not expect all of these changes to be made overnight. However, in exchange for significant movement on at least some of these issues, we will happily take a pay cut. At the same time, we wouldn’t want physicians to be single-handedly responsible for covering the cost of these interventions. No doubt, other revenue raising measures will be required as well. Might we suggest an increased rate of taxation on all high earners, not just on physicians?
Respectfully,
The OMA”
Now that is advocacy with honour. This would be truly “putting patients first.” I don’t doubt that fear is a powerful motivator of human beings and that it certainly works. But I challenge the notion that it is the only thing that works or the only option available. Where others would choose fear, I would choose embarrassment. Faced with a set of public demands like this (or even a subset of this list), coupled with a willingness to take a real pay cut to meet these demands, the government would be left with two choices: either it could give in to the demands and implement real reform, or it could refuse to do so, prevaricate, and risk public humiliation and embarrassment. Our legitimacy would be unassailable.
Thanks Ryan. Its an honourable idea but you and I both know that the government isn’t interested in these ideas. They clearly wanted a billion dollar rebate and they wanted it out of your pocket. It can amount to a 16 percent net reduction in physician payments over 4 years. For those who remember the 10 years prior to the last 2 agreements, they are not feeling all that charitable and I don’t blame them.
The OMA is expanding its focus from having been just a union in the past. It is a big ship and it is hard one to turn. The members understand patient advocacy but I think to ask them to be involved in social justice and greater political advocacy is a stretch in all fairness. There are other mechanisms for that. The OMA has been active on social determinants for health but I think justly doctors don’t understand why they are being singled out as the bad guys.
Good luckmon
Of course institutional inertia can be quite daunting, but that’s precisely why you have young whippersnappers like me: to shake people out of their complacency. If the OMA claims (and it does) to advocate for patients, then greater involvement in social justice and political advocacy should not be a stretch, it should be core to the organization’s activities. My chances of success in this endeavour may be small, but I am not about to stop trying.
I am reminded of another whippersnapper, though not a young one. Ray Bradbury, the recently deceased science fiction writer, said the following in a 1988 interview:
“I’m not an optimist, I’m an optimal behaviourist. We ensure the future by doing it.”
I couldn’t put it better myself.
Alright, I’ve flogged this horse to death. I shan’t be commenting further.
Sorry – bad typing – good luck Ryan. Trying to do too many things at once.
Mark
hi,
Ryan
I apprecite your concern regarding OMA position on doctors leaving province
although I do not support it
how is an organization supposed to respond to a health minister who calls doctors greedy and just want more money(when we have offered no fee increases and an offer to find more savings)
how does it respond when you are left with unilateral cuts. playing nice anf fair is great when the other party has the sense to do the same.unfortunatly patients are confused and afraid
your argument about new grads filling in when others leave is same as saying lets get rid of all the older public service employees by forcing them to leave with wage cuts, since they make more money and hire new grads as they need a job and will be willing to fill in the gap for less.
and my next point to all doctors (including but not limited to Dr.Goel) ,I would like to see proof that they practise what they preach ,ie are they returning all the extra money they make(over and above what an average teacher makes) to the MOH, if they are I have utmost respect for their views but if not it is psuedo activism aimed at getting public attention and political aspirations.
it is a healthy debate with nothing personal against anybody but sometimes it is easy to say and hard to practise
Ryan, thanks for putting into eloquent words some of the thoughts and emotions that I’ve been experiencing myself over the last few weeks. You’ve definitely sparked a lot of interesting discussion here, and I doubt I can add much to ground that’s already been massively trodden in this thread without getting in way over my head — I swore off heated Internet arguments some time ago, with noticeably beneficial effects on my mental health and blood pressure.
I’m curious, though, what sort of reaction from the medical community we would have gotten if, theoretically, the decree from the province would’ve been “We’re cutting all fee codes by 5% across the board” instead of the mostly targeted cuts that have been announced. Any thoughts?
Ed just to be clear, that is an option unused but available. If the cuts as laid out now do not meet the ministry objective then further cuts can be made to do so if I understand correctly. As those would be made after the fact, it is likely that clawbacks would be the tool used to achieve the overpayment payback. We have seen that before, and it’s a cunning move on the part of government. They know doctors behavior – to work harder if prospect of income reduction is present. They haven’t gone to caps which were really counterproductive – people stopped working when they reached the cap. A clawback gets people to work harder and face the prospect of even greater clawback – increasing productivity in the process
Any thoughts why they didn’t go with a clawback to begin with? It seems like such a move could’ve avoided a lot of the specialty-based acrimony.
Probably because the government feels that certain procedures and specialties are over-rewarded. There is a thought process to this, whether it’s palatable to physicians or not.
I suspect because we have not managed the relativity issue ourselves when we should have. And clearly our system cannot have million dollar doctors when we have doctors working hard to make a fifth of that. It speaks to equity.
Ryan & then Mark,
Yes, this speaks to inequity in pay structure for all sectors of physician providers and ‘power’ / professionalism /advocacy attitude toward team members in each of the delivery structures, their interactions and willingness to cooperate, clinical and otherwise.
Pillars, Fear and a exclusive behaviours are not productive
Working to simplify a system toward productive function for the **health and wellbeing** of society is a noble goal.
This, Dr. Mcleod and I agree on.
Not to dodge your potentially very interesting question Ed, but I think it would make no difference. I imagine they would react similarly and make similar claims. I suppose the difference is that the weight might potentially be falling a little more on family docs and less on certain specialists, but I still can’t see that changing the OMA’s reaction.
Not to dodge a potentially interesting question, but no, I don’t think it would make much difference.
Thanks for your kind words.
There has been some conversation on this thread about labour actions that doctors can, and cannot, take. We have just posted a story on healthydebate.ca on the history of OMA and Ministry of Health negotiations and labour relations, focused on the past 30 years.
Read the story here, we’d welcome your comments and thank you for joining the debate!
http://healthydebate.ca/2012/06/topic/politics-of-health-care/history-oma-mohltc
I think that these responses attest to why the “Politics of Fear” figure so prominently.
The posts here repeatedly claim that doctors make “too much” and make inaccurate claims that doctors make X more than other professions, without considering all of the other factors. When asked “how much is the right amount” the answer is that “it isn’t important how much, but right now is too much.” There is no number that won’t be too much, especially since everyone cites gross pay and refuses to consider benefits, pension, overhead, years of training, etc.
Doctors cannot strike. They cannot rely on binding arbitration as other “essential workers” do. They certainly do not win the in court of public opinion. Their collective bargaining rights have just been trashed. Doctors are forbidden by law from gainfully offering their skills outside of the public system. If they feel unfairly treated, their only choice is to leave.
Whether you agree with it or not, it seems sensible to expect it. And I don’t think it’s fear-mongering to point it out. Honestly, what would you do if this happened at your place of employment. Would you really not consider other options?
I disagree that this is entirely an economic argument, and I would prefer if condescending remarks such as ‘perhaps you just don’t understand economics’ are left out of such a discussion. My issue is this – we are living at a time when income inequality is growing. Those at the top have seen their incomes rise (between 1980 and 2009, top 20% saw an increase of 38.4%) and those at the bottom have seen incomes fall (bottom 20%, 11.4% decrease). Why does it matter that we are in the 1%? It matters because unequal societies are unhealthy societies. It matters because while I know docs work hard, I also know that I have many patients with multiple jobs who also work really hard. I know I have many friends who also went to school a long time, got a PhD, have major student loans, and are having trouble finding work. Yes, we went to more school than many other people, but even that is a function of our access to those things. I was fortunate to not have to take a job during my undergraduate education because I had a stable family with a stable income. I was fortunate to have parents who had time to invest in me and to encourage education. And while not necessarily every physician has had those, most of us have.
So to then turn around and say that we are making all this money because we DESERVE it and we EARNED it bothers me. Of course individual ability factors into this, but to nowhere near the extent that I think physicians like to think. Yes, we work hard. Yes, we studied hard. Yes, we have loans. And I never said it’s wrong to be paid more for those, but I don’t think any of that balances out in the end to justify the types of salaries we do make. And no, I don’t have a specific answer for how much we should make. If I thought there was any relevance to sitting down and coming up with that number I would, but I don’t. I do know that what we make now is much higher than anything my non-physician friends make. I could choose to take this as representative of my greater intelligence, my greater sacrifice for society, my greater investment in my education, but at the end of the day, all of that still does not justify the large discrepency. Or is it a factor of the society giving physicians a substantial privilege and social power that has allowed us to bargain for these very high compensation rates. Some people would say, well then this is what society has decided and we should accept it but I disagree with this notion. Society also gives whites privilege over those of colour, and men privilege over women, and straight people privilege over gay people, and those are not things that are okay and that we should accept.
