A day after rejecting a new fee deal from the province, Ontario doctors remained sharply divided about how to approach negotiations over the contract that has eluded them for more than two years.
The leadership of the Ontario Medical Association, which supported the deal, has been put on notice by doctors in the No camp, while divisions remain between specializations and even across age groups within the profession.
In an open letter of resignation from the OMA's negotiating committee, Dr. Scott Wooder, a former president of the group, acknowledged the "difficult road forward."
Many doctors would agree. "It's a lot of uncertainty in the physician world," said Nadia Alam, a spokeswoman for Concerned Ontario Doctors, which spearheaded the No vote.
The state of flux seems to have bought the government time in its stalemate with the physicians. Speaking to reporters on Tuesday, Health Minister Eric Hoskins said he was willing to restart negotiations once the doctors "work through their issues."
The vote against the Physician Services Agreement was decisive. With a turnout of 55 per cent, some 63 per cent of voters dismissed the deal during a heated general meeting on Sunday. The agreement would have increased the physician services budget by 2.5 per cent annually for four years, though doctors argue that the fee increase is outweighed by years of funding cuts and fails to keep up with inflation and the needs of a growing, aging population.
The result has undercut OMA president Virginia Walley, who negotiated the agreement in secret this summer to the resentment of many doctors, and has now lost a vote that she lobbied hard to win.
Dr. Alam and her group are withholding their endorsement of Dr. Walley's presidency, saying that the leadership must now prove itself in line with members.
"Everyone's watching them very closely," said Dr. Alam. "The next few steps of the Ontario Medical Association are going to be defining how members interact with them going forward."
Dr. Walley said she is not resigning, but acknowledged the heightened emotions that produced the resounding No vote.
"I understand that there's been frustration over the last couple of years," she said Tuesday. "We've been disrespected, we've been called out, we've been marginalized. … We need to reset the relationship between the government and the profession."
A more urgent task for Dr. Walley may be resetting her relationship with OMA members. She is in "gathering" mode now, she said, trying to learn what the rank-and-file accepted about the deal, and what they didn't, so she can ask the government to "improve the offer and to come back to the negotiating table."
It will be a delicate undertaking, with some doctors evidently feeling they have momentum on their side, and a potential mandate for leadership change.
"If the OMA continues to misread the members, to misrepresent the members, the members may take action sooner," said Dr. Alam. "We vote them in, we can vote them out. That's the beauty, the pain and the glory of democracy."
Tensions between doctors and their leadership have been mirrored by often-bitter divisions among doctors of different generations and fields, which have sharpened over the proposed fee agreement.
Jonathan Gravel, a medical student, said that he and many young OMA members supported the tentative deal for "idealistic" reasons, out of a belief that doctor compensation was not the most pressing issue facing Ontario health care.
"There are massive issues in Ontario, but I don't think that physician compensation being higher in any way translates to patient care being better," he said. (Mr. Gravel is treasurer of the Ontario Medical Students Association but said he was not speaking on behalf of the group.)
Mr. Gravel made a controversial presentation at the OMA general meeting on Sunday, in which he described students being "bullied, maligned and called naive" for supporting the fee agreement.
"I'm getting torn apart now," he said, pointing to what he described as vicious attacks on the Concerned Ontario Doctors Facebook page.
Dr. Alam acknowledged that rhetoric among doctors could get out of hand, especially online, but said that was partly because many older doctors are new to social media.
"We don't know the nuances of Twitter. A lot of us don't know that writing in all caps means you're yelling," she said. "I think part of the generational divide might come from that."
Dr. Hoskins, himself a family physician, blamed the collapse of the tentative deal on the fractious doctors. "This was not a failure of government," he said.