Picking my own lane

In an article I wrote for Healthy Debate several years ago, I argued that the success of Ontario Health Teams would depend on meaningful stakeholder engagement and deep systems thinking. I recently rediscovered that piece, coincidentally, while waiting for another OHT virtual meeting to begin.

Logging on after my evening clinic, I scanned the familiar Zoom tiles: long-time colleagues, mostly family physicians, some close friends. We earnestly launched into our discussion about a potential collaboration between small Family Health Organization (FHO) clinics without allied health (like mine) and a larger team-based practice that could act as a Third Party Agreement (TPA) fundholder and provide administrative support.

One enthusiastic colleague from a Family Health Team praised the idea but cautioned that it would work only if we each “stayed in our own lanes.” They explained that their role was to provide medical expertise, not to wade into contracts, leases, human resources or IT – areas best left to administrators. Another team-based physician echoed the sentiment.

Their comments triggered a visceral response in me. I understood (and frankly envied) their perspective. But it was not my lived reality. As the lead of a small, six-physician FHO in Cambridge, Ont., the doctors are the administrators. I manage the lease. Another physician manages IT. A third handles contracts.

Put simply: for now, this is our lane.

Co-designing system improvements, or even meaningfully engaging in health system initiatives, requires grappling with the realities of practicing medicine in Ontario. FHO physicians, fee-for-service doctors, community pediatricians and surgical colleagues who work in the same medical building where I practice all juggle clinical care with administrative burden, staff management, leases and overhead, albeit in different ways.

Bringing this everyday reality into system planning, starting as early as the expression-of-interest stage, is essential for success. Compensation that reflects administrative burden and complexity, along with policy advocacy for digital solutions such as form digitization, AI scribes and EMR/HIS interoperability, are critical levers for a sustainable system in which the Ontario Medical Association plays a critical role.

However, at the crux of this is the lived reality of many physicians: that of a complex ecosystem of publicly funded but often privately delivered care. The “care” is paid for by direct physician work per procedure, per visit type, per time unit, etc. However, the realities of the infrastructure costs of “care delivery” – cognitive bandwidth to manage employees and leases, insurance and inventory, IT and IPAC – is not as well socialized. Even amongst our own diverse physician communities.

This conversation took me back to the summer of 2006, when I opened my practice as a relatively new doctor, three months pregnant. One of my first patients admired the newly painted rooms and modern exam tables and asked, “Doc, who pays for all this?” Then followed up his question with a multiple choice: “OHIP or municipal taxes?” I explained that the expenses are taken from my own billings, and that is who pays for everything. Me. The look of dawning realization I saw on his face, changing from surprise to confusion to quiet outrage on behalf of his young new doctor, is a look I have seen many times since.

But back to the OHT meeting with FHO lead physicians …

After explaining that while some of us have more clearly defined lanes, such as pooling a percentage of billings to pay for a clinic manager, others manage their practices on their own. This is not a judgement of each other or diminishing the leadership contributions of physicians in larger organizations, most of whom face their own forms of burnout. It is about recognizing that diversity of perspectives is essential if system initiatives are to succeed at the end-user level. This re-shaping of reality and reset, while at times cumbersome and slow, is necessary and requires physician leadership at every table where decisions are made.

As more physicians provided input, I witnessed that look of dawning realization that I have seen so often. Effective system design will take creativity, innovation and sustained change management. In this moment, when the old paradigm is clearly broken, I am more committed than ever to the hard work of generative thinking and deep engagement.

My ultimate goal? To consign that look of dawning realization to the history books. And, eventually, to choose my own lane.