Reply to Dr. Francescutti on Professionalism

Professor Louis Francescutti recently published an editorial on the CMA website that proposed a ‘radical idea’ about medical professionalism. He talked about the need for physicians to take a bigger leadership role in the redesign of a dysfunctional health system.  He wrote that we need to hold each other more accountable.  That doesn’t sound too radical to me.  It sounds like common sense.  I think most physicians would agree with the premise.

The piece garnered a lot of feedback, which in and of itself is a good thing. We should be thinking and talking about professionalism.  We need to be system leaders and only physicians have the expertise to hold other physicians accountable.

I agree with many of his high level thoughts. However, I have very strong objections to how he proposes that those high level principles should get implemented.

I’ll start by saying that I have a professional relationship with Dr. Francescutti. I was a member of the Canadian Medical Association Board of Directors for two years.  During the second of those two years Dr. Francescutti was also a Board member as the President-elect.  I left the CMA Board to serve as President of the Ontario Medical Association.  So during the time that Dr. Francescutti was President of the CMA, I was President of the OMA.  Louis was very supportive of the OMA during his time as CMA President.

I always found him to be thoughtful, respectful and incredibly bright and funny. I deeply admire Dr. Francescutti.

I was very disappointed to hear how contemptuous he is of Provincial and Territorial Medical Associations (PTMAs) including, presumably the OMA. The PTMAs “all say the right things (the patient comes first) but a quick reality check tells us otherwise”.  I served on the Board of the OMA for a dozen years and I firmly believe that we always considered first the well-being of our patients.  Dr. Francescutti offers no proof for his opinion so I will waste no time in providing proof of my rebuttal.

Dr. Francescutti’s suggestion that physicians all be in “salaried positions on one-year contracts that can be renewed if they continue to meet performance standards” is troublesome from my point of view. The suggestion is apparently inspired by the Cleveland Clinic, which Dr. Francescutti visited while CMA President.

That model may work very well in the United States. Physicians there who lose their positions can move across the street or across the state and practice in another setting.  Here in Canada where there is a single payer, being thrown out by one’s peers would effectively end a physician’s career.  There are no other options.  It is actually illegal in Ontario to practice outside of Medicare.

Can you imagine someone losing their ability to practice medicine because their peers thought they ordered too many ultrasounds?

And there is more to it than that. An academic ED physician might be able to pack up his practice over-night but for a community based family physician like me the costs would be enormous.  I have a five year lease.  If I’m shut down by my peers in year two, I’m on the hook for over three years rent with no hope of return.  I have employees who have worked for me for 25 years.  Can you imagine the severance I would have to pay?  I have no pension, no benefits and at age 56, I can’t afford to retire.  I guess Dr. Francescutti’s plan suggests that after 30 years as a physician, I should have no job security.  And yet this plan is supposed to improve my morale and increase my sense of engagement.

And what about the administrative nightmare of doing quarterly reviews on 70 thousand physicians. That’s 280 thousand peer reviews a year.  At $500 per review, that’s $140 Million per year.  I checked the arithmetic twice on that one.

It would also tie up 560 physicians working full-time for 50 weeks a year, assuming they could do 2 peer reviews per day. I don’t think we can spare the manpower.  But maybe I could get a job lie that.  At least I’d have some security.

“We, as physicians, need to stand up and accept responsibility for what is going on in our dysfunctional health care systems across Canada. If we won’t fix the problems, who will?”

It’s a great question. It’s a great premise.

But can’t we do all that without beating up our colleagues? Can’t we find constructive and realistic implementation plans that help our patients without destroying ourselves?

Scott D Wooder, MD.


10 thoughts on “Reply to Dr. Francescutti on Professionalism”

  1. I believe it’s Dr. Francescutti’s tone that caused the firestorm, which was more than a little patronizing and presumptive of his colleagues. As you point out, the specifics of his plan are unworkable (in fact, they border on the absurd). Had the piece not been so harsh, it could have been fodder for a Rick Mercer sketch.

    Equally worrisome, however, is the CMA bowing to the uproar and taking the piece down. Dr. Francescutti is a past president, and presumably pays the same membership dues we all do. He’s entitled to his opinion, just as those who take exception are entitled to theirs.


