A recent opinion piece in the Toronto Star that discourages family medicine doctors from starting a practice in Ontario at this time has me deeply troubled.
For one, I find it highly unethical for the authors to actively contribute to maintaining, if not exacerbating, the shortage of family doctors in our province. This goes against the principle of non-maleficence, or “do no harm”, as it threatens to compromise patients and the public even more than the current shortage does. It also threatens to extend the crisis into the longer term if a ripple effect of avoiding to open a family practice in Ontario infects future doctors.
Besides being unethical, it does not seem aligned with the policies of the College of Physicians and Surgeons of Ontario (CPSO). The Practice Guide, which contains the CPSO’s policies on medical professionalism, states, “Advocacy involves the responsible use of expertise and influence to advance patients’ health-care interests … physicians have a responsibility to … advance policies that promote the health and well-being of the public.” The article’s call to stay away from family practice in Ontario seems to breach these standards for physician advocacy in our province.
I realize that the political landscape in Ontario has not favoured family practice and, to be clear, I have little to no praise to offer our current provincial government for its management of our health-care systems during its time in office. Recognizing that many health-care issues were already in full froth when the Ford government took office in 2018, its choices of strategies to counter the issues have been, to say the least, baffling. For instance, why would you decimate already crumbling morale by upholding, with childlike tenacity, Bill 124 in the middle of a pandemic that brought health-care professionals to their knees until, backed into a corner, there was no choice but to relent? Or, how can the government staunchly ignore evidence and expert advice against the movement toward privatization of health-care services?
I could go on, but the point is, I know that our government’s choices have worsened the plight of family doctors in our province to the point where facing another day in the profession can seem daunting or pointless. As well, there does not seem to be much political will to improve this situation at this time.
However, our newly trained family doctors – not to mention those practitioners working in established practices – cannot be expected to find solutions, gratification or encouragement by being bombarded with disparaging messages from their most prominent voices.
Why we need a rallying cry!
This brings me to the second reason this editorial was so distressing to me. Right now, health-care workers, and especially physicians, need a rallying cry to up their fight, not a call to retreat.
Right now, health-care workers, and especially physicians, need a rallying cry to up their fight, not a call to retreat.
Listen – I am an allied health professional by training, currently in a support role in a primary practice environment. So, I get it.
Despite some perks, health care is hard work and can be discouraging at times. Serving patients is an honour and a privilege. But trying to do so in a broken system, with little to work with, can be like paddling upstream all the time. Adding to this, the demands of the COVID-19 pandemic have brought burnout closer for many of us. Our own government seems to see us as some sort of enemy faction to be beaten into submission, cubby-holed and out of sight, within corporate portals from which we can be dispensed like Pez candies when needed.
With these current barriers and shifts, any new practice can feel fragile or vulnerable to imminent obsolescence. Trust me, I know. I work in a field that is enjoying some ministry attention at the moment – but next year? Who knows?
Although I share in the disappointments and fears of working in health care at this moment, I have been surprised by the reaction of its prominent voices over the past few years. Instead of acting as beacons of wisdom, encouragement and level-headed advice, we see a growing shift toward inciting everyone to walk out! We’ve seen it in nursing; we’ve seen it among allied health professionals; we’ve seen it from physicians. And now, rather than turning the ship and asking us all to work together, to fight harder and to advocate for better conditions in which to serve our patients, this opinion piece adds to this movement of, instead, discouraging health professionals from entering the fray.
Do we think this serves as some sort of message to our government? (I would argue it actually plays into their plans for our health-care system.) Do we think public trust in medicine/health care will increase if we not only walk away, but encourage others to stay away, when the going is tough?
The problem is, while putting patients, caregivers and the public at risk, this movement doesn’t necessarily improve our collective plight as a health-care field. It doesn’t help us win our demands against government resistance. In fact, it weakens us. And, more importantly, by reducing our staffing capacities, it pits the interests of patients – to whom we made a commitment when we entered this field, regardless of what our role is – against our struggles with our leaderships and governments. And that’s not fair to them. And it’s not worthy of what we committed to do when we choose our career journeys.
Redirecting the message
I am not a physician, but as I noted above, I am an allied health professional in primary care – as well as a user of our health-care system. At this time, I would like to shift the tenor of messaging to health-care professionals by starting with some sincere thoughts about family medicine.
Dear medical students, residents and practicing family doctors: every day, I work with family doctors who handle the triumphs and challenges of their field safely and with grace. They stay the course with passion and have the guts to advocate for better. I have gratitude and admiration for those doctors, and I know you’re up for this. Even in Ontario, there are opportunities for entering practice that can lead to fulfilling careers.
Don’t let yourselves be put off by this momentary trend – this weird need to incite people in health care to vacate their posts rather than to fight harder, to pull you away from what you were called to do.