We can ask for many other professions who contribute to the public good, who makes nearly as much as physicians? Most make less than 100k a year, just like the large majority of people in our society. The point of this is not to bash doctors – it’s to ask ourselves how we got where we did, and whether our making this much then means that we think others don’t work as hard, or didn’t sacrifice as much, or weren’t as smart or hardworking. Those are the conclusions I have a problem with, and whether or not anyone on this list admits it, those ideas are embroiled in much of what is being said.
Sorry Ritika, but my remarks about not understanding are not meant to be condescending, just an accurate portrayal of what is going on. I am more convinced that it is indeed the case given this post. You have injected a moral dilemma into this discussion as per your agenda and are bashing doctors as a result. You have even introduced the concept of disgusting forms of discrimination in you haste to bash doctors. There is really no comparison, and if you truly believe so vehemently that for doctors “being in the 1%” is equivalent to propogating homophobia, perhaps you should really reconsider your line of thinking.
You have displayed ignorance with respect to economics because you keep making normative statements. At no point did I argue that we deserve or expect things. This is your statement that you have been making over and over. Please see my previous posts regarding what the pay someone receives represents. It represents the confluence of supply and demand forces. Period. Nothing more and nothing less. Are you seriously stating that the “doctor lobby” is more powerful than the government? There is really no society in the world where everyone is making the same amount of money and no one is left wanting. Since the numbers are too high, then who would you be comfortable making this money? Who should be in the 1% if not physicians? Not as a form of entitlement but as a point of where society is placing importance. How exactly is this society you have pictured in your mind supposed to be structured? Of course you don’t have the numbers, no one does. For all its problems, I enjoy Canada and am happy to be a Canadian citizen. I am glad that in this society we place value on education and health care and I would be upset if teachers were being handled as heavy-handedly in the same way.
Perhaps you have missed the point entirely in your eagerness to equalize incomes for all. You are looking at this issue in your own cultural context which you have displayed time and again. If you put in as much energy to raise those living in poverty or at the bottom of 1% then we would all be doing better – which I am sure you do given you eagerness here. This is not a zero-sum game, as the classic economic theorists used to think of the economy, but can be a win-win situation. We can all help each other up – if I do better it does not mean that teachers or other professions do worse. You are showing what your ideas are embroiled in from your arguments.
Please note that at no point have I made an argument regarding how I think things should be – that has been you all along. I have never made the argument that we should be making more or less, or even that the pay should stay the same.
I am glad that you are enthusiastic about this topic – it bodes for a great career in politics or health care advocacy as a career if you were so interested. You also do have all my respect.
@GJ
With the greatest of respect, I don’t think that your claim that pay “represents the confluence of supply and demand forces. Period. Nothing more and nothing less” is tenable.
Even the most ardent free market advocate would only believe this in the context of a truly free market, which physician services certainly are not. Even in a freer market such the the US, medical care is also protected by licensure, etc., which many would regard as rent-seeking. (This is not unique to physicians.) This is why Milton Friedman, for example, argued for certification but not licensure for professionals, believing that the market could sort out the charlatans. There are other problems as well, such as information asymmetries, etc.
I think that many of the opinions on physician remuneration espoused here are unfair and arbitrary (but I suppose you would reject that because it is a normative statement). I also certainly agree that medical care is an economic good even if provided by the public sector, and that there will be consequences if it is inadequately remunerated. But that is not the same thing as claiming that whatever the price is must be the right price. The fee schedule is not really shaped by the economic forces that you describe.
Thank you Mark, very nicely stated.
I guess I am oversimplifying and generally do believe that the market supply and demand forces capture all attempts to manipulate it. At no point was I stating that this is a capitalistic free market system alone. An economic market (micro and macro) will still function in predictable ways even with many different outside forces interfering. I am trying to move away from the idea that pay simply represents merit and perhaps stated it in too strong a fashion.
I am purposely staying away from normative statements because I think everyone should be able to believe whatever they want to believe. However, there is a problem when people simply state that doctors are paid too much and then run with that, with no further thought. As well, in ignoring economic forces (whether in a constrained market or not) affecting actions, unexpected outcomes can occur. The government, and other people who choose to ignore those forces, then act surprised. In no way am I claiming that any current price is the right price. For example, I might argue that the price of gasoline should be higher to help spur on the development of alternative energy sources. When OPEC created their artificial oil shortage in the 70’s, the market changed dramatically in a completely unexpected way, much to the detriment of OPEC’s agenda. This is also taking into account that the oil market was (and is) in no way a free market system, however, economic forces still prevail.
I suppose to sum it up, I am simply pointing out that as you stated: ” that medical care is an economic good even if provided by the public sector, and that there will be consequences if it is inadequately remunerated.” Economic forces can take many forms and the fee schedule certainly do capture them (this includes political forces as well). Ritika has argued that doctors have a large influence in this, and this may be correct (to what degree I don’t know), however, the government certainly has a larger influence. I wouldn’t want to work in a system where things are done arbitrarily or unilaterally; but if things don’t work for some reason, then there should be some corrective system in place. Otherwise, a new totally unexpected equilibrium that is no good for anyone can arise (just ask OPEC how badly their attempt to orchestrate the market backfired on them, however, it did benefit the Japanese car companies). This corrective system is simply called working together, which the government does not seem willing to do. Simply stating that the OMA is starting from the position of offering a wage freeze is a huge compromise, which many people don’t seem to appreciate. Only with communication and respect can we work together to make things better.
I get the social justice argument. I do. And for me, I can’t agree – entirely. I should do the math – but if doctors were to earn half as much, as an example, what difference would it make – in terms of equity (recovered dollars divided amongst 11 million people in the province – I know it is a number and I know it’s not 20 dollars. However, I think Ritika even you would agree that the current 1 % vs 99 5 argument has alot less to do with doctors than it does to do with how globalization/corporate demands have driven down the real wage in this country as we happily trade away our unrefined resources for cheaper labour to do it elsewhere. So the failure of our economy to withstand cheap labour elsewhere – whose issue is that to solve? How does bashing doctors address the real problem?
it’s interesting the dichotomous views that the public can hold about value. While they may say that a doctor should make X – they have a different idea of the value of the service provided to them. My patien s if I ask them will overvalue the price of a surgery by at least a factor of 10 and sometimes, it is 40 or 50! That’s it’s value to them at point of transaction. Their own transactional value. What is the value of a hip replacement, or a brain surgery, or a dialysis treatment? Is it the same as a brake job on a car, a new electrical panel, a bag of groceries, a Pez dispenser?
OUr current system is not a good one in many ways. Sure we hold some power – but we are realizing less and less. And lest you think your doctor-ship garners you privilege let me know when your next house reno starts – your renovators will be happy to put on their white coat syndrome. And much to my surprise, doctor and a nickel will buy you a bag of chips 3 steps from your office.
But we also have a system that provides nothing for merit – for a job better done, or for more thoughtfulness etc. We all are paid well and paid largely on time for most of what we bill. I’ve worked where you had half the staff doing nothing but billing and received 60 cents on each billed dollar. So there is alot to be said for the constancy of this system but it has alot of inherent problems too. One is not having a real economy or real balance between employer/employee (to oversimplify)
Where this discussion started is back with the politics of fear and many of my colleagues sound worried and unhappy. That can’t be good. I don’t have any good reason to think ill of my colleagues and the corrections that are necessary should occur in a gradual way to correct relativity disparities, such that people are not unduly harmed in the process – otherwise what is the advantage in that?
If I can find it i will post a link to a letter from the Ottawa Citizen by a lawyer whose wife is a GP – it was thought ful and insightful. Much as you might expect from one who is used to dissecting arguments. If I can find it I will. But from the perspective of a person who works hard in his own profession, his valuation of doctor income seemed pretty realistic.
Lastly, I suspect that moving physician income to 100k would have some interesting effects. I can’t speak for anyone else but there wouldn’t be enough value in my work at that level. 1 in 5 or 6 on call and often up, working in a system that is perpetually broken and usually working against rather than with me . . .. . ., expectations about how I am in the world and what I should be thinking about my work . . . .. sorry, I’m not that virtuous I suppose. I guess I would be on to something else where I thought what I did was more valued.
I get the ideolgy of youth. But pepper spraying your colleagues and your profession isn’t likely to move the sticks very far.
Dr.Goel (I assume you are a physician )
you have managed to completly misdirect the entire conversation into a debate between doctors vs teachers vs nurses-what a shame !!!!!!. just what politicians like to do divide and conquer.
I agree we need health care reform and certain procedures and costs related to those will need to be reassesed with time.
Doctors are integral part of health care.Doctor bashing does not lead to health care reform.careful respected negotaitions will indentify the right changes to find savings.I have not seen any other profession agree to fee freeze and commitment to find additional savings like the OMA has.
why do professional athletes get paid in millions , because it is hard to find the talent and training and commitment to get them to that level. Are they more important to soceity than teachers or nurses?
