Leading through change: A chat with Tim Smith

Few leaders have left as strong a mark on Canadian healthcare organizations as Tim Smith. As recently retired CEO of the Canadian Medical Association (CMA) and its group of companies, he oversaw sweeping governance reforms and guided the $2.7-billion sale of MD Financial Management to Scotiabank in 2018. With more than 30 years of combined experience in healthcare and financial services, Smith has also been at the helm during moments of unprecedented challenge, including the COVID-19 pandemic, when the CMA invested over $100 million to support physicians and the health system. Recently the CMA endowed the Tim Smith Health Leadership Scholarship at McMaster University to offer residents or early career physicians training, experience and networking on the leadership side. We spoke with him about how to increase the physician workforce, challenges facing the CMA and the MD Financial sale.Q: What can we do to boost physician supply?It’s a great question, and now being a user of the healthcare system as I age—and my mom’s 94 and I’m helping her access care—it really comes down to that foundation: family physicians. It’s great to see the good work that the College of Family Physicians of Canada is doing, other organizations like the PTMAs (provincial/territorial medical associations) and the CMA, to pressure governments to provide more funding and more med schools that we’re seeing pop up. The thing that I worry about is that I’m not sure that the numbers that get produced in terms of graduates, is going to be enough in a short period of time. I mean, they’re all medium to long-term solutions because of the extent of training and the time to become a family physician.Some of the work that the CMA did in terms of working with other allied health professionals looking at team support to provide some early access while those resources start to build up (is key).The other concern—and the OMA (Ontario Medical Association) has been very vocal about it—is the number of family physicians that are set to retire in the next five to 10 years. . . .(But) I haven’t necessarily seen anything that’s really innovative—other than some of the programs where the med school’s going to be only for family doctors. . . .I have five physicians in my family, and we’re even finding that access to care for us is difficult—and we’re in the system or have experience in the system, and I do hear stories about Canadians around that access issue.Q: Let’s discuss the MD Financial sale to Scotiabank. I was talking to a doctor with some knowledge of the CMA and he said the decision was made to keep enough of that nest egg to not overly rely on membership to fund ongoing operations. Is that so?One of the challenges that we gave to the CMA board and to ourselves is: We want to put the money to good use (on) the issues and causes that matter most to physicians in Canada and not be limited to revenue coming in from membership dues. Many associations in Canada—and I’ve had a few speaking engagements with non-health associations lately—are struggling with the membership model. The business model for associations is being really challenged.We wanted to make sure physicians were going to be served in the best way from a financial perspective and that was to sell the organization to a bigger, multifaceted financial institution where their core business was in investments in financial services.That’s given the CMA a nest egg to be around pretty much for infinity and do good work and not worry so much about what money is available. That puts CMA in a unique position, because it can hold organizations accountable, calling governments to account, without the threat of any organization or government saying, “Oh, well, we’re going to cut your funding.” It’s like, “Well, that doesn’t affect us.” So, let’s continue to do the good work that physicians want us to do. . . . I know the physicians will hold the CMA accountable to ensure they continue to do that.Q: A different physician who also has some involvement with the CMA wonders how deep the concern really is about membership numbers.The CMA takes it very seriously. Just based on my tenure there, we looked at what were the metrics that we were looking to increase. And the number-one metric was engagement with physicians—making sure that they had access to the CMA so that we were inclusive and not an exclusive club.The previous model was really exclusive to the delegates that would come to our General Council, which was a couple of hundred physicians. They would make the decisions on behalf of all of them. And, you’ll remember there were hundreds of motions that would come forward. . . . I came in as an outsider from the financial side, from MD, and I said, “This is crazy, how am I supposed to deliver on 100-plus motions in a year that we have no control over?” They were just coming from the floor. We said, “This makes no sense, it doesn’t line up with the strategic plan, we have no focus.” And so that is a big accomplishment from my perspective, in that we were able to change that.Membership: I’d say it’s very important to the CMA but . . . is it truly an indicator of support and engagement? I beg to differ. Having physicians engaged in the organization, it changes based on physicians’ life cycle. (It) changes based on the issues and causes (of the time). Some physicians may not care about national licensure, so they say, “ I’m not going to be engaged at that point.” But, you know what? They may be really engaged on capital gains tax as it impacts them.So I think you see the ebb and flow of membership engagement based on the topics and issues that are being taken on in any given period. I don’t know that membership is necessarily the right metric.Like the five physicians in my family, some of them were members, some were not members. It’s completely voluntary. That’s the difference too. When you look at a lot of organizations, it’s mandatory membership or legislated. If those legislations were taken away, you’d probably see similar challenges from those organizations trying to get membership numbers to a certain level.Q: Were there situations where the membership really required the CMA to look busy, but there was actually very little ability to move the needle?Even going back to the capital gains tax, there was a lot of frustration from some members saying, “Well, why can’t you have a lot of influence in terms of that? Because that’s impacting our pocket.”I would say that the CMA did have an impact at this last round when the federal government was threatening to increase it to 66%. There was a lot of work that CMA did, on behalf of physicians, but also working with key partners, like the Canadian Federation of Independent Business, on that topic.And other areas: I think it really depends on the physicians and where they’re at in their life cycle, and which province they’re in, (for what) issues that they might have some frustration with the CMA. A lot of times there’s confusion too, in terms of the role of the CMA versus the PTMAs or the colleges.Sometimes we’d get requests come in, or physicians that were upset about something, and we’d say, “OK, well, that’s not really our responsibility. It’s so-and-so’s responsibility.” And they say, “Yeah, I’ve already talked to them, and they’re not helping, so we want the CMA to fix it.”There’d be a lot of that. You probably saw that, too, at earlier General Councils where issues would come up, and we all of a sudden had this mandate or