    1. He certainly is entitled to his opinion, and he has his own website from which to publicize it. The issue was that the CMA published, as you put it, an absurd and patronizing blog on it’s own website, supposedly dedicated to supporting Canada’s physicians, not denigrating them. The CMA did not bow to the (justified) uproar, it did the right thing by removing the post completely.


  2. Front line physicians did not create the dysfunctional healthcare systems across Canada- they were too busy working as conscientious MDs. Ask the majority of community based practising Canadian MDs and they will tell you they have been blindsided by all the system changes over the past 30 years.
    Responsibility for dysfunctional healthcare systems across Canada rests with politicians, invisible consultants, very visible and vocal academic health economists and vocal MDs, and bureaucrats – whose solution to any problems is to hire more bureaucrats.


  3. Right-on Scott. The problem we as physicians will always have is to be treated as totally powerless civil servants by the public and their representatives without any of the benefits of civil servants, namely the right to strike that essential services such as nurses, teachers and “real”civil servants enjoy and implement regularly or, as a result of binding arbitration, get pay, pensions, holidays, paid pregnancy leave etc that they have been able to “blackmail” the politicians of the time into! Those unable to strike (police, firemen) automatically achieve binding arbitration and those living in inexpensive small towns automatically get paid the same as the salaries required by living in Toronto. For physicians it is just the opposite!
    Physicians, get no such rights/benefits and our politician “masters”, knowing that our obligations to the sick prevent us from striking, do what they wish with us. We get ignored (how many votes do doctors have?), bullied and cannot persuade the government to negotiate in good faith by providing binding arbitration while unilaterally reducing our income 7% or more by fiat since we are made responsible for the global health-care budget, which if exceeded will be clawed back from us!
    Would that the same be applied to our tax and spend governments so that if a department goes over budget (as they all do considering our enormous deficit in Ontario) then all civil servants in that department , in particular those senior employees running the department, should have their income reduced at year’s end proportionately. Furthermore under those circumstances, a forensic audit should be carried out to determine where the budget was spent! And that is just for openers!! Cheers, Michael Newhouse, MD Hamilton


  4. One thing I forgot to mention;unlike civil servants, nurses, and teachers, in practice, Drs must, like all small businesses,pay rent or buy their building, equip it and pay for utilities while employing receptionists. nurses, cleaners etc.The cost of all of these keeps rising while the doctors are paid less and less. Furthermore, the government has repeatedly published Drs gross income and suggested it was their net invcome, not acknowledging that overhead is about 60% of OHIP “income” to run a medical practice. What hypocrisy on the part of the health ministry bureaucrats who collect their $100,000+ salaries no matter the economic conditions of the province. It is really disgusting and our young people should have to seek out greener pastures south of the US border where they are appreciated for their hard work and dedication!! The province of Ontario’s taxpayers and provincial “powers that be” do not deserve them! How many others in our province put in 55-60 hour weeks, get called away from dinner with their family to attend a very sick person in the ER,, miss Christmas at home to care for a drunken accident victim and so on? Their net pay as general practioners is less than senior nurses (no overhead!), Bureaucrats (no overhead), midwives (no overhead)! Cheers, M Newhouse, MD thankfully retired!


  5. Scott’s dissection of Dr.Fransecutti,s piece is as usual right on ,and hopefully make its target rethink his tone As ,to the dysfunctional health care system, that is certainly not my experience in Etobicoke over a 39 year stint in family practise.As a result of our small efficient hard working,team,working under the FHG model,we provide as connected a system for our patients,as any place that I am aware of .We are technologically light,but attention to detail strong,,and our patients benefit from this very personal care,that all members of our team provide.So please no more “dysfunctional,”references, unless you are prepare to explain it to physicians like myself.


    1. I agree, Dr. Russell: The quality of care is most strongly related to the dedication and skill of the people providing it, and their desire to achieve the goal of excellent care. Put those people in any model and you will have success. If people have as their primary goal something other than the provision of excellent care, it doesn’t matter what practice model they are in, the care will not be as good.


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