Also I have not seen any one take responsibility for millions wasted in scandals .I have not heard about any unilateral cuts to politicians pay. teachers and nurses have had the sense to stick to collective bargaining and stay away from bashing up their own colleagues for trying to demand respect for hardwork and commitment.
people lives depend on what we do. so lets do it with respect and commitment and lets also make sure that others recognise us for that commitment.and lets constructively Identify waste/duplication and eliminate it.
There have been multiple comments made on various issues, so I will seek to break down my response in general here.
1. How much doctors are paid – Economics and markets do not determine how doctors are paid in Canada. We are paid through a fee schedule set by the government, negotiated with the (very powerful) doctors’ lobby. The two forces at play here are what the govt thinks we should be paid, and how well we argue that we should be paid more. There has been a lot of bashing the teachers’ unions and their right to strike, but let’s consider the power of doctors as a whole in our society, the incredible amount of money groups like the OMA have and the ability to run campaigns like “Your life is our life’s work.” Yes teachers can strike, but they do not in the slightest hold the influence that doctors do as a whole in our society. As such, we have ended up in a situation where doctors are paid substantially more than almost everyone. Yes, this is in part due to the long training, the difficult education, the hours put in, the grades needed and the value to society in providing healthcare, BUT, the question is whether all of that then means we should be making minimum six figure salaries and maximum 7 figures. Clearly many of us disagree on this point. If you have been spending too much time hanging out only with doctors as many of us often do, it’s important to remind yourself that doctors are part of Canada’s 1% as is discussed in this article citing a new UBC study – http://www.thestar.com/business/article/1206227–canada-s-1-per-cent-how-to-know-if-you-re-one-of-them . The question is whether we as a society feel that makes sense – I don’t think it does, and I think a lot of people OTHER THAN DOCTORS would agree. I think our nurses, social workers, physiotherapists, teachers, firefighters, public transit employees all contribute substantially to our society. And I don’t think we should be paid THAT MUCH MORE than them. There is also no rhyme or reason to why docs are paid what they are in the fee schedule – I don’t think we sat down and decided that based on years of education, hours put in at work, and morbidity and mortality impacts of the work, this is how much people should be paid – if it was, that might make more sense. By 2004 data, a full time equivalent neurosurgeon made $291,000 while a FTE ophthalmologist made about $436,000. Does this make any sense? Do opthalmologists save more lives or work more hours or do more training than neurosurgeons? And even if they did, is that difference worth them getting paid on average over $100,000 more? These are things the Ontario govt is trying to reassess – the reason opthos make so much is because cataract surgeries now only take 15 mins to perform and pay $441. Does no one else think that needs to be reconsidered?
2. International perspective – it is worth noting that Canada has among the highest paid doctors in the industrialized world, not only in absolute terms but also in relative terms to the average wage. OECD 2009 data shows our GPs make about 3.1x the average wage and our specialists make about 4.7x the average wage. In 2004, we were fourth with only the Iceland, US and Germany ahead of us in terms of GP wage to average wage. That same year, we had the 5th highest paid specialists in the world (behind Netherlands, US, Austria and Luxembourg) and our relative specialist wage was also in the 5th position after those same countries at 4.8x the average wage.
3. What we are paid – The question was asked where I got the 400k number, and yes this is taken from the MOH statement of the average pay being 385,000, I think we’re all capable of rounding and it was clear that this is what I was referring to. It is true that we have overhead – CIHI estimated in 2002 that 35% of gross payments by public insurance for self-employed GPs and 29% for specialists went to overhead. I never denied this, but the numbers that are available are always gross numbers so that is what is being used. Even if we used net numbers we’re still looking at substantially higher salaries than the rest of Canadians.
4. Teachers v doctors: Much has been said here about teachers and I wonder if it would be said if we knew teachers were reading. I for one think the people educating our future generation should be paid much more. The arguments made about doctors here (if we’re paid less we’ll leave, if we’re paid less we’ll just work less, or do poorer work) can all be made about teachers, so let’s atleast be consistent in our arguments.
5. Canadian brain drain argument
This myth has been busted over and over by the Canadian Health Services Research Foundation. From 1980-2004 there was a minor net loss of physicians to the US, always accounting for less than 1% of physicians in Canada, and since 2004 there has actually been a net GAIN of docs from the US to Canada. While docs in the US might be paid more, just like here the argument has been made to look at net pay, the same should be made there where malpractice rates are often well over 10x more than they are here, as are office expenses due to a multi-payer system.
I think what Ryan seeked to highlight, the fear and politics of medicine has very clearly been demonstrated on the comments on this blog post alone. People get defensive and territorial and no one wants to see a pay cut which seems to disarm our ability to think rationally about how much we already get paid and whether it makes sense for our salaries to be as lavishly high as they currently are. What the MOH has proposed, although heavy handedly, is by no means a drastic overhaul of the fee schedule. We should be aware of our power in this society and how to use this with care and grace, rather than simply always advocating for more for ourselves. I want to end by thanking Ryan for writing this piece and withstanding unnecessarily personal attacks in order to have this very important discussion.
You made the claim that the average doctor makes 200K per year more than teachers. I illustrated why, adjusting for several factors that you incorrectly ignored, that was not true. Yes everyone wrongly uses gross income, but why perpetuate the error? The fact that everyone wrongly uses gross data and that it was “rounded” does not alter that. Why not round to the nearest million? Then doctors and teachers both make nothing and it’s all equal.
It is popular to claim that “no one disputes doctors should be well paid, but the question is how well paid”? How can we answer that question when incorrect and flippant numbers lead to erroneous conclusions?
If you want to make the argument that the average physician should be remunerated the same as the average teacher or average Ontario citizen or whatever then that’s fine. We can debate that. But let’s at least start from correct arithmetic.
I’d also be interested to know if the OECD data capture the working hours, expenses, etc. of physicians or are they just gross numbers? I genuinely do not know.
Your claim that what the MOHLTC has proposed is not “by no means a drastic overhaul of the fee schedule” is also wrong. The MOHLTC has proposed delisting all radiology services and putting them out to tender in a competitive market. That is a very drastic overhaul. It is too off-topic her to go into details, but It will dramatically affect the way we understand patient care for medical imaging. Potentially it will also affect all of health care if the “competitive” model is considered successful enough to import to other specialties. The fee cut adjustments for certain specialties are a distraction.
Seriously, I don’t think this conversation is any longer helpful. It doesn’t address the issues of how do two sides negotiate and has denegrated into an ideological flame out that doctors are bad for some of them being n the 1 percent.
Beating up your colleagues isn’t helpful. Particularly when for the vast majority of them, they work very hard. The didn’t create the societal values that put them where they are now and I expect they don’t expect, least of all, to be blamed for something they didn’t create.
I’m not denying docs don’t work hard, but so do many other people that never see anywhere near the compensation we do. And resting back and not addressing societal structures that may be flawed because they benefit you, and instead perpetuating them is not something to be lauded. I can talk about a lot of things in history where power structures were maintained because it benefitted some at the top – and no one would argue that those should have been maintained, defended of perpetuated. Yes, this has gone from being a specific conversation about these negotiations to a broader conversation to physicians in this society, but I think that is important and appropriate.
So marvelously well said!
The very basic econ 101 ‘supply and demand’ argument does not apply here. Neither do ?Milton Freidman’s academic / theoretical arguments of the 1960s that are failing all over the world as we speak.
In terms of the attitude of “doctors” and the power availed to them and their ability to cooperate as *team players* in delivery of good health care **and** good medicine with all health sector personnel who often have as much or more unacknowledged training, experience & ability. The power differentials can be changed.
Social change just like fear can change . . . in time. Say “Evidence Based Medicine” in frequently inappropriate contexts and see how that changes in public opinion.
There is nothing basic about supply and demand, and in any case, the point is moot as it is not an argument. Economic principles always prevail, and ‘economics’ is not failing all over the world. That is like saying that magnetism has stopped working. There are certainly differing schools of thoughts and models are revised over time.
What is important to note is that everyone faces different economic constraints. We all had difficult decisions to make in leading up to a career in medicine. I sympathize that the government has its own constraints, but they get to make the rules and thus, certainly have more power than the physicians. We have worked hard to get to where we are as a self-regulated profession, but let’s be clear that this is certainly not a right. I think we have much less power than we believe we have, and in fact, the government would like for all of us to feel more powerful than we really are. It makes it easier to get us to do their bidding.
Physicians do not have a clear union. The OMA certainly is the closest we have, but without the powerful options available to other unions, we are truly on our own. The government knows this and will try to divide us. The only tool we have is to advocate for ourselves. If we all rush to beat each other up, then it normalizes this process and others will join in. It is not my job to advocate for other health care workers, such as nurses who in particular have their own union and in many ways wield more power than physicians. Neither is it my responsibility to reduce income inequality. I did not sign up for this cause as a physician, but certainly respect others who work in this arena. I do not respect being told what I should and should not care about or what I should and should not advocate for.
