Premier Dalton McGuinty has agreed to reopen negotiations with the Ontario Medical Association. So far he has agreed only to discuss the six adjustments to the original deal — a flawed deal that was rejected by 59 per cent of members in a telephone vote. A few more immediate token fee increases are hardly sufficient. He should also consider several more creative incentives if he is to retain the older physicians. If he refuses, he risks precipitating a critical shortage of physicians both in rural areas and in major cities.

The present shortage is easily understood by looking at the demographics. Between 1985 and 2003, the output of graduates from Canadian medical schools declined by 9 per cent. Meanwhile, the population of Canada increased by 22 per cent and that of Ontario by 32 per cent.

For several years, fees for services covered by OHIP have remained at levels that don't adequately reflect the increasing cost of office overhead and personal living expenses. Net incomes have fallen behind those of physicians in other provinces and behind those of many dentists, lawyers and other professionals in Ontario. Some MDs have managed to cope by increasing their hours per week of practice, albeit at the risk of accelerated burnout.

Those practising in hospitals are in an even worse position: they are under additional stress due to sicker patients and inadequate numbers of beds, monitoring and other diagnostic equipment. They may feel unappreciated by government, the public and their hospital administrators. At least one-third of these doctors are age 55 and over and many are on the verge of retirement.

A major factor is uncertainty concerning personal health. Those practising in hospitals risk exposure to SARS, HIV and hepatitis C. Yet owing to pre-existing illnesses, many cannot obtain adequate disability and life insurance to protect themselves and their families. Due to an anticipated loss of income, many are postponing needed orthopedic and other elective surgery. Ironically, most physicians are less well protected against disability than are many of their patients.

Surely the government and the public owe them greater peace-of-mind. After all, it would take little to cause them to downsize and rely on their savings or a spouse's pension in order to leave the work force prematurely. If McGuinty is truly committed to shortening wait times and improving access to primary and specialty care, then he must reach out to physicians now by offering sufficient incentives to keep them working in the system.

The original deal did offer a token incentive to these physicians — a $25 million contribution to a critical insurance policy — but this wouldn't take effect until January, 2008. Unfortunately, aging MDs with diabetes, heart disease, etc. would probably fail to qualify for coverage if this were managed through a private insurance company.

In the event of disability, all Ontario physicians should be guaranteed income replacement from OHIP, thereby avoiding the many pitfalls of private insurance. This would give them a compelling reason to keep working in a system that desperately needs their experience and expertise.

Benefits might be paid out according to a sliding scale to encourage physicians to remain in practice in the province as long as possible. For example, those physicians in practice in Ontario for five years, if disabled, would receive 70 per cent of their average monthly billings directly from OHIP after a three-week waiting period. Those in practice for 10 years would receive 80 per cent after a two-week waiting period, and those in practice for 15 years or more would receive 90 per cent after a one-week waiting period.

McGuinty might also make available to all physicians affordable life and out-of-country medical and hospital coverage, much as the federal government does for its public servants.

Such benefits are unavailable from private companies at any price to an increasing number of aging physicians. They would entail a relatively low short-term cost to the province, and would encourage physicians to remain in practice for the next decade or so until new graduates could replenish the system.

The Ontario health minister originally threatened to impose a slightly modified agreement without obeying due process and obtaining consent of the OMA executive and its council. Such action would further alienate Ontario physicians and would almost certainly lead to more shortages of specialists and family doctors in the province.

Don't forget that the original deal was most strongly supported by younger physicians. More than half were female and many willing to work part-time in a group practice. Some were motivated by enhanced maternity/paternity benefits.

However, unlike many middle-aged physicians, they are fairly mobile and still have time to change their mind about where they train and where they set up practice. They may well be galvanized by heavy-handed bullying tactics to move to another province or country where their professional freedom is more respected.