Several weeks ago at TVO Today, I lamented a challenge I was having going about my daily work: people were willing to tell me things off the record that they weren’t willing to say on the record.
Navigating this is just part of my job. But what I’ve been noticing for the past few months is that medical-sector participants — health-care workers of all kinds — are telling me absolutely horrifying things off the record that they are reluctant to say on the record. The gap, or the “delta,” between on-record and off-record remarks in Ontario’s health-care system is like nothing I’ve ever seen.
Normally, someone’s off-record remarks are a bit blunter, saltier, maybe even nastier than what they’d say on the record, but the reader would come away with generally the same understanding. I cannot reconcile the versions of what I’m hearing from health-care professionals off the record with what many of them are willing to say on the record. And that, to me, is fascinating.
In my previous column, I asked people to speak with me clearly and directly. Dr. Ramsey Hijazi, a family doctor from the Ottawa area, answered that call. Hijazi spent a decade in family medicine and recently decided to leave his practice for another job in the health-care sector. He spoke with me about the state of family medicine in Ontario, and I could not fault his decision to leave. His on-the-record comments below, lightly edited for length and clarity, are the bluntest version of extreme concern I’ve yet found anyone willing to put on the record.
Matt Gurney: You are not just a family doctor. You’re also part of a group of family doctors, the Ontario Union of Family Physicians.
Ramsey Hijazi: The founder of it, yeah.
Gurney: That’s actually how you ended up on my radar. A family doctor I know personally knew I was looking to get blunt talk from someone and suggested you, based on your advocacy there. I want to point out to readers at the outset, though, that you’re not a union in the sense of organized labour. You’re an association of concerned physicians. With that established, tell me about the group. Why did you choose to found it?
Hijazi: That’s correct, yeah. Not a union, but a group of doctors worried about family medicine in Ontario. I formed it in July of last year.
I founded it because I was frustrated. I was frustrated about the trajectory of family medicine in Ontario. It’s been going down for a while. I say this as a family doctor, someone who’d been doing that work for a decade. But I’m also someone who lives here. My family is here. I see the struggles they’re having navigating the system and dealing with the frustrations and inefficiencies. And family medicine is being defunded over time. Access to care is already not acceptable. For all our talk about a universal health-care system, in Ontario, we have, really, three tiers: people with no access to a family doctor, people with access to a doctor, and people with access to a doctor and through that doctor, full team-based care. Those lucky patients have access to allied health-care professionals: social workers, psychologists, dietitians, and the like. That’s available to patients in that clinic.
This is not a fair system. We have unequal access to care. And I felt like there wasn’t enough advocacy about this and not enough effort to get at the root causes of what is causing the crisis in primary care. I wanted to generate pressure on the politicians and even the Ontario Medical Association to make changes so that we can make life better for the physicians, yes, but also, we can improve access to care for all patients across Ontario.
The crisis in family medicine, with Dr. Ramsey Hijazi
Gurney: So you just broke that down into two sources of frustration: someone working inside the system, and someone outside the system trying to navigate it. And I imagine that basically everyone in Ontario has some version of the second problem. But very few of us have any insight into the first. Tell me about your experiences. What have you observed first-hand during your career?
Hijazi: In my 10 years, I think I could safely say that I’ve seen changes every year. Each one, 10 years in a row.
There has been a steady decline in the working conditions for family doctors in Ontario. It’s all tied to funding needed to run family medicine clinics. This is what my group has really tried to raise awareness of.
There are two key issues. One is what we’ll call administrative burden. Paperwork. And this will sound counterintuitive, but as we’ve tried to introduce more technology into the system — to eliminate actual paper — the problem has gotten worse. It’s all electronic now, but the burden has gone up.
Let me give you an example. Not that long ago, let’s say one of my patients went to a hospital emergency room and was admitted. I’d get a report when that patient went in to the ER. Probably a report after they are admitted and checked out by a few staff members there. And then a report when they are discharged. That’s three reports. Now, with the electronic systems, I’m getting automatically sent a report at every step of that patient’s process through the ER, and I’m getting notes on things related to their hospital stay that aren’t relevant to me as their family doctor. And because of the way the system is designed, many of these notes are being duplicated, so I might get three or four of them for every part of the process. And then these reports can be updated by hospital staff, so I need to check all the reports to see if there’s anything I didn’t see the first time. So instead of getting two or three reports that detail the patient’s stay in the hospital, I’m getting 12 or more, and that’s taking up a lot more of my time.