I am still unclear as to what this social change everyone wants is all about. I have gathered these opinions thus far from some of the comments: we make too much, how much we need to make is not clear, we should be worried about how our income will affect the health of a population as large income inequalities create unhealthy populations, that physicians should not be in the top 1% for some reason, that other professions deserve (?) more respect, that physicians provide value to society that can somehow be related to what other professions provide, that physicians are entitled, that the OMA should be more clearly concerned about patient rights, that physicians should gladly give up some income, that the government should then turn around and use those savings to fund a plethora of programs and services, that power differentials are somehow inherently bad, that we should not have a fee system, that the fee system we have is flawed, and no one should worry about the threat of doctors leaving the province as in the past that amounted to less than 1% of the ‘brain drain’, and that young medical students are eager to fill in the shoes of the older physicians if they leave.
Idealism is great, but to ignore economic forces would be folly as I have stated again and again. If the older physicians were to leave after the government imposes sweeping fee changes and the young physicians were to eagerly take their place, then I have one question. What will stop the government from doing that to the young physicians when they get older? They will see that it worked successfully for them in the past and will do it again.
A few other questions that arise from the other points: if the government takes some of the physician’s salary in an ‘honorable’ compromise, what will stop them from doing it again? If physicians are not in the top 1% then who should be? How much should doctors make exactly (I realize no one has the answer to this, but the answer seems to be at the root of many of the opinions expressed here)? If it is our responsibility to mitigate income inequality, then where does our responsibility end? Should we be advocating for a society where everyone makes the same amount of money? How can the OMA reconcile advocating for both patients and physicians when apparent conflicts arise? If they are unable to, then who should be advocating for physicians (should anyone)? Why are power differentials inherently bad? If there is no pecking order, then where will you assign liability? If we put everyone on salary, how will you spur on improved productivity (it is a cop out here to give them more for increased work as that is what billing allows for)?
These are just a few issues that cross my mind when we have these discussions and they come about in thinking about what the marginal benefits and marginal costs are when people/governments/unions have to make decisions.
@GJ, below this post.
Alright, I thought I was done, but you’ve sucked me back in. If I may compliment you, this is easily your best comment yet. I think you’ve made an excellent summary of what has been discussed here. I’ll respond to some of it.
“Neither is it my responsibility to reduce income inequality. I did not sign up for this cause as a physician, but certainly respect others who work in this arena. I do not respect being told what I should and should not care about or what I should and should not advocate for.”
Hmmm…I’m not suggesting that it’s any one person’s responsibility to reduce income inequality, but I would say that all Canadians should care about this growing problem. As physicians, we do have a lot of power and are significant “opinion-leaders,” therefore I would say we bear slightly more responsibility for the problem than an average citizen. I am not telling anyone what they should or shouldn’t care about, but let’s just say I’m making hearty suggestion. Feel free to reject it. I do, however, suggest that all physicians have a professional responsibility to advocate for a healthier society, which, yes, does mean advocating for a more equitable one. It comes with the territory, just like educating people about the benefits of smoking cessation. It shouldn’t be optional.
“I am still unclear as to what this social change everyone wants is all about. I have gathered these opinions thus far from some of the comments: we make too much” (yes)
“how much we need to make is not clear” (true, and probably always will be)
“we should be worried about how our income will affect the health of a population as large income inequalities create unhealthy populations” (true)
“that physicians should not be in the top 1% for some reason, that other professions deserve (?) more respect, that physicians provide value to society that can somehow be related to what other professions provide,” (none of these I agree with or care about so I’ll leave that alone)
“that physicians are entitled” (as evidenced by many of the comments here)
“that the OMA should be more clearly concerned about patient rights” (yes)
“that physicians should gladly give up some income” (gladly, no. gracefully, yes.)
“that the government should then turn around and use those savings to fund a plethora of programs and services” (I just put up my ideas, they are far from the only good ones or even the best ideas necessarily. But I think all of those interventions would either make the system more sustainable or improve it for patients.)
that power differentials are somehow inherently bad (Yes, they cause marginalization and are the opposite of patient-centred care.)
that we should not have a fee system (maybe, the evidence is mixed)
that the fee system we have is flawed (very)
and no one should worry about the threat of doctors leaving the province as in the past that amounted to less than 1% of the ‘brain drain’ (not that we shouldn’t worry, just that the histrionics of the OMA aren’t exactly justified)
and that young medical students are eager to fill in the shoes of the older physicians if they leave (I was very clearly referring specifically to cardiologists and on that point I will stand.)
“A few other questions that arise from the other points: if the government takes some of the physician’s salary in an ‘honorable’ compromise, what will stop them from doing it again?”
Nothing. If I thought the cuts were drastic and unfair, trust me, you’d see me arguing the other side of equation. But I don’t. Should that day come, I’ll be at the barricades right with you, comrade.
“How much should doctors make exactly (I realize no one has the answer to this, but the answer seems to be at the root of many of the opinions expressed here)?”
The exact number doesn’t really matter, the point is that there shouldn’t be such a gap between rich and poor. This is not because doctors are inherently unworthy of what they are paid, but because all humans are inherently unworthy of being paid so many times more than the person who picks up their garbage or cleans their Starbucks washroom. I feel the same way about CEO’s. The companies I’d most like to work for are the ones with the lowest CEO-to-mail-room-worker salary ratio. Same goes for the broader context of society.
“If it is our responsibility to mitigate income inequality, then where does our responsibility end? Should we be advocating for a society where everyone makes the same amount of money?”
That’s a straw man argument. No one here is a communist. Since income inequality has been rising steadily since the ’70s, I would suggest that we can be content when we have reversed the trend back down to 1970s levels. But I am open to suggestions on what the target should be.
“How can the OMA reconcile advocating for both patients and physicians when apparent conflicts arise?”
It can’t! That was the point of my original post. It’s ludicrous that it even tries. It’s ridiculous that it claims to “put patients first.” If it is going to make this claim, then it should do some of the things I suggest. If it just wants to be a union that fights for physician earnings, then that’s fine too. But then drop the slogan and stop pretending that patient care is the top priority! It’s the hypocrisy that bothers me. So, in a way, we couldn’t agree more on this point.
“If they are unable to, then who should be advocating for physicians (should anyone)?”
Perhaps the OMA should stick to true union-type activity (or admit that this is its main focus) and an arms-length “patient board,” should be created with real teeth. This board I envision would have real power in helping determine how hospitals run, how much doctors are paid, what mix of fees and salary to use, etc., etc. Now that would be patient-centred care. Oh, dream of dreams.
“If there is no pecking order, then where will you assign liability?”
Another straw man argument. This is not an all or nothing proposition. Doctors would still bear ultimate responsibility for patient care, just as a pilot bears ultimate responsibility for landing a plane safely. But by lowering the power differential between the people involved, you reduce the chances of a catastrophic error in communication and make everyone safer. You also, again, make the system more responsive to the patient.
“If we put everyone on salary, how will you spur on improved productivity?”
Many health systems around the world find adequate productivity despite their use of salary. Check out some of the Western European ones, for instance. Also, this excellent article by Andre Picard highlights some American health systems that achieve excellent results with doctors who are mostly paid by salary:
http://m.theglobeandmail.com/life/health-and-fitness/minor-surgery-on-doctors-fees-isnt-the-cure/article4216596/?service=mobile
Hello Ritika,
Since no one has been directly answering some of the questions I have posed, I will discuss your summary on a point-by-point basis.
1. “How much doctors are paid” – Economic principles certainly determine how doctors are paid. Are you seriously stating that if doctors were not as powerful a lobby then the government would be given free reign to pay us whatever they felt we deserved? I think not. You are looking at this in an overly simplistic fashion. Economic principles underlie the backbone of all these types of decisions. This includes every single transaction or decision in health care that you can think of. There is no bashing in my mind of the teachers’ unions and their right to strike. As I have mentioned before this is a two-edged sword that works in both directions. Running campaigns is very important – if it offends some, then who is to be their moral arbitrator? Can I please ask this person to stop political campaigning, because I may find it offensive?
Teachers certainly hold a lot of influence in society – I think you may be confusing individual influence with the influence of a group. At no point have I put teachers down. I think they deserve all they get, and have always been supportive of their efforts to negotiate and resolve their own concerns. Why is it alright for everyone to bash doctors though? Should I be arguing that teachers should be paid less? Does anyone else not see the double standard here?
There is a more complicated economic analysis here relating teachers to doctors that may shock you: http://benbrownmd.wordpress.com/category/student-loan/
This applies to the US, but the economic principles and analyses appear sound.
One important point here that gets lost is that what physicians bill is not a salary – it is essentially revenue that is used to fund a number of activities, including rent, diagnostic equipment, medical receptionist, etc… This is one reason doctors receive certain tax breaks, because they are running a business. Along with all the other stress, most doctors have minimal business training, but are expected to run one anyway.