As a family physician/GP who has been in practice for almost 30 years, it was disappointing to read your article and I don’t think you don’t actually get how bad family medicine has gotten in Canada. Since the passing of the Canada Health Act (CHA) in the 80’s and our governments taking over funding of family medicine, the funding to family practices has decreased to the point that the fees paid to family doctors are less than 40% of what they should be with inflation (the typic visit family doctor fee is now $37/patient visit when it should be closer to $100). With the passing of the CHA, family doctors are not allowed to bill patients or insurance companies the extra fees the government refuses to fund their practices, and as a result, we are at a breaking point when many family practices have closed because they are no longer financially feasible. Ironically the CHA which was to guarantee universal health care to all Canadians, has been a main cause of the destruction of family medicine in Canada.
I practice in an area that has been reported to be the 2nd fastest-growing urban area in Canada. Yet, we have had a net loss of 12 family doctors over the past two years, with many retiring early or pursuing other areas of medicine. On top of this, we have a local Family Medicine Residency program and of the 16 grads from the last 1 1/2 years, none have pursued comprehensive family medicine. The Family Medicine Residents are well aware of how bad the funding has become for comprehensive family practice in Canada, along with the increasing unpaid administrative burden it is to run in family practice. In simple, our graduating doctors are pursuing other more lucrative areas of medicine where they are better funded for their work.
If there isn’t a major increase in funding such as the doubling or tripling of fees for family doctors to run their practices, comprehensive family medicine may completely die in the next few years. The next patient option that is happening already in many communities, is the only place for people to seek primary care will be in the expensive ER.
This is laughable. Are you really criticizing 3 family physicians who already take care of thousands of patients between them PLUS sacrifice family, sleep and any remnants of free time to do further education in health care policy, then write this honest article??
I honestly don’t know where these 3 doctors still find the mental energy to battle for improvement in the health care system and keep trying. Most of us gave up long ago, because propping up the healthcare system and dealing with daily immediate needs of our own personal patients 80 hrs/wk consumes us. We are not robots.
Before lecturing others about ethics you might want to read about the use of “cand.” next to a degree you haven’t earned.
I am a new grad in family medicine. Drs. Alam, Ghandi & Mathew aren’t telling me anything I don’t already know: I have not started a practice because I can’t afford to. It’s a bad job with negative income. The purpose of their letter is to educate folks like YOU about the situation and the solution, which is to increase the pay for family doctors. Clearly you missed the point.
Out of touch and tone death. Not surprising coming from a bureaucrat masquerading herself as a frontline worker.
I disagree with the implication that hospital based practice is somehow less worthy than community based practice. As a new grad from family medicine residency, I am working in hospitalist and emergency roles largely because of no overhead costs and better work life balance. There are many ways to make meaningful contributions to patient care, as outlined in the original article.
Out of curiosity, how would you recommend family doctors rally?
They aren’t allowed to strike.
They get the opportunity to negotiate with the government every 4 years, and because they have no striking leverage they historically get bulldozed in these negotiations.
Believe me, they’ve asked for what they’ve needed – it has fallen on deaf ears.
They just, a few weeks ago, got an e-mail saying that they will not be getting the expected raise this year because Ontario had an unexpected amount of newcomers this year (No, we don’t understand the logic behind this sentiment either).
Walking away is the only option family physicians have left. Using the “Do No Harm” mantra to push them to stay in conditions that are harmful for their mental and physical health is selfish. As is, so many doctors stayed as long as they did out of concern for their patients. Ultimately, they’re only human.
Yes – The authors of the article you discussed made a recommendation to new doctors to put themselves first. Perhaps, if we were doing that all along, instead of absorbing the abuse the government puts on us, we never would’ve gotten this breaking point. The authors also point out that once doctors leave due to burnout, the likelihood of them coming back even after conditions improve drops. Walking away from family medicine temporarily might be the best strategy to ensuring doctors return in the future under more favourable conditions.
Regardless of it all, I’m very curious as to what unique and untried methods you’d recommend family physicians use to rally.
Thanks for your piece. I certainly value different opinions. I was debating how to respond, but the other respondents have done a much better job than I could. I would simply suggest that you have badly underestimated how bad the current family practice crisis is, and just how frustrated family doctors are right now.
As a recently retired family physician, I agree with almost all the responses below. I am particularly troubled by the fact that you have mistaken working adjacent to family doctors as sufficient to understand what they face, leading to you being misinformed. Worse, your assessment of Drs. Alam, Ghandi and Mathew is unjust.
But, that’s not why I am commenting. Instead, I am coming at this as someone with some experience in medical ethics, both as a long-time member of community and teaching hospital ethics committees, and as a teacher of medical ethics to family medicine residents.
