Ontario's Doctors have had five tumultuous weeks: beginning with the surprising news that the Ontario Medical Association (OMA) had negotiated a four-year Physician Services Agreement (PSA) with the Ministry of Health (MOH) and culminating with repudiation of the PSA by Ontario's physicians. How did these events come to pass and, perhaps more importantly, what happens next?
The General Members' Meeting, requested by approximately five per cent of OMA members, and attended in person by less than two per cent, was an opportunity to discuss the merits and faults of the tentative PSA. There was riotous applause for the leaders of the Coalition of Ontario Doctors and all those speaking against ratification, and only a smattering of applause for those speaking in favour. The Coalition's lawyers were also present, challenging the OMA from the microphone and providing legal advice to the leader of the Ontario Association of Radiologists (OAR) throughout the meeting.
The media, to date, has largely focused on the divisions between the OMA and the leaders of the Coalition.
The speeches were, by and large, articulate and passionately delivered by doctors who care deeply about their patients. The key themes identified: health system funding and a lack of trust in the OMA leadership and in the Ontario Liberal Government. However, the redress for these issues was not to be found at a General Members' Meeting, or even in the PSA.
The vote on the PSA, at its very core, was about physician income. Long wait times, underemployed physicians and patients without family doctors are larger health system issues (e.g. hospital funding, medication costs, need for long-term care) that are only peripherally related to individual physicians' paycheques. Throughout a physician's training, discussions of income are largely taboo so it is understandable that the nuances of collective bargaining, socioeconomic factors and political climate have been absent from the debate.
What is Happening Now?
The PSA was clearly defeated. Of the 55 per cent of Ontario doctors who voted, 63 per cent voted against the deal. The media, to date, has largely focused on the divisions between the OMA and the leaders of the Coalition. However, a broader narrative is emerging, one in which the government, rather than physicians, is rising above the fray. This leaves doctors to fight it out amongst themselves before the government is willing to re-engage with the OMA at the negotiating table.
The divisions between physicians are fierce, generationally: with older physicians attacking younger physicians and physicians in training, between types of physicians: generalists versus specialists and community physicians versus academics. Similarly, physicians on the Concerned Ontario Doctors (COD) Facebook group are calling for resignations from the OMA Board and are accusing the media of misrepresenting their position.
For their part, the Progressive Conservative Party and New Democratic Party leaders are calling on the Liberal government to reconsider binding arbitration while they themselves are unwilling to commit to do the same should they form the government in two years. Historically both the Conservative and NDP governments have had no compunction targeting doctors when economic times have been rough.
Clarity and Communication are Needed
The time for mending fences is now. In order to do this effectively, the OMA must engage with their membership, re-earn their trust, determine what they are looking for and have frank conversations about what is achievable. The OMA has committed to doing this and time will tell how effective their efforts will be. In order for physicians to create the organization they want, they must engage with the OMA, participate in meetings, fill out surveys, vote in elections and run for office.
The Coalition has achieved a decisive victory. It is interesting to note that despite their claims of an alternative option, none was or has been presented. The Coalition is also pressing the OMA for redress of wrongs and to fight for their rights, while simultaneously calling for the resignation of their leadership. In order to be considered a credible group, the Coalition must provide clarity on a number of fronts: what are their goals, who do they represent, what are their links to political parties and where does their money come from?
They have no member lists, collect no member dues and elect no officers. Their claim of "representing" 20000 physicians is unclear as many of their members were passively added to the Facebook group or are being counted based on their specialty, without their consent being obtained. The Coalition is accountable, it appears, to no one -- an accusation they routinely level at the OMA.
Government needs physicians to deliver health care; however, equally, physicians need government as they hold the purse strings and set public policy.
Supporters and detractors of the PSA both advanced their arguments on social media. It was clear from several posts that those against the PSA were prepared to personally attack those in support, with particularly fierce and, in some cases threatening, attacks leveled at trainees. Dr. Nadia Alam, erstwhile leader of the Coalition, has brushed this off in the Globe and Mail: "We don't know the nuances of Twitter. A lot of us don't know that writing in all caps means you're yelling."
This is unacceptable and must stop. Physicians are a self-regulated profession and we are responsible for holding ourselves and our colleagues to a professional standard. The College of Physicians and Surgeons of Ontario (CPSO) has clear guidelines regarding the use of social media by physicians. Leaders from both sides should step in to call out bad behaviour if and when it happens.
Physicians Must Engage
By rejecting the PSA, physicians have turned their backs on the proposed system of co-management. Physicians have clearly identified that they can see the failings of the system and it is critical that those perspectives are heard by government to ensure that the solutions implemented are effective. Physicians have also stated that they wish to be engaged and now is the time for them to suggest processes to work with government to ensure that their voices are heard. Government needs physicians to deliver health care; however, equally, physicians need government as they hold the purse strings and set public policy.
Physicians must be prepared to have frank discussions regarding the services they provide, their incomes and the cost that physician incomes represent in a health-care system with limited resources. Progressively escalating physician income, driven by providing more services to an aging population, is unsustainable. Physicians must also participate in rational health system reform discussions that are decoupled from negotiations about their fees. Creating the framework for these discussions is the labour that must be undertaken in the coming months. Physicians must take up the challenge, or have a new reality imposed upon them.
Special thanks to Dr. Melanie Bechard, Mr. Ali Damji, Dr. Bruce Fage, Mr. Jonathan Gravel and Dr. Natasha Snelgrove for assistance with this piece
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