Again, I am not bashing teachers, but this is an issue that others have brought up. The entitlement here is not coming from the physicians, who have voluntarily suggested a wage freeze. In fact, I would say the entitlement comes from other groups who do not feel that they are being compensated fairly and choose to crucify physicians. If a physician personally does not feel that physicians should be making a certain salary in this country, that person has the right to choose another profession or to donate their money. That person can certainly also advocate against whatever they would like, however, to be clear, again that person may be ignoring the underlying economic principles and simply making normative statements. Who cares if doctors are part of “Canada’s 1%”? Clearly some people are hung up on this point – would people be happier if doctors were part of the 2%? Again, Ritika, you have not answered the question then as to how much you think doctors should make, since you seem to think the current number is too high.
Of course, you could come up with your own economic analysis and revise the few thousand items in the fee code to what you think is appropriate and pass it along. I suspect it would be a boring undertaking. There is certainly a rhyme or reason as to why doctors are paid what they are paid in the fee schedule, you simply seem to ignore that there may be some economic forces behind it. Or perhaps you simply don’t understand them – which is also a possibility.
What is the history of neurosurgery training in this country? Are you aware that for many years most neurosurgeons trained in Canada (roughly 25 a year, and way too many for the Canadian population) were leaving for the US and that with the residency requirement changes in the United States a few years ago many currently in a residency program in Canada did not know where they would be working (because there were no jobs)? What is the number of neurosurgeons per 100,000 population versus ophthalmologists? These are all some of the driving factors behind the economics. You have turned the entire thing upside down. If you want to understand why a number is what it is, you look at the history behind how that number got to where it is. There is a rhyme or reason to things, just because they don’t make sense to you does not mean that they are unreasonable. As I have mentioned in another post, the government has certainly used the fee schedule to shape physician practices and has cut fees in the past, just not unilaterally. Of course as technology progresses, some things get easier and the fee schedule will eventually reflect that.
2. International perspective – “it is worth noting that Canada has among the highest paid doctors in the industrialized world, not only in absolute terms but also in relative terms to the average wage. OECD 2009 data shows our GPs make about 3.1x the average wage and our specialists make about 4.7x the average wage. In 2004, we were fourth with only the Iceland, US and Germany ahead of us in terms of GP wage to average wage. That same year, we had the 5th highest paid specialists in the world (behind Netherlands, US, Austria and Luxembourg) and our relative specialist wage was also in the 5th position after those same countries at 4.8x the average wage.”
To this entire paragraph, I state so what? What does this actually mean? It is worth noting that Canada was the only industrialized nation to have positive GDP growth during some of the worst parts of the recent recession. We also pay a lot of taxes – more as compared to the US anyway. Anyone can throw up facts and numbers, but I’m not sure what your point is. Maybe I’ve just missed it. We could also discuss professional athlete salaries, but I don’t know if that would help. Perhaps you are more offended that physicians in Canada are paid by the government, would it be better if they were paid by the private sector as in the US?
3. What we are paid – “The question was asked where I got the 400k number, and yes this is taken from the MOH statement of the average pay being 385,000, I think we’re all capable of rounding and it was clear that this is what I was referring to. It is true that we have overhead – CIHI estimated in 2002 that 35% of gross payments by public insurance for self-employed GPs and 29% for specialists went to overhead. I never denied this, but the numbers that are available are always gross numbers so that is what is being used. Even if we used net numbers we’re still looking at substantially higher salaries than the rest of Canadians.”
Again, so what? What is so wrong with having a “substantially higher salary” as compared to other Canadians? In my first point above I mentioned that doctors’ billing is not so much a salary as a revenue. What does substantially mean anyway? You keep saying it’s too high, but what is the actual number you would be happy with? I’m starting to get the feeling that any number is too high and that you may actually prefer that we pay the government for the pleasure of working for them. Flippant, I know, but I’m sure the government wouldn’t mind.
4. Teachers v doctors: “Much has been said here about teachers and I wonder if it would be said if we knew teachers were reading. I for one think the people educating our future generation should be paid much more. The arguments made about doctors here (if we’re paid less we’ll leave, if we’re paid less we’ll just work less, or do poorer work) can all be made about teachers, so let’s atleast be consistent in our arguments.”
No one that I read said that the same could not be said about teachers, so I’m not sure what the consistency is you’re looking for. Please see my response to point number 1 above regarding teachers. How much should we pay teachers, what is the absolute number you would be happy with? Perhaps doctors and teachers should switch places with respect to salary, would that be more palatable to you? Sorry, what is irritating is when people just state ‘more’ or ‘less’ with respect to certain numbers (never actually stating a specific number) and then state that with respect to the actual real world numbers there is no “rhyme or reason”.
5. Canadian brain drain argument
“This myth has been busted over and over by the Canadian Health Services Research Foundation. From 1980-2004 there was a minor net loss of physicians to the US, always accounting for less than 1% of physicians in Canada, and since 2004 there has actually been a net GAIN of docs from the US to Canada. While docs in the US might be paid more, just like here the argument has been made to look at net pay, the same should be made there where malpractice rates are often well over 10x more than they are here, as are office expenses due to a multi-payer system.”
So what? Income tax and sales tax are also much lower in the US, as well as prices on almost all items. In the United States your dollar always goes much further. I was not aware of most Americans coming to Canada to buy items across the border. Gas is also must cheaper in the US. I could go on and on, the point is that going to where there is more money coming in is certainly an option for most physicians.
“I think what Ryan seeked to highlight, the fear and politics of medicine has very clearly been demonstrated on the comments on this blog post alone.”
Yes, this is true, however, I would also state that when a medical student (I am not putting you down Ryan, it is what you say you are and you have a wonderful future ahead of you) writes a controversial piece, it is meant to open a healthy debate.
“People get defensive and territorial and no one wants to see a pay cut which seems to disarm our ability to think rationally about how much we already get paid and whether it makes sense for our salaries to be as lavishly high as they currently are.”
I don’t know how you define lavish, because I simply can’t get a straight answer from you about what you would like the actual number to be regarding pay for anybody. Please stop misrepresenting a physician’s billings as actual pay – it is a revenue meant to run a practice, not just pay. I know you don’t mean to, but when you say ‘lavish’ it conveys a certain mental picture. There is a lot of goverment and taxpayer waste, but cutting revenue to physicians is not the solution.
“What the MOH has proposed, although heavy handedly, is by no means a drastic overhaul of the fee schedule. We should be aware of our power in this society and how to use this with care and grace, rather than simply always advocating for more for ourselves.”
I think that when people feel a threat to their livelihood they would respond in kind. I don’t want to be the kind of physician where I am always a physician and expected to be always responding with care and grace; I am also a human being. I think people may be shocked to learn of the actual cost of running a practice – this is not just overhead, but professional fees, CME time, etc… Much the same way some teachers feel underappreciated and overworked, I sympathize certainly, it may be shocking perhaps to think that doctors as human beings may also feel that way as well.
“I want to end by thanking Ryan for writing this piece and withstanding unnecessarily personal attacks in order to have this very important discussion.”
Ryan, I have also thanked you and appreciate your enthusiasm as others have also conveyed the same sentiment.
Ritika, my responses have been made with all due respect. None of this is a personal attack on you in any way, but simply wanting to present a more moderate point of view and to illustrate some of the thought processes behind the economics of health care.
Hi RJ,
You’ve made some good points. But most of your argument can be summed up in this paragraph:
“Economic principles certainly determine how doctors are paid. Are you seriously stating that if doctors were not as powerful a lobby then the government would be given free reign to pay us whatever they felt we deserved? I think not. You are looking at this in an overly simplistic fashion. Economic principles underlie the backbone of all these types of decisions.”
You’re right – economics are certainly part of the equation. But in Canada, health care lies almost entirely in the public domain. That means health care is not an economic good. You cannot use a purely economic argument, no matter how detailed your model is (see other posts on this forum for a purely numeric breakdown).
A more balanced argument would demonstrate both the economic *and social* value of doctors, relative to other positions. You need to use arguments that incorporate quality of life and net benefit to society. Is an ophthalmologist 5-10X more beneficial to society than a police officer every year?
Perhaps I was not clear. Economics certainly does take into account social values. This is why certain Canadian doctors do not make as much as American doctors. While the opposite is also true. We have placed value as a society on what we find acceptable. Health care is certainly an economic good. It is irrelevant how is paying for it. An economic good is an economic good. Our society certainly does derive tremendous benefit from a centralized health care system, but there is a pendulum of power that swings.
The argument is balanced and whether you agree where that balance lies is your own prerogative. There is never going to be an argument comprehensive enough to fit in this comment section to satisfy all. The point is the numbers represent something – I could say gas prices are too high, but they represent a set of market factors that have gone into their determination. They didn’t arise out of thin air. It appears that people believe that the numbers doctors are paid have arisen out of thin air without any regard to social aspects. This is not true and is overly simplistic.