To put it simply: Your ethical analysis of my colleagues publishing the opinion piece in question is both facile and flawed.
I crafted an ABCDEF mnemic to help residents remember six fundamental principles of medical ethics:
A – the right to Autonomy in decision-making
B – the moral duty of physicians to be adhere to Beneficence when caring for patients
C – the obligation to safeguard patient Confidentiality
D – the patient’s right to receive Disclosure of all information pertaining
E – Equity in dividing finite resources among patient populations
F – First, do no harm (nonmaleficence)
We then apply these principles to a given situation, understanding that the principles might conflict with one another. It is very rare that a single one of these principles can be used to judge a given question. We also have to accept that there are almost never absolute rights and wrongs, just better and worse answers.
I am confident that we can agree that the current primary care crisis is first and foremost a violation of equity: present circumstances have divided the people who want a family doctor into those who have one and those who don’t. I am also confident that you are aware of the evidence that demonstrates that patient outcomes are better when the have an ongoing relationship with a family doctor.
But, you make the elementary mistake of applying a single ethical principle to the matter at hand. Furthermore, you seem unaware that physicians graduating from family medicine programs have been entirely consumed with their training over the previous 5-6 years, nor aware that the medical education system has largely withheld what they face as they enter practice. In that light, the letter is a long overdue disclosure that brings transparency to the current state of family medicine.
That’s right, physicians have the right to disclosure too. We also have rights as people to autonomy, confidentiality and equity. Yet when it comes to our work, we are forced to accept legislated pay and work conditions from a monopoly payer, the government. And the government uses the fact that physicians are independent contractors (something that in fact saves the government money when it comes to paying for overhead) to justify the fact that we have not had any of the increases paid to other health or educational professionals.
Finally, I think you fail to recognize that family medicine poses particular challenges to satisfying all the principles of medical ethics, which work best when applied to “cases” (a single patient at a single moment in time). In contrast, family physicians’ work is longitudinal and has a significant responsibility to populations of patients as well as individuals. That means that we accept short-term harm when we do things like stick vaccination needles in people’s arms or wean them from opioids, understanding that we are looking to provide a net benefit in the medium to long term.
To my mind, that is precisely what Drs. Alam, Ghandi and Mathew have done. In other words, they are acting very ethically. For while the short term consequences of their disclosure may accelerate the intensification of the immediate crisis, the sooner the crisis provokes action the sooner we start climbing out of this horrendous hole.
Dear Dr. Dermer,
Thank you for your thoughtful response.
You are absolutely correct, that the analysis of a given clinical scenario through the lens of mainstream medical ethical principles is a complex process involving the consideration of many points and angles with the goal of reaching a consensus on the best action in a specific situation. The final decision usually, though not always, requires leveraging more than one of the principles – at times, however, one of them stands out as the salient reason to follow, or avoid, one strategy or another.
As a physician with practical experience in this area, though, I’m sure you are very familiar with the limitations of the principled bioethics system and why further critical thought needs to be applied to the ways in which we make decisions for our patients, the publics and our professions/specialties. Principle-based medical ethics excludes, and/or renders invisible, many considerations/contexts/groups. A fulsome discussion around that is outside of the scope of this response.
For this context, it’s enough to say that my own analysis – although it pointed me to the one, in my opinion, salient, relatable, bioethical principle that I quoted – involved broader consideration of the (I feel, understandable) reactions of patients and the public that I heard and/or observed when the original article came out. There was quite an outcry on social media from individuals in areas – such as Sudbury, Sault Ste. Marie, to name two – where the shortage of family doctors is much more dire than it currently is in areas in Southern Ontario….people were wondering whether/when they would actually get new family doctors, if doctors were being discouraged, so publicly, from opening practices. While I was canvassing these, I received a phone call from an elderly individual I know, who has begun having some health problems in the last couple of years and whose family doctor is closing their practice and instructing patients to begin looking for another doctor. “If these doctors are telling new doctors to not open practices, right now, how am I supposed to find a new family doctor?” this individual complained to me. Then, one of my patients – who is a person with disabilities with complex health issues and whose family doctor also recently left, but for different reasons – spoke to me about how frightened they were by the article and what it might mean for their search for a new family doctor. (I have the consent of both these individuals to speak of their concerns in a de-identified manner.) Many of these individuals may never speak these concerns other than in a fleeting social media post or by providing feedback to someone (other than the authors) they know in health care. Reasons for this range from personal bandwidth to trepidation over backlash but the upshot is that I received enough feedback to observe that the original article gave rise to anxiety over access to care, just when people need it most.
