Physician compensation in ON

[shikimate]

For those aspiring to practice in Ontario, you may or may not have heard about all the battle between OMA and the Wynne/Ford government in the last decade or so. In any case, long story short, there was a cap on overall physician compensation, which resulted in percentage decrease in some years, and that was reversed few years back, which resulted in some % increase.

One big issue that is of huge contention in the OMA is the idea of "relativity", aka how do we estimate the "appropriate" amount a specialty should be paid relative to other specialists. OMA calls it the "CANDI" model. There are lots of assumptions and disagreements, which I am no expert on. But in case you want to learn more about the issue, you should check out this document: http://www.oags.org/CRICRelativityMethodologyReviewApril2012.pdf

My impression is that this is a fishing expedition in the muddy yellow river. The OMA relied on PwC study which only got self reported response rate of 8.6%. Those who bill very high or very low may have stronger incentive to respond/not respond than those who feel they bill "average" compared to their peers. Just like the business world in general, there are some who are very well off, and some poorly off, and some in the middle. Those who do very well, by whatever means, are not incentivized to report and reveal themselves. While the Toronto Skunk newspaper has obtained billings by physician, again it does nothing to account for such factors as hours worked, type of work, non-OHIP income, overhead, etc etc. 

So my advice to medical students is that stay positive but don't stay naïve. Those who want to make a lot will find a way to make a lot. And if you aren't that type, you'll do fine too as a middle upper class professional. Do comparative shopping of attendings/residents when it comes to advice on career/work/business. You'll find attendings who are great clinical mentors but terrible people at managing their practice, and vice versa. It's ok to be ambitious and want to make a lot, but also don't be over the top and forget you still have a reputation as a clinician to maintain. 

[bearded frog]

The real takeaway is that we need to accept that in Canada, physicians are public servants, and that compensation and other aspects of our job will change over the long term, as governments come and go, and public opinion matures. It is a fact of our lives that we cannot predict what our practice will be like in 10 years or longer, so when making a long-term decision like what specialty to apply to and where you would like to work, keep this in mind and don't use the current circumstances to guide you. As shikimate says, talk to trusted mentors and look at how things have changed in the previous decades to see trends.

TLDR: Don't gun optho because they are currently overcompensated

[blah1234]

I suspect we are past the golden age of medicine with regards to compensation. I think physician remuneration is increasingly under scrutiny from multiple provinces which gives Ontario physicians less leverage. I think ultimately we are well compensated compared to most Canadians but I think a lot of what we take granted for now may not exist forever in our professional lifetimes.

[1D7]

On 7/6/2021 at 12:15 PM, bearded frog said:

The real takeaway is that we need to accept that in Canada, physicians are public servants, and that compensation and other aspects of our job will change over the long term, as governments come and go, and public opinion matures. It is a fact of our lives that we cannot predict what our practice will be like in 10 years or longer, so when making a long-term decision like what specialty to apply to and where you would like to work, keep this in mind and don't use the current circumstances to guide you. As shikimate says, talk to trusted mentors and look at how things have changed in the previous decades to see trends.

TLDR: Don't gun optho because they are currently overcompensated

I believe that any specialty that can make a substantial amount of income from non-OHIP sources is probably best positioned for maintaining pay in the long term. Provincial governments have been very aggressive and taking unilateral action against physicians over the last decade, and with decreasing ability (and incentive) to hop over to the States, we really have little-to-no recourse. IMO the specialties that have been traditionally involved in cosmetics and ophthalmology are better positioned to hold their own and continue to do well in the future.

In general physicians are very poor negotiators.

With income relativity our current situation is akin to knowing that your coworker "Bob" makes 10k/yr more than you doing the same thing, having started at the same time. Except instead of asking for a raise, you go to your boss and demand "Bob" gets paid 10k/yr less (despite your boss making 100x more than you two combined). This is the sort of envious greedy behaviour you wouldn't even see in the corporate world, or in other healthcare fields like nursing, yet this type of thinking is prevalent even at the medical school level.

