Who Knows Best?

The dead of summer used to mean rest. Stand-ins covered talk radio. Politicians attended Canada-Day celebrations, and everyone hit pause on life.

Summer meant nothing happened in medical politics; you might as well go to the cottage.

Not anymore. Now, summer means no one is looking, so why not push through something doctors will hate. At this rate, summer will become the new fall, and we will all need vacations in September.

In an effort to pretend I’m ignoring medical politics, here are my rambling from a Muskoka chair.

Who Knows Best?

Mark Twain said,

“I would rather listen to a soldier who has been to war talk about war than listen to a poet who has never been to the Moon talk about the moon.”

Someone also said, “The eye sees what the mind knows.” Doctors see and know problems in clinical care. We must give doctors voice. Government cannot know enough to know, let alone solve, all the problems.

This raises Hayek’s knowledge problem. Every system contains more knowledge than any single person can know. No one can ever know the thousands of decisions people make inside a system.

You choose sausages over wieners.

You buy orange juice, not lemonade.

You make Smores with crackers from the Dollar Store instead of Metro.

Maybe Big Data will solve Hayek’s problem. Computers could collect everything. Theoretically, someone could know it all. The thought makes authoritarians giddy with anticipation.  Society might finally be transparent, compassionate and equal, like The Circle.

But even with perfect governance powered by Big Data, do facts qualify as knowledge? This raises the epistemology of politics problem.

How do politicians know what they know?

How do they determine truth?

Perhaps, they do not care about truth, but only about what wins elections. Are politicians, then, nothing more than rudderless populists? Do they have ideas of their own?

Do politicians just give bread and circuses to mobs of ignorant voters?

Trump’s election made public ignorance and democratic theory interesting again. Pundits complained that voters could never know enough about government. They insist that ignorant people elect politicians. Government will always be formed by the will of the uninformed.

Although a favourite topic for the coastal chattering class, it actually supports a core tenet of those who argue for smaller government.

Classical liberals believe in ‘government failure’ for the same reason that socialists believe in ‘market failure’: information asymmetry.

Socialists worry about ignorant customers, who never know enough to avoid being duped by sellers who possess superior knowledge. A benevolent government could protect the ignorant masses.

But the same ‘ignorant masses’ elect governments. How can they avoid being duped by politicians who possess superior knowledge?

Who can rescue us from this dilemma?

Economists have an answer: Public Choice Theory. Politicians choose what’s in their own rational self-interest. They establish policy based on what will win the most support. To get power, they need a winning platform. Winning platforms are those that gain the most support.

Voters want help most with things that respond to price control; voters want help paying their bills.

Politicians, who put money in the average voter’s pocket, win elections. That’s why handouts work so well.

Promise the moon; win political office. But no politician knows what the public will care about next.

Which brings us back to healthcare. Voters never care about the price of seeing their doctor, in Canada. Our governments control healthcare with rationing, not prices.

Naturally, voters worry least about things farthest from their daily lives. Canadians want to know that healthcare exists, but we do not worry too much about it, until things get really bad.

Even then, only 4% of us need acute care at any time. Wise politicians can wave their wand of policy to calm the worried well with new funding and special programs.

New programs create barnacles of new interest groups – concentrated interests – that fight to maintain new programs indefinitely. They spend their spare time fighting for conditions that benefit themselves, at a small expense to the diffuse masses.

And so, single payer healthcare is political, by necessity and throughout.

Those in political power use their position to maintain office and to influence change that they could not achieve otherwise.

Those in power outside politics use their connections to maintain their position and to influence political direction that they could not achieve otherwise.

Where do patients fit in all of this? Do they represent concentrated interest groups? Are they politically powerful? Can they get answers from politicians, when it comes time to vote? Has modern access to information solved the knowledge problem for patients?

Patients are much smarter than we expect. They manage their own health 99.9% of the time and make critical decisions about medications and when to seek care. They research and learn.

But patients need advocates. They need to decide who they can trust.

Patients need a doctor who knows the front lines of care to talk about care, not pundits who have never been to medical school talking about guidelines, budgets and control.