I, also, was perplexed by the strategy – and especially its public reveal by leaders in the field – of actively discouraging trainees from opening comprehensive practices in the community, even in the short term, in an environment of severe shortages of family doctors. I do not delude myself – and have experienced first hand – that the line between struggling over practice and labour issues in health care and safeguarding the interests of patients and the pubic is a hard one to negotiate. People in healthcare – doctors, nurses, support staffs – have rights and needs also and these are very difficult to weave into enacting the services we have committed to providing. But I have to ask if the long term gains, for both physicians and the public, that are anticipated by the strategy in this article have as unequivocal a priority over shorter term care needs of individuals as we might think? Can we exclude/minimize these short-term concerns expressed by patients and the public? Or is there a different way to reach a balance between these, while solutions are advocated for? Also, given what we’re seeing our provincial government doing, I had to wonder if this strategy was actually helping the situation that you, and the public, are grappling with right now? And finally, would reading about this strategy be somehow hurtful to members of the public? It is around these elements that I became uncomfortable with the piece these doctors wrote.
I do not think many would argue the importance of a family doctor for achieving optimal health outcomes. That is why these people were confused and frightened by the article. Neither would I argue that the actions of our provincial government have created, and are exacerbating, an environment of inequitable access to family doctors and other health services. That is why I firmly agree that advocacy and raised voices are required. And I have no argument against the notion that physicians are entitled to full disclosure, as are patients. That is why – in all fields, actually – mentors could and should discuss the pros, cons, challenges and potential rewards of various career strategies.
But public trust in medicine and healthcare is a delicate, and potentially crumbling, structure – and people are still reeling from the confusing and frightening experience of the pandemic and how it impacted their health care. These, too, are longitudinal considerations, which is why I feel we need to be sensitive to how actions/words reach, and impact, the public.
I’ve read other comments/editorials by these doctors and find their advocacy admirable and important – and their endurance, in this advocacy, remarkable. I’ve had no issues with other strategies and messages they have leveraged. But, with respect to possible harms that individual patients and the public may incur, I did not find this particular strategy – maybe specifically, its public declaration – to be a neutral one, in terms of defensibility.
Did you even bother to read about the authors of the article and see how involved they have been in advocating for a better health care system, one that works for patients and family physicians alike?! Did you go out and talk to community family physicians to see the extent of the damage that has been done, before writing this piece? You obviously have no clue of the degree of abuse that community family physicians are suffering from, to the expense of their own families, children, financial security and livelihood. To say their attempts to ring the alarm bell once more is unprofessional, after thousands of times physicians have been speaking out in the past 20 years, and have been treated with disdain, is overtly offensive. Physicians have no tools to fight the government – they have been sneakily stripped away over the past 20 years. They are not allowed to strike, or use any of the tools that teachers, nurses and other health workers have used successfully many times in the recent years, so the only thing left to do is stop taking the abuse, and prevent new grads from stepping into this abusive relationship, as many have mentioned before me in their comments, with much more eloquence. It looks like this is the only way people (like you) are finally starting to pay attention. It only took 20 years!!!!!!! Thank you Nadia, Sohail and Silvy!
As for the intentions of this government, they have already started privatization of healthcare and have their own agenda, pushed by their sponsors, and they could not care less what happens to community family physicians or our patients, or they would have listened to all the cries they heard for many years. But THEY ARE responsible for the crumbling of family medicine, not the physicians working 12-14 hours a day and drowning under bureaucracy.
Everyone has provided really great replies with details so I’ll just share some added info.
Maria, you imply that we have not adequately worked hard to improve the system, but the truth is, all three of us along with hundreds/thousands of others family physicians, over the past decade have sounded alarms, spoken in media, become involved in medical politics and leadership positions in order to prevent this exact scenario.
I would argue we did everything we possibly could do to ensure we had a functional primary care health system, WHILE working within it full time.
A story:
Dr. Alam and I did our master’s together in health economics and policy in London UK, with an international cohort. She introduced herself and then said “healthcare in Ontario is on fire”. I was embarrassed, and so followed her saying it was a slight exaggeration. That was in Dec 2017.
By the time the three of us finished our terms on the OMA Board, we predicted family medicine at this rate (due to lack of interest, investment and innovation) would collapse in 5 years. That was 2020.
This was over two separate govt’s. Two political parties.
At this point, the system is being forced to change, because it CANNOT and SHOULD NOT continue to rely on individuals trying to piece it together. Those of us who stay in it, do so for our reasons, not the least of which is because we are invested in the lives of our patients. See the article by Dr. Petrosiak who is afraid to retire at 74 yrs old. He is dedicated; we all are. It should not be that he must stay on past his desire to, in order to hold up a system. That’s not ok. It’s not something to be proud of.
And yet that’s exactly what we have been expecting family doctors to do… Forever.
Just now, you have to add in the 24hour burden of responsibility, the costs, the complexity and the lack of resources in a burgeoning and aging population.
New graduates carry a lot of weight.