 

[who_knows]

3 hours ago, 1D7 said:

Except instead of asking for a raise, you go to your boss and demand "Bob" gets paid 10k/yr less

Any examples of that? This is a very bizarre accusation. Here's an example of doctors protesting their own pay raise
https://www.cbc.ca/news/canada/montreal/doctors-march-raise-health-care-1.4591726

But I agree, doctors need way better organization, a much stronger lobby and much smarter negotiators. I think current leaders are in a very good place individually, they have been through the golden ages and they do not have incentives to fight. It is up to us, the next generation, to do all the hard work. And I'm fine with that.

[bearded frog]

3 hours ago, 1D7 said:

With income relativity our current situation is akin to knowing that your coworker "Bob" makes 10k/yr more than you doing the same thing, having started at the same time. Except instead of asking for a raise, you go to your boss and demand "Bob" gets paid 10k/yr less (despite your boss making 100x more than you two combined). This is the sort of envious greedy behaviour you wouldn't even see in the corporate world, or in other healthcare fields like nursing, yet this type of thinking is prevalent even at the medical school level.

Unfortunately, often healthcare budgets are zero-sum, ie the total amount going in isn't going to go up any time soon so increased funding for things/professions has to come at the expense of something else. In a public system these decisions are inherently political, it's not that family doctors point at opthomologists and say take from them and give to us, it's that looking at the whole system, if certain professions/procedures are getting paid more than the perceived value in the "public good" compared to others, then it may change. I think the research is clear that each dollar put into preventative medicine saves money in intervention medicine.

[JohnGrisham]

46 minutes ago, bearded frog said:

Unfortunately, often healthcare budgets are zero-sum, ie the total amount going in isn't going to go up any time soon so increased funding for things/professions has to come at the expense of something else. In a public system these decisions are inherently political, it's not that family doctors point at opthomologists and say take from them and give to us, it's that looking at the whole system, if certain professions/procedures are getting paid more than the perceived value in the "public good" compared to others, then it may change. I think the research is clear that each dollar put into preventative medicine saves money in intervention medicine.

Yet we continue to devalue preventative medicine...and this is often also at "odds" with certain specialist fields, because if you had better preventative medicine and funded primary care...they would get less soft-ball referrals.

 

[zoxy]

As long as some people are willing and able to move to the US for better wages, then Canadian provincial governments can't underpay Canadian doctors too much relative to what American doctors make. In fact, Canadian physicians, and family physicians in particular, earn some of the highest multiples of the median wage of their country among OECD countries. This is a symptom of a poorer (relative to the US) country having to pay US standard wages to avoid doctor flight.

It should be noted that there are no cost controls in place for Physician compensation in the US. Barring the implementation of medicare for all in the US, which is highly unlikely IMO, physician wages in the US will continue to grow. In fact, the American system seems to have been designed to shovel as much money into the healthcare industry(including doctor's) pockets as possible. Physician pay is only 10 percent of total healthcare spending in the US, so there's a lot of other fat to trim before they start fighting doctors.

If the provinces do underpay Canadian physicians, it will be the 90's again where Canada was losing the equivalent of 30 percent of the graduating class a year. It will be worse for specialties that get paid the most in the US and have good job markets down there. We should all thank our lucky stars that the Americans accept our training to be equivalent. Otherwise, we'd be in a worse situation than British Doctors under the NHS. Imagine having to negotiate with Doug Ford, Wynne, Legault, or Kenney if you couldn't threaten to leave the country.

On 7/6/2021 at 10:15 AM, bearded frog said:

Canada, physicians are public servants

Tough pill to swallow that you're a public servant when the government provides no paid vacation, no paid federal holidays, no pension, no benefits, no sick leave, no 40 hour week, no overtime, and no supplementary health insurance. The government would be responsible for managing every single aspect of healthcare delivery including running every single physician's office if we were public servants.  Additionally they've taken away some of the perks of incorporation as well so being a public servant would be better than before. The costs would far outweigh the benefits for the government.