Gurney: This sounds like an experience I’m sure everyone has: some reply-all email goes berserk or one of your group chats lights up, and you’re suddenly getting so many notification pings on your phone you can’t do anything else.
Hijazi: That’s it. That’s 100 per cent it. Our inboxes are being flooded with this stuff all the time. At the same time, we’re also being asked to do a lot more paperwork of our own. Filling out paperwork for insurance companies has gotten a lot more complicated. They’re asking for a lot more information. Government forms are getting longer and more detailed — filling out paperwork for the disability tax credit, for example, takes much longer now. We are getting a lot more information coming in from pharmacists and also a lot more requests. They’re requesting prescription codes from us or sending us the results of medicine checks they’ve done with a patient. There is just a lot more work coming in — information coming into us and requests for information going out. This all adds up to a lot more work for us.
Gurney: So you mentioned funding. With funding, you could hire some more admin support staff to stay on top of that. A more efficient system would be better, but more admin support would be good.
Hijazi: That would help! But, yes, let’s talk about funding. It’s a huge component of this. Within the first few years of my becoming a family doctor — this was under the Wynne government — there were huge cutbacks to the fees we can charge. OHIP was cut. There wasn’t warning. We’d get our OHIP statement at the end of the month, and our fees had been cut by 2 per cent. You didn’t know what was going to come next, when the next cut would be or how deep it would be.
I was a new grad. I had student debt. And I had no idea what I was going to be making in a year or two years or three years. That was nerve-wracking!
That went on for a few years, and the fees have been basically stagnant since then. The Ontario Medical Association tracks this, going back decades. The funding family doctors have gotten for their services had been in steady decline since the 1960s. Our revenue is down to about 38 per cent of what it historically has been. That’s the revenue we use to pay for everything — staff, supplies, our facilities, everything. We cannot increase our fees. They are set. We have no other sources of revenue. Inflation, cost-of-living, and the increased workload I referenced above has steadily eroded our business model.
That started before my time in practice began, but over my 10 years, it’s been steady. With the current shortage of medical staff across the province, we are having to raise our pay for our support staff to keep them working for us. If we aren’t offering competitive wages, we’ll lose our nurses, for example, to a hospital or a private clinic or a dental clinic. So that cost is rising fast as we match the going rate for health-care workers. That’s hard to do with stagnant funding. Every year, our clinic, at year-end, we have had a shortfall. And the physicians are making that up out of their own pay. The only thing keeping family medicine clinics open in Ontario is doctors subsidizing them with their own money.
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Gurney: Let’s pause here just for a second. I want to make sure I understand this. There is a common belief that doctors are very well paid — multiple hundreds of thousands per year. And that might be what you’re billing OHIP. But you are, in practice, an independent contractor, and whatever you bill OHIP for — the set rate fees for exams and tests and whatnot — you then have to deduct from that total all your costs. You have to pay your staff, rent on your facility, insurance, office and medical supplies, and all the other varied and sundry expenses required to run any small business, which is what a family doctor is, basically. You’re a small business. Doctors often come together in practices to help pool some of those costs: rent, utilities, supplies, administrator and nursing support. And when you take everything that you bill OHIP based on the set fees and subtract all your costs, what you’re left with is what you, the doctor, earn as your salary. Do I have that right?
Hijazi: Yup. That’s it. That’s accurate.
Gurney: So we’ve talked about workload. We’ve talked about administration burden adding to that. We’ve talked about stagnant fees not keeping up with inflation, cost-of-living pressures, and the wage growth among health-care workers, given their scarcity. You’ve given me a 10-year view on that. What did the pandemic do, in particular?