Part of the responsibility of mentorship is honesty and guidance.
It is our opinion that new graduates should absolutely know what the situation is for starting a comprehensive care practice, so that they can make informed decisions.
Anything less than this is unethical.
Pretending things are not completely dire is unethical.
And continuing to ask individuals to prop up a failing system at their own personal mental, physical and financial expense, is unethical.
Thank you
I am a full-time community family physician, and I read this article with great disappointment.
I am at the face of our health care system. When patients cannot get a timely breast biopsy or a knee replacement, they come to ask me. I address their frustrations, alleviate their pain, and manage expectations.
I am the backstop when issues are missed during transitions in care and issues that require follow up.
I am the navigator that helps patients, and their families orient themselves to housing resources, mental health and financial resources.
I am the advocate for my patient’s health when they deal with their employer or insurance companies.
I do all these things and more, alongside everything from newborn care to palliative medicine.
I, like the great majority of family physicians, take pride in our work, and in what we contribute to our patients and the community at large.
But Banks do not grant loans for a new clinic based on my contributions to Ontario’s healthcare system. My rent payments do not decrease because of the positive impact I make on my patients’ lives. The salaries of our exceptional staff are not funded by the sound of clanging pots and pans.
Today, to outfit a new clinic with the minimum number of physicians for a FHO requires high 6 figures to 1 million dollars, loaned at 6.95% interest. We guarantee our own lease – we are on the hook for ensuring it gets paid for the entire term. We are responsible for hiring and ensuring our staff are paid a living wage. We invest our own time in making sure the clinic runs. For many community family physicians like me, there is no assistance for any of this from any level of government. No money for staff, no incentives for starting up, no support for logistics. We are in a precarious, failing business model with ever growing administrative burdens patching the system equal to a part-time job. We have been trying to expound on this, and frankly have been completely unsuccessful in this.
You realize that “… there does not seem to be much political will to improve this situation at this time.” Yet, you ask family physicians to work harder expecting a different result from the government.
You state that “With these current barriers and shifts, any new practice can feel fragile or vulnerable to imminent obsolescence.” Yet, you expect new graduates to take on a massive financial risk: long term lease, EMR contracts, and double their already tremendous debt in start-up costs.
You lament that “Instead of acting as beacons of wisdom, encouragement and level-headed advice, we see a growing shift toward inciting everyone to walk out!”. Do you apply this standard to the teachers in Quebec who recently concluded a strike? Are they less dedicated to their students? Do you apply this standard to all groups who organize to make their voices heard?
The authors, Drs. Alam, Ghandi and Mathew made it clear that there are many options available to new family doctors. They warn of the current state of specifically locking into comprehensive family medicine, to ensure that new grads do not put themselves in a position where they will be burnt out early in their career. To me, leadership requires honest conversations, not empty promises, or exploiting the ideals of new family doctors. I find it unethical to sell a romantic vision of what it is like to start and maintain a Family Medicine practice in the current environment. It is a recipe for moral injury when those ideals run flat into the economic realities, as I have experienced. And frankly, to say to those of us, like myself, still practicing longitudinal family medicine we should be working harder, or we are just doing family practice wrong is demoralizing. It is grossly offensive to my early-mid career family medicine colleagues who have burnt out through great moral struggle and guilt. Disillusioned family physicians who leave longitudinal family practice will not return. The greater harm to the public and to patients is not the Star article that speaks truth to the issue, but the issue itself: that family physicians, whose concerns are being gaslit, continue to leave longitudinal practices.
Hi Maria,
The tone of the comments section demonstrates how serious the problem has become.
I would ask you to read these comments and reflect on your writing. Ask the doctors you work with how they feel about their job compared to the past. Try to speak to many people and get as informed as possible before publishing.
I sometimes feel the state of being a family physician in Ontario is like being in an abusive relationship. Where the government, the general public and even some of our specialist colleagues are our abusers. When I read your article it feels like someone telling us to just tolerate the abuse and that we should try harder in the relationship.
As an allied health care provider (NP), I’m disappointed that you felt publicly calling out Family Physicians was the right approach here. They-alongside some other frontline healthcare providers -are literally carrying primary care on their backs, at the expense of their own physical, mental, psychological, and financial health. They are clearly getting abused by the ON government-there is really no other accurate way to represent it.
I’d like to say you simply haven’t taken the time to educate yourself, but you say you work in primary care, so you should know better. These are our friends and colleagues. We need to support them, not publicly call them out.
I don’t think it’s uncalled for to say: shame on you. Once you read all the comments here, you will know better, so you can do better.