Personally, it would be a dream come true if I could get paid something decent like 180,000K but with a 40 hours a week,  a pension, and had all the ancillary work of running a practice taken care of. And if you think 180K is too much for a physician, go peruse the provincial sunshine lists. I guarantee that some of the numbers will shock you. The numbers certainly surprised me.

[1D7]

8 hours ago, bearded frog said:

Unfortunately, often healthcare budgets are zero-sum, ie the total amount going in isn't going to go up any time soon so increased funding for things/professions has to come at the expense of something else. ..., it's that looking at the whole system, if certain professions/procedures are getting paid more than the perceived value in the "public good" compared to others, then it may change. I think the research is clear that each dollar put into preventative medicine saves money in intervention medicine.

Budgets can be increased/decreased and costs can be shuffled around. If provincial governments were truly that judicious with costs and budgets, we wouldn't somewhat regularly read about how X project cost Y millions over the projected costs/budget. I agree that it would be excellent if every family doctor had a whole team of allied health and public health/mental health resources were expanded. Undoubtedly this would improve access to healthcare and probably improve outcomes/quality of care.

In ON the government aggressively took action against physicians over the past decade. Despite that, there hasn't been any improvement in availability of SW/PT in my area or public mental health resources. There are increasing lengthy wait times for referral to medical specialties and procedures/surgeries and if anything we are doing less in some areas.

In other areas of the world where governments/corporations have taken aggressive action against physicians, the story is no different (NHS, corporatized American specialties, etc.). Attacks on physician pay and autonomy do not lead to an improvement in care at any level, rather, the opposite tends to occur in places where this happens.

[bearded frog]

10 hours ago, zoxy said:

Tough pill to swallow that you're a public servant when the government provides no paid vacation, no paid federal holidays, no pension, no benefits, no sick leave, no 40 hour week, no overtime, and no supplementary health insurance. The government would be responsible for managing every single aspect of healthcare delivery including running every single physician's office if we were public servants.  Additionally they've taken away some of the perks of incorporation as well so being a public servant would be better than before. The costs would far outweigh the benefits for the government.

I'm not sure what you're arguing for here. You don't want to be an "employee" of the government, yet you want all the things that come from being an employee and not an independent professional. There are salaried jobs in medicine that come with holidays and benefits and sick leave, etc. but you are giving up control of your own schedule, hiring your own staff, etc. Some docs love that, some hate it. The option is there.

10 hours ago, zoxy said:

Personally, it would be a dream come true if I could get paid something decent like 180,000K but with a 40 hours a week,  a pension, and had all the ancillary work of running a practice taken care of. And if you think 180K is too much for a physician, go peruse the provincial sunshine lists. I guarantee that some of the numbers will shock you. The numbers certainly surprised me.

I don't think 180k take home is too much. I think 180K take home with 40 h/w is actually quite realistic for a lot of specialties. The shocking numbers from the sunshine list is exactly the point I'm trying to make... certain specialties are billing millions, and perhaps that they are not delivering millions of dollars worth of "public good" compared to specialties who don't bill enough to even make the list... who probably deserve to be paid more.

9 hours ago, 1D7 said:

Budgets can be increased/decreased and costs can be shuffled around. If provincial governments were truly that judicious with costs and budgets, we wouldn't somewhat regularly read about how X project cost Y millions over the projected costs/budget. I agree that it would be excellent if every family doctor had a whole team of allied health and public health/mental health resources were expanded. Undoubtedly this would improve access to healthcare and probably improve outcomes/quality of care.

I 100% agree that health care should be a top priority for government budgets, but unless they run for politics, physicians won't have much sway in that area I think... However as physicians we can (and should) have a say in how that budget gets spent to maximize the health of the public and deliver the most "good".