Advice to the Profession companion documents are intended to provide physicians with additional information and general advice in order to support their understanding and implementation of the expectations set out in policies. They may also identify some additional best practices regarding specific practice issues.
Physicians provide the people of Ontario with quality health care and are committed to delivering this care in an ethical and professional manner. However, there may be rare instances where physicians may consider withdrawing their services as part of a job action.
Physicians are aware that their decision to withdraw services can have significant negative implications for individual patients, specific patient populations and/or the public at large. Withdrawal of physician services may expose patients and/or the public to risk of harm, and may compromise physicians’ ability to fulfill their professional responsibility to patients and their collective responsibility to the public. In addition, when the withdrawal of services puts patients and/or the public at risk of harm, it can negatively impact the public’s trust in the profession.
In light of this, and the shared duty of both the College and the profession to protect and serve the public, there are important considerations for any physician contemplating and/or undertaking a job action. This advice document is intended to help physicians determine whether undertaking a job action is appropriate, and the steps they should take to mitigate the impact on patients, in line with the expectations set out in the Providing Physician Services During Job Actions policy.
Does the policy restrict physician’s ability to withdraw their services during job actions?
The policy does not categorically prohibit job actions. However, in line with the College’s mandate to protect and serve the public interest, the policy does set out a number of requirements physicians must meet when contemplating and/or undertaking a withdrawal of services.
In particular, the policy articulates the College’s expectation that even during job actions physicians must continue to provide medical care that is urgent, or otherwise necessary to prevent harm, suffering and/or deterioration. This will include ensuring health care concerns are assessed and appropriately triaged so that urgent and/or necessary medical care can be obtained.
Physicians know that completely abandoning patients and communities en masse would never be acceptable as it would leave patients and the public without access to urgent and/or necessary medical care.
Does the policy prevent physicians from advocating for changes that benefit both physicians and patients in the province?
Not at all. In fact, advocating for patients is one of the principles of medical professionalism set out in the College’s Practice Guide in recognition of the fact that physicians have a crucial role to play in shaping and improving the health‐care system.
There are, however, many ways for physicians to advocate for change without withdrawing their services. The policy expects physicians to explore these other options first. If a physician believes that withdrawing services is the only way to achieve necessary changes, the policy does not prevent them from doing so, provided that the adverse impact on patients and/or the public is mitigated.
What should a physician consider before making the decision to withdraw services?
Given the significant negative implications a withdrawal of physician services can have on patients and/or the public, the decision to participate in a job action cannot be made lightly. The policy states that when contemplating a job action, physicians must first explore all alternative options that may be available to resolve the concern that has motivated their desire to withdraw services.
The alternative options would vary depending on the nature of the concern and circumstances of each case. For example, in a clinic or hospital setting, physicians could consult with an ombudsperson, relevant committee, senior management, board of directors, etc., in accordance with its established policies/procedures, as applicable. In the context of fee negotiations between the Ministry of Health and Long-Term Care (MOHLTC) and the Ontario Medical Association (OMA), physicians could proceed with the facilitation and conciliation process set out in the MOHLTC-OMA Memorandum of Agreement.
Does a physicians’ ‘collective responsibility’ to the public mean physicians have a duty to care for all Ontarians?
No. Collective responsibility and duty of care are distinct concepts. Collective responsibility refers to the ethical and professional obligations physicians have, as a group, to the public, as articulated in the Practice Guide — the commitment that all physicians have to provide quality care to their patients, and to uphold the reputation of the medical profession. This is distinct from the legal duty of care a physician has to a patient.
The policy contains a number of terms like ‘best interests’ of patients, ‘abandoned’, ‘deprived of access’ to medical care, ‘risk of harm’, and ‘mitigate the adverse impact’. How will the College interpret these terms?
The College has not set out concrete definitions of these terms because their meaning will differ, depending on the circumstances and context in which the withdrawal of physician services occurs or is contemplated. In applying these terms to specific situations, the College will be guided by the values and principles of professionalism, as set out in the Practice Guide, the spirit of the policy (to ensure individuals are not harmed by physician job actions), and our shared commitment with the profession to serve and protect the public.
For example, it may not be in the ‘best interests’ of patients if physicians in a remote community participated in a job action for reasons related to physician compensation when, as a result, patients are prevented from accessing necessary medical care.
Some steps physicians may take in that situation to ‘mitigate the adverse impact’ could include: transferring the care of patients to other physicians and/or facilities, ensuring sufficient coverage is provided for emergency situations, regularly monitoring the impact of the withdrawal on patients and/or the public, etc.
What does the College consider to be medical care that is ‘urgent’, or otherwise ‘necessary’ to prevent harm, suffering and/or deterioration?
What is ‘urgent’ or ‘necessary’ medical care would depend on the specific circumstances of each case, and is a matter to be determined by a physician’s clinical judgment, informed by the existing health status and specific needs of individuals, and physicians’ individual and collective ethical responsibilities to provide care.1
For example, patients and/or the public would likely be unable to access ‘necessary’ medical care if every single physician in a rural community or every single physician in a specialty (e.g. all anesthesiologists) stopped treating patients for a significant amount of time.
Is the College’s definition of ‘necessary’ medical care the same as ‘medically necessary’ services that are insured?
No. In the context of the policy, the College considers ‘necessary’ medical care to be care that is required to prevent harm, suffering and/or deterioration, as determined by the physician’s clinical judgment. The medical care physicians deem ‘necessary’ may very well be insured services; however, it does not mean that ALL insured services are ‘necessary’ for the purposes of the policy.
Is it okay to discuss concerns about the situation with patients during their appointments?
It is not appropriate to initiate discussions regarding a dispute during clinical encounters with patients. This would include asking them to sign petitions or other types of political advocacy. However, if a patient raises the issue, a physician can neutrally and objectively indicate that there is a current disagreement without dwelling on the issue or trying to influence the patient. Physicians may elect to post materials in their waiting room, but patients should never feel pressured to sign petitions or take any other action.
What will happen if a complaint is made about a physician who withdraws their services during a job action?
As with any complaint received by the College, it will be investigated. A panel consisting of physicians and members of the public will then consider the circumstances of the case and determine whether the physician’s conduct or the care provided was appropriate, doing so in accordance with our duty to serve and protect the public interest.2
1. Physicians’ individual and collective responsibilities refers to the ethical and professional obligations physicians have, as articulated in the Practice Guide.