You are contradicting yourself by stating that an ophthalmologist must be 5-10x more beneficial to society than a police officer because they are paid more. That is not the argument. People’s pay is not based on merit or social value. Supply and demand. How many more people qualify to be police officers versus ophthalmologists? Perhaps we should lower the bar for entry into ophthalmology and you could have a speeding ticket and an eye surgery done by the same person. Again, these arguments lead to logically inconceivable places. Please note I have not stated that a police officer can not be an ophthalmologist, just that the bar is higher as evidenced by the differing numbers per 100,000. Also, police officer pay would have to be raised substantially to fund required equipment for ophthalmologist.
The McGuinty Government postition is that they will hold the physician spending envelope constant over the next 4 years. The effect of this policy is that existing physicians will fund new physicians, new patients, new programs and new spending related to an aging population.
To achieve their policy they must make cuts to fees and programs. These cuts will have a negative impact on patient’s access to care.
Ryan has tried to make some personal sense of a very unpalatable situation. I am outraged at the marketing efforts on both sides of the equation pandering to public opinion. Certainly this money is needed in many different places (in Health Care & Health Education, Training and Management).
Fear is a powerful motivator so I imagine that the group with the deepest pockets who can create the greatest anxiety in our society will ultimately be the victor of this particular dispute. I think many are weary of the constant battles that serve no one except public relations and advertising agencies.
It gives me hope that young health care professionals are entering into this difficult debate with a healthy amount of scepticism and intelligence. Only by looking for mutual gains within the constraints of the health care system and current funding scheme will any of us be truly better off.
There isn’t any squaring the ideological circle of how much a physcian should make. The spectrum will be vast and no one holds the truth entirely. If we are working in this system, the reality is that physicians here work less hard for about the same amount of money on average compared to American counterparts. But that’s only one comparison. Being in this system means accepting it’s limitations, in a manner. Far bigger than the issue of absolute income is the income disparity between physicians and specialties that has created winners and losers of specialties and practices. And introduced structural changes in health care delivery that may be fairly fixed (ie the amount of labs and diagnostics that are privately delivered and outside of hospitals, including noninvasive cardiology as an example)
One thing is for sure, the currency of valuation continues to be monetary, like it or not. Move on that, take something away and individuals will feel devalued in their work. It’s natural and normal. And don’t expect them to be happy about it or want to be helpful. That too is natural and normal.
So I’d ask everyone to take a bit of a breath. Don’t be so smug about righteousness or entitlement and take a pause before jumping to condemn your colleagues or soon to be colleagues. Even if it throws fuel on the fire, I’ll be honest and say the worst day on the farm is better than the best day at work. I wish I had known that 25 years ago.
Well so much for my proofreading. Physicians here work on average harder than American counterparts. In many specialties, the ratio can be 4 or 5 to one in raw terms of cases for about the same average remuneration. There are about 19 physciains per 100000 in Canada, 27 or so in the US and more than 30 in most Euro countries. So that incomes in this country are higher is in fact meaningless in terms of productivity etc.
Cutting fees to the most productive medical workers in the Western world aint gonna solve any problems. Those who can will move or retire, those who cannot will take more time for family and life.
Been there seen that. Family docs in the 90s were a very demoralized group. And ophthos took two months of holidays when they reached their cap. Orthopods too, remember Dr MacLeod? That’s what started this whole waiting list stuff.
Matthews is incapable of leading a system as complex as ours, she’s shown that with ORNGE. The health care budget is going up 6% this year, and they are trying to fix their fiscal incompetence on the backs of doctors.
do you hear your self?
Ryan I see you hashtagged your windsor star tweet #careerendingmoves. You are correct. You will never get a cardiology fellowship in Ontario, I predict.
A well trained cardiologist can make $2million US tax free in Abu Dhabi per year. Ontario produces very well-trained cardiologists. If it cannot compete, the best will leave. Patients will suffer.
It happened in the 90s, I saw it. It will happen again. These are not fear tactics; they are well-informed predictions.
I hope that this is simply someone being emotional when answering. I respect anyone who puts their opinion out there and is open to debate. Doctors from all walks of life (and all opinions) are needed to serve a diverse patient population. Ryan, there is really nothing other than hard work and dedication that will affect your chances of entering a specialty or subspecialty (as well as suitability). I guess the hope is that with experience you will use your passion for the good of your patients, and this is an attempt for you to engage in a meaningful way with your colleagues.
There is no cognitive dissonance when one is discussing the fundamental economic forces at play. Of course, it would be convenient to ignore them, as the government tried in the 80’s and look at the havoc that wreaked.
The government can impose whatever restrictions it wants, at the end of the day, no one can force the physicians to work. Not allowing doctors to have the same bargaining tools other professions have is a two-edged sword: doctors can’t vote together, but then that means you also can’t force them to work. Wouldn’t it be great for the government if it could unilaterally impose restrictions and then follow them through with forced job action?
I would be careful about criticizing certain specialties. A fundamental economic reality is that one needs to pay for talent. Cardiology training is extremely taxing and extremely difficult to get into – this means those that complete it should be paid commensurately. There is no entitlement here, simply cold, hard truths. Certain Canadian specialties are also paid less than their US counterparts, and there is certainly a physician shortage in the US. There is nothing inherently different in the medicine practiced, so what will stop doctors from going south? Again, another economic reality has to be faced.
It is easy to proselytize, however, certain fundamental economic principles may be ignored in the ensuing verbigeration. It is easy for others to look at medicine and believe that doctors are paid too much, however, I would personally not want to advocate for a system where we would encourage paying less. Another economic principle is that there is no such thing as a free lunch. Of course, people do medicine for the love of it, but if money was not a concern for some, then they must have come from wealthy origins. Is that really the system you’re advocating for?
As usual, the government is shooting itself in the foot and everyone will pay for their mistakes in the future. There is nothing new under the sun.
Yeah game the system rather than working with the government. Fee models need to change!
I’m not sure I understand. How is the person ‘gaming the system’ in my example? Please let me know of anyone you know of that would work that hard if he or she were salaried and would make the same amount of money if they only worked regular hours.
Why do you state that the fee system needs to change? I would think that is unfair to all the people who have chosen medicine as a career with the expectation of a fee system. Some places have salaries and others use a fee for service model. You are free to work wherever you are comfortable.
Did you not note that everyone’s goal is to work with the government to find a solution, but it has been the government who has been unwilling to work with the physicians?
Mark: how are doctors’ ‘bargaining tools’ unlike teachers’?
I know of many professions that involve great sacrifices to enter into: years of training, huge debt, unpaid internships, excessive hours, and near poverty earnings as a less ‘senior’ member of the profession. Yet I can only think of one where the payoff is a high six-figure salary by default. I value doctors, and they certainly deserve what they’ve worked for, but I don’t value entitlement.
Thanks, Ryan, for your informed, honest, and considered article. It’s a healthy profession that remains open to criticism. I’d also like to commend you for your courage not just to share your perspective, but also to put your name on it. That is a true professional.
Sorry Andrew but Doctors cannot strike (people die when we strike). I’d love to see teachers have a new negotiation contract shoved down there throat and take it without striking.
As a matter of fact I would love to see teachers be told by the government that they must rent out classroom space, register students, hire administration staff, pay for computers and get paid $x per student. Then imagine the government says “we are immediately going to cut the $x per student by a little bit, and we want you to absorb the costs of maintaining your classroom, paying your employees according to their previous negotiated raise and take on a few more students – perhaps even more disabled students (as reference to aging population and chronic disease) and do all of this on your dime and still try to provide the same level of attention to everyone”.
I love teachers, especially the ones who do it for the right reasons, I am just using this as an example to show the bold differences between the two public professions and hypothesize how they would handle a large cut in salary. I anticipate STRIKE.
M
Hence my statement that Doctors do not have the same bargaining tools/weapons as teachers.
Mark
I think before saying all this we should ask teachers if they would trade all those ‘freedoms’ to be paid on average $400,000 and get tremendous social status as physicians do.
Sorry Goel but I am going to make this short and sweet because I think someone answered you below regarding economic forces and you completely ignored my argument and chose to strawman my point.
A teachers salary is what it is because it is an appropriate salary (economics) to drive people to put in the work to become educated to teach, to work a bit after school preparing lesson plans and to enjoy the summer months off and all weekends.
