Marchildon and Sherar's (2018) "Doctors and Canadian Medicare" presents a specific dilemma for healthcare reform: the ability of physicians to negotiate ever-increasing incomes without reference to the consequences to healthcare costs or provincial budgeting. This commentary situates that discussion in the broader debate of the challenges to healthcare reform as exemplified by studies such as Paradigm Freeze (Lazar et al. 2013) and the ability of provincial medical associations to act as both system insiders (gatekeepers) and outsiders (with no responsibility for system finances). The resolution to this dilemma may be to follow the lead of the Alberta government by negotiating a stewardship role for physicians that requires them to take broader governmental goals into account. There is evidence to suggest that physicians may be the best actors to insist on and enforce changes in physician behaviour. Furthermore, adding physicians as stewards of the system may help create better checks and balances in the currently dysfunctional dynamics between federal and provincial stewards.

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