Hijazi: It was, to put it mildly, a stressful time. The government’s initial response was very disorganized. Communication … there was a lack of communication, we’ll say that. There were expectations that family clinics could pivot on a dime and absorb a lot of extra costs we were incurring. We did receive some minor help in terms of supplies, but the costs of masking everyone — staff and patients — plus a lot more sanitization, that was borne by the clinics. Those costs were thrown onto us, too.
But it was the communication that I think about it. Honestly, Matt, it was insulting. I’d be at work, and a patient would come in or call me and say, “Hey, this new vaccine is approved. Do you have any? The government said to call your family doctor with any questions.” And we’d been told … nothing. Things were being announced in the media first. I wasn’t following the news on a daily basis, and I was learning about things from my patients. That was just disrespectful. That was disorganized. We didn’t have any time to anticipate patient calls or questions. The government would announce something, and our clinic would be flooded with calls. Can I get this new vaccine? Can I get Paxlovid? We tried to answer their questions, but we’d received no guidance and no warning whatsoever.
Gurney: I talk about the pandemic a lot with health-sector workers, and everyone has a different story, but there is something of a common thread through many of them. The pandemic didn’t cause their problems, but it accelerated them. It stripped them bare of whatever reserves of money, staff, and patience they had left. Does that fit for family medicine?
Hijazi: To an extent. It was definitely an accelerator. But I also think I’d describe it as an independent stressor. One thing about administrative burden, though. The way they did the reporting of vaccines was horrible. I had 1,500 patients. I got a notification every time they got a vaccine. That could mean 50 or 60 a day. That was paperwork that wasn’t necessary for me to have to see directly. But aside from that, yeah, it was an accelerator in that it increased burnout and job dissatisfaction and admin work. It was added on top of the stagnant fees and then, since then, there has been the inflation, the cost-of-living increases, and the rising wages of staff. This has all really exacerbated our problems. I can’t say if that’s directly related to COVID, but the last three years have really seen a lot of acceleration in just how hard it is to run family practices as businesses.
Gurney: So, as you know, I’m in a position where I’m being told a lot of things off the record that I’m not getting told on the record. Here is one of those things: that there is a major exodus of family doctors from family practices in Ontario. Some are leaving Ontario for other provinces, the United States, or destinations in Latin America, I’ve heard. Some are getting fed up and retiring. Others are staying in medicine in Ontario but in other roles — going to hospitals, going to cosmetic clinics, becoming medical consultants, and the like. Are you as an individual or as the founder of your union able to comment on that?
Hijazi: Yes. This is a problem. It is not being talked about enough. It’s not getting the attention it should. Over the last few years, a lot of people have been deciding that family medicine is not a sustainable career in Ontario. This means retirements. It means people finding other work in the field. It means family medicine graduates never opening a clinic or never joining one and pursuing a different career from the outset.
We have something called CaRMS — the Canadian Residency Matching Service. It matches up medical residents with their specialties. And over the last 10 years, 20 per cent fewer residents are choosing family medicine. Anecdotally — and I don’t have stats to back this up, but it’s what I’m seeing as someone who teaches and supervises residents — there aren’t many choosing to specialize in family medicine.
But, and this is important, the fact of the matter is, we have more trained family doctors practising in Ontario than ever before. On a per capita basis, we’ve never had more family doctors. But they aren’t practising as family doctors. They are finding work elsewhere. And that really speaks volumes about the state of family medicine. For years, though, when they made their career decision as a resident or left to do something else or retired, they did so in silence. We need to change that. We need to educate the public and the politicians so we can get the right policies to correct this issue.
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Gurney: I’ve been in this business long enough to remember when it became a talking point that “a million Ontarians don’t have a family doctor.” You’d hear that everywhere. And then one day, out of the blue, the talking point changes. Now it’s 2 million. And based on some things I’ve been told by others, on the current trajectory, very soon, it’ll be 4 million. What can you say about that?
Hijazi: Yeah. The Ontario College of Family Physicians has looked at this extensively. Currently, we’re at 2.3 million Ontarians without access to a family doctor. The college projects that by 2026 — that’s only two years from now — that is going to rise to 4.4 million. Some of this is population growth, but it’s mainly fewer residents choosing us and more exits and retirements.
Gurney: What will that do to our health-care system?