If teachers had to go to school for 4 years undergrad and earn 90s consistently (by making up huge sacrifices such as weekend parties with friends, trips abroad, etc), had to spend a summer in university studying for the MCAT (some students take courses that cost $2000 to help prepare them), had to write the MCAT exam (many people take 2 tries), had to conduct research after school in labs as well as spend a summer doing research to enhance their resume, had to volunteer outside of commitments in hospitals to better understand the career and to again enhance skills and your resume, had to write numerous essays, obtain numerous reference letters to get INTO TEACHERS COLLEGE – then if they, when in teachers college, had to study non stop and read textbooks that are thousands of pages and write tests that often cause breakdowns for some students, then had to work 2 years as clerks running around the hospital (or in their case the classroom) pretty much doing paperwork for higher-ups and spending every 7 days or so in a SCHOOL sleeping there working 30 hours shifts sometimes without sleep, then write a licensing exam that is quite thorough to GRADUATE – then if when they graduate, spend on average 5 years doing a residency for which they on average work 10-12 hour days and have enormous responsibilities and stress for 5 full years – then, when they graduate decide to do a fellowship in a subspecialty because they are having a hard time getting a job for an additional year – then if they finally land a job they can FINALLY start to pay back that $150,000 of debt they have accumulated at the age of 32-35 then I…
as a public servant would be honoured and proud to pay them them $500,000 that the economy determines is appropriate for their services there on out.
Heck if teachers trained like doctors trained we would have the smartest society on the planet without doubt.
Anyways, all of this is pointless because if you don’t understand economic principles and market forces that determine the adequate pay for a position then I am arguing with an unarmed opponent.
By the way I love teachers, again just an example. The public needs to understand how doctors train and why they get paid what they do.
M
“He whose heart is firm, and whose conscience approves his conduct, will pursue his principles unto death.”
― Thomas Paine
If it is just the money (economy stupid) I quit. . . I sacrificed my youth for this????
@ JLK
Posted June 9, 2012 at 12:22 AM
Perseverance is a trait that is quite useful when trying to accomplish one’s goals. You appear to contradict yourself, as you state that you have sacrificed your youth and that you are practicing medicine for lofty and noble causes, however, at the same time, appear to consider quitting altogether if someone else might be concerned about money. I’m confused, which is it?
I also know of another saying known in communist countries that you might find amusing: “they pretend to pay us, and we pretend to work”. Although for some reason I think you might be the person working while upset at others for being concerned about little things like being compensated.
While I appreciate that you’re trying to see both sides of the equation, I think you need to be careful of criticizing the response of the cardiologists represented by the OMA. I agree that fear-mongering campaigns are not the answer, but can you really blame them for feeling angry/threatened as the government unilaterally brings cuts to their livelihood? These physicians have made both lifestyle and financial sacrifices in order to complete their training and earn these large salaries to which you refer. Your average cardiologist will have completed a minimum of three years of call-heavy internal medicine residence + 3 years of arduous cardiology sub-specialty training. It’s easy to look at the six-figure salaries these doctors earn and label them as money-hungry, but let me tell you that you don’t make it through that type of training without truly having the best interest of patients at heart. Don’t they have the right to look out for their own best interests?
You also speak of the graduating fellows who would be eager to fill the older ones’ shoes. While this may be the case for some, many of these young physicians on the verge of completing their training (many of whom carry hundreds of thousands of dollars in student debt) are fiercely opposed to the cuts and supportive of the plight of their senior colleagues. It is clear that different physicians will have different views on this topic, however I do think that until you’ve walked in the shoes of those currently being affected by these cuts, perhaps you should abstain from looking down at your colleagues with such dissent.
RB, I don’t think anyone contests that cardiologists have studied a long time and done a lot of call to get to where they are, but at some point we have to sit back and evaluate what is reasonable for a society. Physicians are paid among the top 1% in salaries. Canada has a much higher ratio of physician wage to the wage of the average earner in this country. Do we really think physicians deserve THAT much more than other workers? I can understand being paid more because you’re in healthcare (but then what about nurses?) and because you’ve got long years of education, but the amount that physicians make is astronomical. When 400 physicians are making over 1 million dollars in this province, we have a problem.
The Ontario govt has done what it has with a heavy hand, and I don’t like this approach, but when the OMA’s offer was simply to “freeze” physician wages for two years, I don’t see what their options were either. Physician salaries make up the third highest area of expenditure in our province (after hospitals and drugs), and I think it makes sense to look at the fee schedule to not pay unreasonable amounts. People will ALWAYS advocate against their pay being cut, but if they were making 5 million a year, they would still advocate against cuts because that is in their own best interest. At some point, we need an objective measure of what we think is reasonable in a society, and I don’t think an average of $400,000 per physician is it.
I just want to respond by bringing this back to economics as this is where the root of the problem is. There is a dearth of positive statements made, but a lot of normative statements made. For example, the statement that “the amount that physicians make is astronomical” is not particularly helpful, since, as valid an opinion as it may be, it is not a fact. There should generally not be a problem in a fee for service system if people are lawfully working very hard and billing appropriately. If a family doctor works 7 days a week and works shifts in the ER, all for fee for service, then they should be able to bill for it, as that would be his or her expectation. If not, what would be the driving motivation for working so hard? The government would like physicians to work this hard, but with less compensation, and the argument you make works in the government’s favor. We could also make the same statements about CEOs regarding the social impact of their big salaries, but they would not make sense. As well, many nurses are comfortably in the 6 figure range – please look at the list provided by the government for health care pay over 100,000$. There are a lot of people on that list and they are not just doctors and nurses.
Freezing wages when the cost of everything is increasing is actually an appropriate response. Purchasing power has changed dramatically in the past decade – why should new physicians be penalized? It certainly makes sense to continuously revise the fee schedule, but in the past, the government has used it as a tool to shape the delivery of services; i.e. cutting fees in areas where there was less need for a service and increasing fees in areas where there was more need for a service. Unilaterally cutting fees, when physicians are willing to help the government work it out, sends a strong message that they are going to do whatever they want to do and the consequences be damned. So, if $400,000 (only 2-3x what some nurses make as per the sunshine list) is not an objective measure per physician (an average that is not substantiated) then what is? Where would you draw the line if you had to draw it? 300,000$ (about 1.5-3x what some nurses make) or 250,000$ (1.5x what some nurses make) or 75,000$? This is a ludicrous discussion – if physicians became salaried, they would then do less work as the value of their leisure time has just increased. The point here is not to knock on nurses, either, they work hard and deserve what they get – the difference is they are in a much stronger position with their union, while physicians do not have this luxury. In fact, if physicians were unionized, the government would be unable to pull this current stunt.
The government is dabbling with fundamental economic forces, and while we would all like to be as ideological as to think that we should be doing it for the love of the work, it would be folly to neglect the microeconomics facing each practitioner as a sole entity. The government has displayed that it enjoys benefiting from the power of having a monopoly in paying physicians, but does not want to assume the responsibility of its actions. In economic terms, the government wants to assume all the benefit in this relationship, while at the same time having the physicians shoulder all the economic costs. These types of situations are precisely what has historically laid the groundwork for the formation of unions, whether for good or not.
This is a thoughtful, moderate, and cogent analysis. Thank you
@Mark Fruitman:
Try to be consistent with your argument. Let’s break this down. You start by saying:
“Dr. Goel, the average doctor is not paid $200K more per year than a teacher.”
But your next sentence is:
“A top earning teacher in Toronto makes 94 707 per year.”
See what you did there?
You said “don’t take the highest paid example, take the average for doctors” and the rest of your argument uses a skewed economic model, taking into consideration only the HIGHEST PAID TEACHER.
Like most doctors, you’re completely out of touch with what other professions actually do.
The average teacher works 10-15 years before they make what the lowest-paid doctor makes in year 1. The average teacher works far more than 10 months, and way more than 9 am to 3pm.
“The teacher is also not awoken in the middle of the night (or on a night shift), does five years of post-secondary education and not 9-13, etc. Their training does not require them to sleep in the hospital. I don’t see how you deny that that the degree of responsibility and expertise is greater being a physician than a teacher, which should also increase the remuneration. The average doctor’s day is longer than that of the average teacher, even allowing for lesson plans and marking. It is true that I have used the top teacher pay scale, which is slightly unfair, but the teacher’s working life starts sooner, too. This is very back-of-the envelope.”
Straw man. No one is suggesting doctors shouldn’t be well compensated, the argument is HOW MUCH BETTER they should be compensated. The condescending way you’ve described what teachers do is incredibly insulting and speaks to a culture of entitlement in your profession.
“Why have I gone to all of this trouble? Because these comparisons have to be apples-to-apples.”
This is laughable given how you skewed your argument in favor of our poor (rich) doctors, and without understanding the full responsibilities of the average teacher.
@Milan Gokhale
I acknowledged that I had taken the top pay scale of a teacher and that it was not completely fair. I also did not say that teachers work 9 to 3, which would be 6 hours. I said seven hours which would be 9 to 3 and two hours of marking or lesson planning plus a paid lunch break. Some teachers work more and some work less. I’m not suggesting that good teachers don’t work hard; I know that they do. At the same time, doctors do a lot of unpaid work as well, including work at home. That should also be added into their time, which it never is. I know that teachers do work in their off hours including the summers; I also know enough teachers to know that it’s not a full time job in the summer. Some teachers take other jobs; many spend time with their kids.
