Ontario doctors’ dispute lays bare deep divisions within medical profession

TheGlobeandMail.com
Aug. 13, 2016
By Andre Picard

“It’s tough to make predictions, especially about the future,” the baseball philosopher Yogi Berra famously said.

It’s an apt caution for those trying to divine how the 44,000 members of the Ontario Medical Association – practising physicians (both general practitioners and specialists), residents, medical students and retirees – will vote on a contract offer on Sunday.

The labour negotiations between the OMA and the Ontario government leading up to a tentative deal have been unusually protracted, prickly and odd. Two years without a contract, a full year without talks and then a deal suddenly hashed out over a couple of days.

But the classic union-employer wrangling was downright dainty compared with the scrap between doctors who support and oppose the deal.

The showdown between the official Yes side, the OMA, and the dissident No side, the Coalition of Ontario Doctors, has been intense, litigious and oftentimes vicious, especially on social media.

Both sides have hired high-priced lawyers and public-relations firms, with the OMA turning to Navigator and the coalition retaining Kingsdale.

It’s a big money battle because there is a lot at stake, in Ontario and beyond.

On the surface, the Sunday vote is about whether or not doctors accept a four-year deal that calls for a modest 2.5-per-cent annual increase in the Physician Services Agreement (the overall pool of money available to pay for physician services), after four years of cuts.

But, of course, there are many other related issues, which have been laid out in various pro/con lists.

The Yes side says the offer stanches the bleeding by ending unilateral cuts, ensures stability and opens the door for doctors to “co-manage” the health system, giving them more power. There is also an oft-unstated recognition that doctors have done well over the years and they can afford to take a bit of a hit.

The No side counters that the proposed deal formalizes and perpetuates cuts because the increases in spending are far less than required to account for inflation, population growth and an aging demographic, and that the promises of a stronger physician voice are vague and meaningless. The No side features of strong undercurrent of disdain for a health system that does not allow private practice and a hatred of bureaucracy.

It would be too simplistic, however, to paint this as a straight left-right political split.

What the two sides do agree on is that contract disputes should be resolved by binding arbitration – though the OMA wants to pursue its constitutional challenge and the coalition wants to demand arbitration before any negotiations resume.

And, of course, the three sides – government, Yes and No – have all insisted that this is all about building a better health system, ensuring better care for patients and so on.

But, let’s be frank: Labour negotiations are about ensuring the best deal for workers and, on the government side, controlling spending. There’s no shame in that; you don’t have to wrap it all in a pretty pink “putting patients first” bow.

The reality is that the way physicians are paid makes no sense but the necessary revamp is impossible with a conflictual contract negotiation model. But no one dares open that Pandora’s box.

As much as anything, the contract dispute has exposed the divisions within the medical profession, of which there are many. Physicians who bill on a fee-for-service basis have very different concerns than those who are salaried or have blended payment models. The gaps in how much is billed by individual family practitioners and specialists, and even among various specialists, are enormous.

Generally speaking, the big billers – ophthalmologists, radiologists, diagnostic imaging, cardiologists – are the most vehemently opposed to the deal because they stand to lose the most.

But, for many doctors, the contract dispute is about much more than how much money they will earn over the next four years: It’s a vote of (non-)confidence on the OMA’s leadership and a plebiscite about the place of physicians in an evolving health-care system.

It would be foolish to try to predict how the Sunday vote will turn out. Traditionally, a very high number of Ontario doctors vote on their contracts – it was 84 per cent last time around – but the vote is usually done via phone-in/online/mail. This time – because of a petition/lawsuit by the No side – there will be a general meeting. Only a small fraction of OMA membership will be present, but a handful of doctors will likely be holding proxies for thousands of their colleagues who cannot be present.

In this contract dispute, there has been a lot of noise generated by a very small, vocal and active-on-social-media minority. We have no idea what the silent majority thinks and how will cast their votes.

The one prediction that can be made with certainty is that, whether the contract is endorsed or rejected, the labour dispute will not be fully resolved. Nor will the profession emerge unscathed.

The fault lines have been exposed. On Sunday, we will start to get a sense of how big the cracks will become.