Hijazi: It’s going to put a strain on the entire system. Without access to a family doctor, people have to go to an emergency room, particularly if it’s an acute issue. This is already happening. Look at ER wait times. They’ve skyrocketed. With 2 million more Ontarians not having a family doctor by 2026, that’s going to be even more strain. That will lead to delayed diagnoses. People will get sicker. There will be undiagnosed cancers that will progress much more before being diagnosed. Patients with chronic conditions like congestive heart failure and COPD will be admitted to hospital far later in their disease. Maybe if it had been addressed earlier, they may not have needed a hospital admission at all. This will mean more resources being needed to support very expensive hospital care.
In the end, in short, we’re going to have poorer patient care, and it’s probably going to be more expensive, as well. Significantly more expensive.
Gurney: We often talk about how to fix these problems with a view to the long term. But that figure of an additional 2 million Ontarians without a family doctor in only two years is, I say bluntly, horrifying. I don’t want to downplay the importance of long-term, systemic changes, but what can we do as a quick fix now to prepare for what’s coming in 2026? How can we stop the bleeding or at least slow it down?
Hijazi: We’ve got to get back to those two main issues. We have to get the admin burden, the “paperwork” burden, down. But that’s complicated. There are a lot of players involved in that, like I said: hospitals, pharmacies, doctor’s offices. All these different record systems and processes that need to be worked on and made efficient. And, realistically, that’s going to take years. We need to work on that and correct it, but that’s not going to be a solution in the short term.
So all we can do in the short term is address funding. If OHIP funded us at a level where we could run our clinics more easily, we wouldn’t have to worry about inflation cutting into our business model every year as expenses rise and our fees stay stagnant. We also need to incentivize family medicine. Like I said above, we have enough trained family doctors, but they aren’t in family practice. If everyone trained to be a family doctor was a family doctor, we’d have an excess of family physicians. So financial incentives could have a dramatic effect — and it could happen almost immediately. We just need to change the incentives.
Gurney: Okay. [Heavy sigh] So. I’ve been doing this a while. I’ve seen the government in action — not just this government. Ontario governments in general. I’ve seen them negotiate with the Ontario Medical Association. And I’m honestly wondering … [long pause] … who is going to fix this? What person? What organization? Because I have a feeling, and you can call me cynical, that we’re just going to drift further and further into some kind of catastrophe.
Hijazi: Only the government of Ontario can fix this. The Ontario Medical Association negotiates with the government to determine what the fees will be set at. They are the only two players. The College of Family Physicians has done really great work the last few years advocating for family doctors, doing education and raising pressure, and that’s what my group has tried to do, too, but only the OMA and the government are directly involved. The OMA has, in my view, really failed to advocate for physicians appropriately. They haven’t negotiated in a way that protects our interests, physicians’ interests. But an issue here is that physicians, historically, have had no leverage. We cannot strike. We have binding arbitration now, which we didn’t have even just a few years ago. There is no leverage, and the government can do what it wants. So I have to be fair: the OMA just hasn’t had a lot to work with. There’s no recourse.
All we can do is get public opinion on our side. The public is increasingly aware. They are on our side. They’re realizing how bad things are and the trajectory things are on. And that’s the only chance we have. The government only cares about votes. The public needs to pressure them.
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Gurney: I worry this will be a depressing question. But do you see signs of progress? Do you see anything hopeful?
Hijazi: I see progress in terms of public awareness. My group’s work has gotten a lot of attention. And my own family members, and I hear this from other doctors, seem to get it. They’re listening and learning about our struggles. All of a sudden, people seem to understand now how hard it is to be a family doctor, how unsustainable the financials have become. I feel like we’ve broken through a barrier and the public understands our situation a little bit better.
But has that led to any progress with the politicians? I don’t think so. I don’t think we’ve made any progress. The OMA gave us an update on the ongoing negotiations in January and said that the two sides were nowhere near an agreement. So arbitration is likely. That said to me that the government wasn’t taking this seriously. That they don’t see this as a serious problem. I’m not seeing any signs of goodwill. So with the public, yeah, we’ve made progress. But with the government? I don’t see any.
This interview has been condensed and edited for length and clarity.
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