Thank you for your piece. I think you have a fundamental misunderstanding of the physicians’ arguments in the opinion piece. They were not suggesting that family physicians leave or don’t enter healthcare. Family physicians are trained and expert at many areas of healthcare including comprehensive primary care but not limited to it. Family physicians work in emergency rooms, in low risk obstetrics, hospitalist, palliative care, coroner work, and so much more. These are important parts of healthcare to.
Finally you seem to have missed another part of the physicians’ point: they want Ontario to have family physicians working in comprehensive primary care for the long haul. If a doctor starts working in it and burns out and leaves they’re unlikely to every come back. They are arguing for said new grads to not put themselves in the position to burnout and become poisoned to primary care. They can always come back later. But if already burned out the authors argue they’re less likely to in the future
Maria – It’s you, hi. You’re the problem, it’s you.
You don’t get “it,” including advocacy, or fighting for a better tomorrow. The letter to the Toronto Star was a beautiful example of advocacy. It was part of a concerted, organized effort by Family Physicians, (with their already limited time and energy,) to save community Family Medicine by denouncing the true reasons for the family medicine crisis, and putting public pressure on the government to change it. In other words, fighting. This effort was undertaken because they want high quality Family Medicine to be available to everyone in this province, and that can’t happen without profound system reform. It’s advocacy. It would be easier for these doctors to quietly fade away into other roles like ER and Hospitalist, as thousands of family doctors are doing, but instead they’re choosing to fight to make Family Medicine a sustainable career choice. We don’t have a “shortage of family doctors,” we have a shortage of sustainable family medicine jobs, forcing qualified family doctors to choose other career options like ER and focused practice. If it’s “Do No Harm” you’re worried about, I suggest focusing on the harms of a short-sighted, reactionary system bailing water out of a sinking ship with a thimble. Why are you attacking the people advocating to repair the damage? You are asking human beings to “stay the course” and continue to sacrifice their own health, time, money, relationships, and dreams of a fulfilling career, to keep treading water so they can hold up a sinking ship with their bare hands. Is that what you ask of the family doctors you work with? The letter you are responding to is the wise guidance from leadership that you’re calling for. Would you counsel a new-comer to a sinking ship to jump right in and drown with you, or would you suggest that they stay safe and get help?
I find it incredible that so many don’t view it as a brave act of advocacy.
So many issues with this piece of writing.
#1 You are not an allied health professional, you are a member of the burocracy that has flooded our health care system. This distracts from your message, Your linked in profiles states you have worked in your current field for about 5 years. Yet you dare to reprimand experienced physicians with decades of experience in their field.
#2 You are feeding into the “medicine is a calling” woo that makes doctors feel guilty. Medicine is a JOB. It is a very difficult profession that most people do not have the skill set to perform. Why make it so;that to ask for a paycheque, that allows them to pay their bills and support their families, is considered disgraceful?
If you were told you would have a 30% pay cut for what you do right now, I bet you would start trolling linked in for a new position and you would tell your friends that this is not a good career path to follow.
#3 How will we fight harder? Strike .. Nope not allowed, Work to Rule? seeing that already, not going great. Perhaps we should shed our health team of some staff… hmm
and finally #4 a rallying cry sounds so lovely but it will not pay my light bill, so I may need to just turn the lights off.
sincerely a family doc who is tired of people trying to shame her for making a living.
No honey you don’t “get it” unless you work for free 30% of the time. Do you? Do you contribute your own money to pt care? I highly doubt it so shut up and sit down until you work as a physician in this system. You are part of the problem. Do you think those three doctors wanted to write that letter? Do you think they did it on a whim? No, we on the front lines, outside these wonderful “teams” with all the trimmings, we are dying strangled by financial ruin. You have no clue!
You are wrong.
You are not on the front lines. You don’t “get it”. Please read and understand some of what others have written here.
There is no shame in warning the future cohorts about the disaster that awaits them in primary care- and it’s absolutely no fault of the doctors.
The suggestion that the article in question somehow goes against the principle of non-maleficence as absurd. The system and the govt are hurting our population and hurting our family doctors- to the point where they no longer want anything to do with it. This is burn out. We are burnt out.
With all due respect, your opinion is the reason this letter warning new grads was needed.
I find your article to lack a depth of journalistic integrity or authority to warrant publication.
There is however a need for physicians to mobilize in solidarity to save the PHYSICIAN-LED primary care system if we want to maintain the principles of the Canada Health Act. The growing GOVERNMENT-LED system cannot recreate the physician-owned system with any sort of cost-efficiency, let alone uniform and adaptable quality.
So I do agree on one point – ALL doctors, whether working for themselves or as part of an organization that has deliverables to someone else, need to come together to save our independent professional status and the crisis that our country is facing.
Until docs come together in solidarity, I’m firmly on the side of my esteemed colleagues who wrote the letter you mention.
Here is the reply I put together with perspectives from my personal friends, all of who work outside of medicine.