If I take the midrange of teacher’s salaries, it’s about 70K. By my analysis above that would put doctors at 120K above midrange teachers. For family physicians, it would be less. Does that fundamentally change much? It is still not 200K, which is what the OP was claiming.
A teacher may work ten years before they reach the top of the pay scale, but a family physician (who would earn LESS than the average that the government is using since the average includes more highly paid specialists) does at least four years of medical school at a cost of roughly 18 000 per year and then two years of residency. While the physician is paying tuition, teachers are earning money for those four years. The minimum pay for a teacher in 2011-2012 was 45 709, so the teacher is effectively earning 63 709 more than the physician for those four years, plus pension and benefits. A PGY-1 will make the same or slightly more than a teacher with four years experience (again ignoring pension) but work longer hours.
I was responding to the claim that the average physician makes 200K per year more than a teacher. I don’t think anything you’ve said supports that claim, either. The teacher’s “Year 1” is not the same as doctor’s “Year 1”. Teachers have moved up the pay scale while MDs are still in school.
This isn’t about teachers versus doctors, it’s about comparing apples-to-apples. You could use any other number of professions as a comparator, but teachers were the ones that the original poster chose. It is dishonest to claim, as the OP did, that doctors make X more than profession Y, and not adjust for years of education, hours worked, pension, vacation, etc. You can quibble with my assumptions if you like, although I thought that they were fairly charitable. Most doctors will have to build practices, for example, so their overhead will be more than 30% (which was already a very low number) and they will not bill anywhere close to the “average” in year one. I also took the government’s number for average, which is probably exaggerated, and certainly exceeds even the gross billings (never mind net earnings) of the average family doctor.
It is easy to snipe that physicians are “entitled’ and “out-of-touch” if you don’t put any numbers to it. If my analysis is flawed, please post your own. Include all benefits and paid breaks. Include the value of the pension and opportunity cost of education and working-years lost. Include the relative costs of continuing education and ongoing professional certification, including the unpaid time to achieve it. If you are going to include out-of-hours, uncompensated work, please do the same for physicians. Consider the intensity of work. Consider the premium for working inconvenient hours; of if you don’t believe that there should be on then explain why. Then we can have an intelligent discussion.
Somehow I edited out of my post that I am not knocking teachers. I am not making any claim about whether they are over- or under-paid. I chose teachers because they were chosen by the OP. It is how the comparison was done that I was objecting to.
I am making the point that the way salaries are compared has to be done more thoughtfully and thoroughly. Not just numbers pulled out of thin air. Teachers are just the example chosen by someone else.
The comment about physician pay being astronomical recognizes that we are among the highest paid people in Canada period. Among the proverbial 1%, and we make this off the public purse. This is a question to be determined by a society – how much do they think their physicians really ‘deserve’. My issue is that pay becomes a measure of merit. I may have gone to school longer but I don’t think I work $200,000 a year harder than a teacher. The relative pay of physicians to all other public sector workers suggest that our contributions are somehow many many fold higher than their own, and I think this is wrong. It also greatly contributes to income inequality in our society which we know is bad for people’s health. Also while there may be some nurses that make over 100k in Canada, that is by no means even close to average, while our average runs at close to 400k.
Sorry that you seem to be confused about what pay means. Pay is not a measure of merit. One does not go for a job and have pay determined by how much is deserved. It is determined by basic economic principles. Supply and demand and that’s it, unless there is some outside intervention, which is precisely what the government is trying to do. Perhaps you would feel more comfortable in a communist society where everyone makes the same amount of money. Would you be comfortable with a teacher doing your surgery? Perhaps we should also not allow professional athletes to earn high incomes either because that leads to an unhealthy population. I suggest you look up the term economic rent. Also you keep citing that average physician pay is 400,000. Can you please cite a reliable source for this? I am curious to know how much you actually think physicians should make, since you keep saying they earn too much? In your theoretical perfect world where physicians make less, how will you stop them from leaving the province or the country?
I would suggest that you think long and hard about the actual numbers involved in running a practice. Physicians also do not receive benefits as do other public service employees. Lastly, in reference to another one of your posts, who says teachers are not as respected as physicians?
Dr. Goel, the average doctor is not paid $200K more per year than a teacher.
A top earning teacher in Toronto makes 94 707 per year. They have fully paid for life insurance, long term disability and (almost) dental. I don’t know off the top of my head what that’s worth, let’s say 3000. So roughly 98 000 with benefits. They have 12 weeks of vacation per year, and 20 paid days of sick leave that they can accumulate and have paid out as a “gratuity” when they retire. (The government is currently trying to take this away.) They also get about one PA per month that they work, so 10 PA days or roughly two weeks of additional paid time off.
Back of envelope, they work 10 months or about 40 weeks. Subtract the PA days, that’s 38 weeks. Subtract the 20 paid days (or 4 weeks) of sick time (since they are paid for that time if they do not use it — you can equivalently add it to their salary) and they are working 34 weeks. That’s 98 000/34 = 2880 per week.
An average doctor DOES NOT earn 400K per year. Even the government doesn’t claim that. The number the government uses is about 380 000 per year BEFORE OVERHEAD. Let’s say 30% overhead (very conservative), that leaves 266 000. Suppose the physician takes 6 weeks of vacation. That’s about 5800 per week. If the doctor worked the same number of weeks as the teacher, they’d earn 197 000, so about $100 000 more.
We have left out the teacher’s pension, which (according to the OSSTF) the average teacher collects at 58. The physician has no pension, and I don’t know many physicians who can retire at 58. The teacher is also not awoken in the middle of the night (or on a night shift), does five years of post-secondary education and not 9-13, etc. Their training does not require them to sleep in the hospital. I don’t see how you deny that that the degree of responsibility and expertise is greater being a physician than a teacher, which should also increase the remuneration. The average doctor’s day is longer than that of the average teacher, even allowing for lesson plans and marking. It is true that I have used the top teacher pay scale, which is slightly unfair, but the teacher’s working life starts sooner, too. This is very back-of-the envelope.
Why have I gone to all of this trouble? Because these comparisons have to be apples-to-apples. Most of these arguments about physician pay are innumerate. If physicians are going to be compared to salaried government employees, then they should get the perks as well: pension, predictable hours, paid time off, sick leave, etc. But you are grossly inflating the physician’s salary (even your gross billings are not the gross billings of the average physician) and underestimating the teacher’s salary. This is more propaganda than a reasoned argument. The argument that we should put physicians on salary usually runs along these lines, that we can get the same services for less money. But being a salaried employee also means that we should expect the same working day. Most physicians do not work a seven hour day.
I also strongly disagree with your comment that the public should decide what they think physicians “deserve”. No one’s pay is determined by plebiscite, for good reason: everyone will always pay less when given the option. Even teachers, your exemplar, bargain collectively. And I’ll add they also strike when they feel mistreated.
BTW, my numbers for teachers salaries are all available online with a quick Google. I can point you to my sources if you like. Also, I’m not knocking teachers, just pointing out what I think is a common and flawed argument.
@Mark Fruitman
Milan has already pointed out several of the issues with your comparison that I was going to bring up, however there is one point that has not been discussed yet.
Physicians are permitted to form a personal corporation that provides them several tax advantages not available to teachers. Not only is a portion of their income exposed to a greatly discounted rate of taxation, but they are also allowed to share their income among family members for further tax savings. Incorporation can save a physician thousands of dollars in taxes using methods that are not available to the vast majority of Canadians. If you were truly interested in comparing ‘apples to apples’, you would have to inflate the physicians gross income substantially to account for these exclusive tax efficiencies.
@KC
Any regulated health professional can incorporate, including nurses. So can lawyers and small business owners. Why single out doctors?
It’s a fair comment, though. I agree that it needs to be considered if teachers are the comparator, but not necessarily if you are using other self-employed people. Also, you have to understand what the real benefit is. That is too off topic to discuss, but it is not a simple tax reduction, as you imply. Some doctors cannot benefit at all.
The point was never about teachers. I’m sorry that has become the focus. The point was that you have to consider more than gross billings and salaries and throwing around numbers without considering other factors. This is particularly relevant if you want to talk about putting doctors on salary. They should get the same benefits as anyone else. You may not agree with my numbers, but at least I made an attempt and put my name on it. No one has responded with anything quantitative. (Indignation is not a number.)
Make sure you voice your concerns to the OMA leadership, or you are only perpetuating your own embarrassment and silently supporting the problem.
I find it upsetting that doctors are held to different standards than other public employees. They do not have the same range of bargaining tools as teachers for example. So doctors in Ontario are forced to take this unilateral imposed changes to the system down the throat without a voice.
I’m embarassed the government refuses to negotiate with doctors. They have helped in the past make cuts and they can do so again. I think doctors are better at making changes in the system than politicians. I understand the conflict of interest though.
Finally, my doctor has said that we will likely add an extra vacation week to his schedule this year because of these cuts. In a community with so many patients without doctors this is going to worsen the problem. So the government must learn to put patients first.