motion to do something, and it’s not even our area, it is a provincial issue.That being said, I think the CMA has demonstrated and (is) in a good place to help provinces and territories with some of those local issues.Q: What are the next steps to get a pan-Canadian licence?This is something that I personally brought forward to the CMA back in 2015 or 2016. It really drew my attention because—now it is very serendipitous around wildfires in Canada but (then) there were ice storms—where workers need to go between provinces and provide emergency services without having to worry about interprovincial barriers.Meanwhile, we fought really hard that physicians are accredited under the same standards at all medical schools in Canada—and even the U.S. So a physician trained in Canada should be able to work in any province or territory without going through significant hoops or fees to provide services.I know the critics have said, well, that’s not going to solve anything. However, it does, based on the work that we did with Dr. Ian Bowmer (former dean of Memorial University faculty of medicine). It does provide some relief in terms of rural areas because physicians are interested and willing to work in other provinces and territories, even if it’s part-time or locums, just to have a change of pace.So I think making it easier for physicians to be mobile makes so much sense. It’s unfortunate that some provinces aren’t jumping onto it as fast as others, like was done with the Atlantic Registry.I think one of the key things is they’ve got to look at the right metrics. It’s not necessarily the number of physicians that are migrating to those provinces to work, it’s more about, is there the flexibility and freedom to provide support when needed, and even in emergencies?Q: Those on the regulatory or government side will express concern about doctors doing locums purely for financial reasons.I think that’s a false worry because if physicians wanted to move to another province to earn higher compensation, they can do it anyways. They just have to wait longer.At the end of the day, I don’t know that we had any data at CMA about doing it for money. There were other reasons: Their spouse has got a job offer in another province or territory, so they want to move. There are all kinds of different reasons.Q: Physicians traditionally have mixed feelings about the value of teams, but do you think that that is settling down?I think the new grads and the new programs are more team-based and more collaborative care-based versus the older physicians who were the solo practitioner, which is just not sustainable today economically and work-life balance-wise. I mean, if they’re not in a large call group and can have backup, how do they take time off? And so I think there’s more openness to it.You know, there’s more than enough demand. I don’t think family physicians need to be frightened about losing their place in the system. And they can focus on the things where they can provide the most value. So I think they’re starting to see that, particularly as younger physicians come into the marketplace.Q: If you could anonymously brief your successor on one unspoken rule of leading the CMA—the thing you’d never really say in public—what would that be?That’s a good question. I had a little bit of time with Alex (Munter, new CEO of the CMA). We didn’t have any overlap; we did that on purpose. I just said to him, listen to the physicians, listen to the board, listen to staff. They know what’s going on on a daily basis. They know what’s going on in their region. And try to facilitate that listening and that knowledge into action where it fits into the strategic plan. . . . .You really have to focus. I would say that’s the unwritten rule that the CEO has to remind everybody—the board, the staff, others—that you’ve gotta focus because everybody reaches out to the CMA to help them. You know, it’s hard. It’s hard to say no, but that’s definitely the thing that I learned over my 10 years, is saying no.It upsets people when you say no, but you gotta do it to be successful; at least to achieve your goals.Q: Looking back at your time as CEO, what do you think your proudest accomplishment is?There’s been a lot—being involved at the CMA, starting at MD 28 years (ago) and I would say the last decade for sure, as CEO:When we look at some of the key issues and causes that matter to physicians going back even as far as the legislation around medical aid in dying. Being a key voice at the Supreme Court level for that.Representing physicians and other small business owners, when it came to tax issues and capital gains issues. We had a unique position because of the background we had in terms of our financial services.I’m proud of modernizing the CMA to be less around a large board size and having more engagement through our Health Summit versus a small group of representatives through our General Council.Many other issues as well: climate change, physician health, Indigenous health, the apology at the CMA and the work that went behind that.And I think the CMA did and will continue to play that big advocacy role. To really leverage their ability to hold governments and groups accountable.Q: And sometimes physicians think ‘I’ve got more than a full-time job plus family’ and they can feel almost too busy to be engaged. Is there anything you can say to those people?I look at it in terms of volunteerism. I think volunteerism is waning a bit when it comes to boards and unpaid positions. That’s part of the challenge, too, for even training and re-entry, because physicians in the community aren’t paid to take in students and residents unless they’re attached to a university GFT (geographical full-time) position, they’re doing it on their time. It does slow them down in their practice and if they’re not in a capitated model then it does impact them. So I think changes like (some) funding models for primary care teams, will help get them engaged early and help (when they are) compensated for administration time, which we’re seeing in many of the primary care models. There’s actually a financial component to say, ‘your time is valuable, particularly on leadership and administration. You don’t have to do it for free and you don’t have to do it on the side of your desk.’ So, it’s really positive to see those changes being included in some of those primary care models that are being implemented now across Canada.Q: The CMA always walks the line between representing doctors and advocating for broader healthcare system reform. How do you see balancing those two competing interests?We’ve had many, strategic discussions with the board over the years and our strategic plans to reflect the voice of physicians on a national level, based on those issues and causes that matter. Those issues and causes were based on engagement with doctors and surveys and focus groups.(During that process) physicians brought to the table, ‘well, what about the patient voice? Because they’re the ones that we’re serving as an organization.’And that led to us creating a position of a non-physician on the board to help provide some outside perspective in terms of the work that we’re doing.We also know that having a patient voice is incredibly important when talking to the federal government. When we started to change our focus and broaden it to include the public more, we got more doors and ears opened at the federal level.

Leading through change: A chat with Tim Smith

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