——-
Patients write a response to our esteemed colleagues Nadia Alam, Sil Tor, Sohail Gandhi
Dear Esteemed Doctors,
As the Patients of Ontario, we find ourselves increasingly frustrated as we witness the unfolding of a largely unrecognized two-tier healthcare system within our province. On one side, we have the primary care system run by dedicated physicians; on the other, a system increasingly dominated by government directives and managed by physician-leader-employees. This dichotomy has led to a neglected and eroding physician-run primary care sector, overshadowed and outvoted by the government-run counterpart in critical decisions, including Physician Services Agreements, and leadership tables about primary care.
This division has fostered a climate where the voices of those in the trenches, running clinics and directly engaging with patients, are drowned out. These professionals, who have dedicated their lives to the care of their communities, find themselves with little representation or influence in the shaping of policies that directly impact their ability to provide care. The result is a stark imbalance in authority and income that disadvantages both doctors and patients, perpetuating a system that seems to prioritize bureaucracy over the human element of healthcare.
Furthermore, it’s imperative that we address the elephant in the room: the negotiations surrounding the financial aspects of healthcare must pivot to focus on the 2/3 of each service cost currently absorbed by doctors. This unsustainable model not only places an undue burden on physicians but also jeopardizes the quality of care available to patients. It’s time to unlock the earning potential of our healthcare providers, finding solutions that align with the Canada Health Act (CHA) while ensuring the viability of physician-run practices.
As patients, we are growing weary of the blame placed on government policies for the current state of affairs. While external pressures cannot be denied, the responsibility also lies with the medical profession to stand up for its rights and interests. For over 40 years, doctors have acquiesced to agreements that undervalue their services and undermine their autonomy. This trend cannot continue. Doctors need to grow a spine and assert their worth, both for their sake and for the future of healthcare in Ontario.
The conflict between the two primary care systems—one run by physicians and the other by the government—is unsustainable and detrimental to the health of Ontarians. It’s a conflict that remains largely unacknowledged, yet it is central to the challenges we face in healthcare today. The physician-led primary care system is not merely an alternative; it is a vital traditional component of a comprehensive healthcare model that values personalized care and professional autonomy. It is the system that is disappearing before our eyes.
In light of these challenges, we call upon you, our doctors, to take a bold stand. It’s time to demand fair compensation and autonomy in practice. This is not just about financial gains; it’s about respecting the profession and ensuring that patients receive the quality of care they deserve. And by taking this stand you may be able to write letters to your young colleagues that encourage them to join you in a revitalized healthcare system.
The current situation is a clarion call for change. We urge you to reject the status quo and advocate for a healthcare system that recognizes and rewards the indispensable role of physicians. Let’s move towards a future where the negotiation table reflects the diverse needs and realities of all doctors, and where patients can rely on a healthcare system that is both equitable and sustainable.
In Conclusion,
As patients who rely on your expertise and dedication, we are not just concerned; we are irritated. Irritated that your response to systemic pressures seems to be a retreat, a suggestion to new generations of doctors to avoid primary care in Ontario, or to give up on the profession’s ability to self-advocate. This resignation does a disservice not only to your profession but to all Ontarians who depend on you for their healthcare needs.
Therefore, we ask you, our esteemed physicians, to consider these three hard questions:
1. Why have you, the medical professionals upon whom we depend, accepted diminishing autonomy and compensation for over 40 years without a unified, forceful response? Is it a lack of solidarity, fear, or perhaps resignation to a system many believe cannot be changed?
2. How can you reconcile advising the next generation to avoid family medicine in Ontario with your Hippocratic Oath to serve patients to the best of your ability? Does this not signal a surrender to systemic pressures that could instead be met with collective action and negotiation for better conditions?
3. What specific steps are you willing to take, beyond the confines of traditional agreements and negotiations, to reclaim the value and autonomy of your profession? Are there alliances within your ranks that could challenge the status quo and present a united front for the betterment of healthcare in Ontario? It appears the time to act for us all is now. Why are you paralyzed?
Furthermore, we implore you to consider these additional questions, which cut to the heart of the matter regarding the financial viability of physician-led practices:
1. Why has there been reluctance or inability among physicians to effectively negotiate with the government for a fair valuation of services rendered by physician-led businesses? Is it a lack of cohesive strategy, fear of repercussions, or a misunderstanding of the collective power you wield as essential service providers? Why do you negotiate based on what the government has in the past been willing to pay, instead of the actual value of the services you deliver?
2. What concrete steps will you take to collaborate with government officials to rectify the crippling pay structure that undervalues physician services, ensuring that physician-led businesses can thrive without compromising patient care? Are there innovative proposals that have yet to be explored or presented as viable options during negotiations? Preferably prior to the negotiations about the GOVERNMENTS physician services budget.
