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[Heberto Calderon]

The Ontario Medical Association (OMA) called attention to the increasing number of family physicians who are leaving practice during a February 15 panel discussion. OMA officials called for government intervention to address what they described as an urgent problem.

By the time Natalie Leahy, MD, left her 16-year family practice and her 1200 patients in Oshawa, Ontario, Canada, in September 2023, she had been spending about 3 hours per day on administrative tasks outside of patient charting. She often had to contact three or four specialists to find one to treat a patient.

"Right now, in Ontario, family medicine is a failed business model," said Leahy. "The amount we're able to bill has not kept up with inflation for the last 10 years." At one point, she took a part-time job doing on-call work overnight in a hospital to make ends meet.

After she experienced significant effects of burnout in 2014, Leahy took steps to protect herself from it. But 6 years later, the pandemic made the problems worse than ever. Additionally, two of her family members had health crises at the end of 2022. She needed to take some time off, but "we simply don't have replacements available when we need them."

A recent survey by the Ontario College of Family Physicians "found that two thirds of its members plan to change their practice model, reduce hours, or retire in the next 5 years," Park added. And the number of medical school graduates choosing family medicine is the lowest it's been in 15 years, according to the Canadian Residency Matching Service.

When Dannica Switzer, MD, started working in the rural north Ontario town of Wawa as a family physician, the community had seven doctors, which was the number that the government had assessed was needed. Now Wawa has three doctors. This change influenced Switzer's decision to work part time as a physician where and when she wants.

"We need immediate measures to retain these practicing rural physicians who have so much experience and play such an integral role," said Switzer. "We also need long-term plans. We cannot recruit our way out of a retention problem."

Ontario was the fifth of the 10 provinces to sign a deal for a portion of the federal government's promised $100 billion commitment to healthcare, which the government made a year ago. But this amount falls short and won't stabilize the economic spiral, said Park.

During the discussion, the doctors listed several actions that would help immediately. Government stabilization payments to family physicians are needed now to help with overhead (such as payments for staff and rent) and keep practices from closing, said Barber.

Another need is a centralized referral system. Currently, family doctors use a "Yellow Pages" type system to research which specialists are right for each patient and what their wait times are like, said Park. "This is crazy," he added.

Streamlined information from hospitals and standard forms for imaging requests, rather than a different form for each hospital and diagnostic imaging center, would ease the administrative burden, said Leahy.

In addition, eliminating the requirement for sick notes for employees would help, said Barber. That requirement was ended after the beginning of the pandemic, he added, but has been reinstated and is adding to the paperwork burden.

In the small towns of northern Ontario, where family doctors are providing all the medicine, "we need immediate locum tenens support," said Switzer. Wawa needs 20 doctor days per month for each of the four doctors who no longer practicing there, she added.

All the physicians stressed the urgency of shoring up primary care. "All of our health is at stake," said Park. "Evidence shows that fewer family physicians in our communities is associated with poorer quality of life and shorter life expectancy. We need to act now to ensure there's a future for family medicine in Ontario."

Marcia Frellick, a graduate of Northwestern University's Medill School of Journalism, has been a Chicago-based healthcare journalist for more than 20 years. Her move to writing followed a progression of editing roles at the St. Cloud Times, the Iowa City Press-Citizen, the Cincinnati Enquirer, and the Chicago Sun-Times. Her writing has appeared in the Chicago Tribune, Science News, and Northwestern Magazine in addition to Medscape Medical News, MDEdge, and WebMD.

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Premier Doug Ford's government is promising to phase out faxes in health over a five-year timeline. To hammer home the point, the fax machine gets an entire page of the government's new health-care plan, and the page is designed to look like it was faxed.

More than 90 per cent of doctors still use fax machines, says the Ontario Medical Association (OMA). Prescriptions, test requisitions and specialist referrals are among the health-care documents most commonly faxed around the province.

"In my clinical practice now, whether it's through the long-term care work that I do or in the hospital, we routinely will either receive or send faxes to other providers," said Dr. Adam Kassam, a physiatrist and past president of the OMA.

The fax machine persists in Ontario largely because the province's doctors, hospitals, labs and pharmacies use an array of different systems for electronic medical records and many of those systems can't communicate with each other in the way that faxes can.

Kassam says paper-based faxes add an administrative burden because health-care providers have to spend time manually re-entering the information they received by fax. But he adds that the transition to all-digital communication will take time.

Misdirected faxes are the leading cause of unauthorized disclosure of personal health information in Ontario, according to the province's Information and Privacy Commissioner. Nearly 5,000 privacy breaches related to misdirected faxes were reported to the commissioner's office in 2021.

The Ministry of Health already has launched some efforts aimed at alternatives to faxing, such as the Ontario eServices program, which allows clinicians to make referrals and seek specialist advice digitally.

Recruitment and retention of doctors in Ontario is "not a major concern," the Ministry of Health suggests in arguments it is making in arbitration with the Ontario Medical Association over physician compensation.

The argument from the province comes as the OMA, which represents Ontario's doctors, has repeatedly warned that more than two million residents don't have a family doctor and thousands of physician jobs are going unfilled.

But the talks are going so poorly that an arbitrator is now being asked to determine compensation levels for the first year while the two sides work on the 2025-2028 period, one of the doctors involved said.

"Things are in such dire shape that that's the fastest way to get money out the door to stabilize family doctors' practices," said Dr. David Barber, chair of the OMA's Section on General and Family Practice.

"The numbers are one thing, right, but ... the government's approach here is their briefing essentially says there's nothing wrong. I get there's posturing, but this is actually quite dangerous posturing on the side of the government."

The OMA is proposing a five per cent general price increase for the year, a 10.2 per cent "catch up" to account for inflation and "low price increases" since 2012, as well as 7.7 per cent to be directed to various health system programs.

"We will illustrate that there is no concern of a diminished supply of physicians. Across Canada, Ontario has the best record in attracting medical graduates to train in Ontario. Further, Ontario has enjoyed a growth in physicians that far outstrips population growth."

"What we're saying is that Ontario physicians are a really important part of our health-care system, and we'll continue to work with them to grow the workforce," she said Wednesday after question period.

"We've done that through commitments to two new medical schools. We've done that through expanding residency positions ... in fact, the interest to practice and work in the province of Ontario is high."

The ministry's arbitration submission cited various data points to back up its arguments. The supply of doctors has grown 8.9 per cent from 2019-20 to 2023-24, while the population grew 7.1 per cent, it said.

"These considerations are particularly relevant when the (arbitrator) considers issues such as retention and recruitment of physicians," it wrote. "There is an entirely different consideration for this hearing than there was in the recent health-care decisions in hospitals."

The OMA's arguments also contain a multitude of numbers. There are 2.3 million Ontario residents without a family doctor, they argued. Using a calculation involving census data the province is short more than 2,000 doctors, they said. Data from government agency Health Force Ontario show more than 3,000 physician job vacancies, they said. As well, Ontario has 234 doctors per 100,000 population, one of the lowest rates in the country.

"The evidence of this is everywhere. It can be seen, for example, in the unprecedented number of patients unattached to a family physician, the closures and crowding of emergency departments, the long wait lists to see a specialist, and the backlog of surgical procedures and diagnostic imaging in the post-pandemic era."

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