The sustainability of physician-led primary care is crucial not only for the health of the profession but for the overall well-being of our healthcare system and the patients it serves. We urge you to confront these challenges head-on, with the courage and determination that your profession is known for.
Let this be a turning point where we see a united front of physicians advocating not just for their rights but for the very essence of quality healthcare in Ontario. Identify the divisions in your ranks and work together to lift one-another up.
With steadfast support and eager anticipation of meaningful change,
The Patients of Ontario
Thank you for this, Clay.
I find the letter adds nicely to the spirit of my piece and presents a varying perspective on the matter.
Maria – It’s you, hi. You’re the problem, it’s you.
You are NOT an allied Health Provider and should not represent yourself as such. The fact that your role of “Patient Navigator” even exists is a testament to the ridiculously complex and ineffective system in which we work. And who does the patient “Navigation” when there is no funding for your position in our own practices? Yes…we do. Physicians who are trained in medical care, are reduced to doing your job (without pay) as well as struggling to do our own. We are treading desperately to keep our heads out of this toxic soup and you are saying kick harder, while encouraging others to jump in. We are simply trying to save our would be colleagues from the same fate in hope of a better future for all.
Glad I scrolled ahead to “I am not a physician”…. saved me this tiresome read.
Our group has stopped taking students and residents. This is much more serious than a letter to the Toronto Star, but a true sign of what’s to come unless the Govt steps up and funds family physicians appropriately.
RIP Family Medicine.
You clearly never worked on the front line. Just another bureaucrat telling the boots on the ground to toughen up. Family doctors are right to sound the alarm about our collapsing system. They are the vanguard. The government (and you) should consider listening. “Allied” is a stretch of the word in your case.
Family Doctors can’t afford to practice Family Medicine in Ontario. And your article is an example of lack of awareness and ignorance.
This 1000%. Frigging disappointing that ignorance gets published.
There is no “fight harder”. Community-based family physicians…especially the ones who don’t have the government paid support of family health teams and academic centres…have their backs firmly against the wall and there is no more to give. After giving 10+ years of their lives, training 20000 hours to develop the knowledge base and skill set to be family physicians and going hundreds of thousands of dollars in debt, there needs to be a significant value proposition to start a family practice business and keep it going. Right now, that value proposition is negligible to zero and falling fast. Starting a family practice business is a guarantee that every year, you will work harder for less. You will work half of a full time equivalent doing administrative tasks for free. Every single month…every single year…gets worse. And there is little to no hope that it will improve without drastic action that no government in the past 40 years has shown any ability to execute. There is no one in their right mind who would ever run a business where they have only one customer that dictates if and what they will be paid for what they are selling. That is a recipe for disaster and one that is currently coming to fruition as community-based family physicians are extricating themselves from this predicament in accelerating numbers.
Being a community-based family physician is the WORST job in all of medicine. In no other job in medicine will you work harder and longer for less. Family physicians, who have been resilient in the face of the deterioration of their community business, are increasingly being pushed across that line in the sand by contempt from government. Everyone has their own line in the sand. Family physicians, like any other human being, will look for opportunities that improve their situation…both economically and in work/life balance. Who else would not leave their current position for one that pays more for less hours…the same for less hours or more for the same hours.
Medical students with crushing debt already KNOW about the value proposition of community based family practice. That is why they are avoiding family practice residency in droves. Those in family practice residencies already know…which is why most of them will not be starting community-based family practices. I commend thos who wrote this letter to family practice residents. They have lived this life and business for decades and have watched it get worse despite all of their best efforts to improve things for the better. I am happy to add my voice to theirs advising family practice residents to avoid setting up a community-based family practice. It is a set up, from the start, for failure.
I hesitate to take this further…but I will because you clearly demonstrate a lack of understanding of the economics of a community-based family practice business. In business, you either are the overhead or you pay the overhead. You state that you are not a physician. Only physicians…in this publicly funded system…are locked into this business model where they pay overhead. Everyone else is the overhead paid by someone else and is part of the inflationary pressures experienced by physicians in the face of increased complexity, falling income and increasing expenses. Your exhortation to “stay the course” shows your lack of understanding of the pressures experienced by community-based family physicians. They have been…it is not working…it shows no signs of changing except to continue to get worse.
Dr. Conte, I couldn’t have said it better. Thank you for the time and energy you took to respond to this ignorance.
No honey you don’t “get it” unless you work for free 30% of the time. Do you? Do you contribute your own money to pt care? I highly doubt it so shut up and sit down until you work as a physician in this system. You are part of the problem. Do you think those three doctors wanted to write that letter? Do you think they did it on a whim? No, we on the front lines, outside these wonderful “teams” with all the trimmings, we are dying strangled by financial ruin. You have no clue!