Photo credit: huffingtonpost.com

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19 Replies to “Who Knows Best?”

  1. Frederick Hayek was a big government skeptic , the opposite politico philosophical pole to collectivist statists and Keynesian liberals…his book ‘ The road to serfdom’ should be standard reading…it is the road that our profession finds itself on at present.

    Slick intellectually arrogant politicians such as Obama , totally unaware of their own ignorance, who put their faith in big government are far more dangerous than those , supposedly their lessers, who wish to reverse the process.

    Obama revealed himself in his Presidential campaign debate with McCain when asked if he had any areas of ignorance, McCain agreed that he had, Obama denied it.

    Real knowledge is to know the extent of one’s ignorance ( Confucius and Socrates).

    Those advocating for the collective are far more dangerous than those who are advocating for individual freedom….those driving to grow and increase government are far more dangerous than those who are trying to shrink it.

    ” Socialism, in general, has a record of failiure so blatant that only an intellectual could ignore or evade it” ( Thomas Sowell, a real Afro American intellect).

  2. Its probably time for us to not dwell on the lint in our bellybuttons while discussing the views of philosophers. Its time for action. Repetition of the same old arguments is getting us nowhere. The OMA could start with a letter of intent to the provincial government that if the proposed changes to the corporations act go through, we will be expecting compensation in the next round of negotiations. Maybe the Wicked Witch of Queen’s Park can whisper in the Monkey King of Ottawa’s ear and stop this madness.

    1. No you don’t tell them you expect something in return in the next negotiations, they will betray you again. How many times do you have to get punched in the face before you decide to punch back? If docs are not willing to make this a line in the sand, today, we are doomed to continue as whipping boy. We have been down this road of compromise and promises before and here we are. Time to think of a better way of opposing this punitive attack. Together we are very powerful.

      1. Good point, Carole.

        The latest attack is an affront to a whole nation, and not just doctors. We will fight it. I think the public will support once they understand. It will take 20,000 or 30,000 letters I expect…and hundreds of meetings with MPs…and, and, and… A massive coalition is forming. Each province is developing specific action items.

        It’s unbelievable…

        Thanks for taking time to share a comment!

        Shawn

  3. Thanks Andris, Ernest and Sam.

    I’ll admit that this post was much less practical, more rambling and probably somewhat irritating to action oriented docs. As I said, these are thoughts from a few days at the cottage. I can’t help thinking about the ideas that led us to this place.

    Thanks for taking time to share a comment!

  4. To avoid enslavement our profession has to act, has to resist….unfortunately it is sleepwalking into it.

    The profession’s leadership is not beating the drums, raising the alarm and is not rallying the troops.

    The grass roots will carry out guerrilla warfare , but the government and the CPSO will work against them.

    Retirement or emigration will be the only solution for many….it is noted that President Trump is modifying US immigration laws favouring the skilled and those who can speak English …the USA needs more medical professionals and primary care physicians in particular….a good fit…many will choose to step off the down going Ontario elevator and step into the up going US or other foreign elevators such as that of Australia.

    There is no substitute for action to preserve our freedom, the grass roots detects no positive action .

  5. If we are recognizing Hayek’s Road to Serfdom, we must recognize the current political trends of:
    1. Solzhenitsyn’ s Gulag
    2. James’s Marxism, Fascism & Totalitarianism.
    The learned were always the one’s to be taken down first. Their leaders were often bought. Doctors are becoming those who are sentenced to the Gulag. It is very unlikely that a measured approach to resistance will work. The alternative, an anarchic Alinsky approach, is not within most physicians’ morals. So what are the options? A previous blogger talked about strapping ourselves to the Mast in the presence of those wicked persuasive sirens. Do we do that or end up as Joan of Arcs? Since you are “relaxing” ha, ha, at the cottage, iTune the following by Dead can Dance: How Fortunate the Man with None: Here is one verse-the other verses have same meaning:
    “You heard of honest Socrates
    The man who never lied
    They weren’t so grateful as you’d think
    Instead the rulers fixed to have him tried
    And handed him the poisoned drink
    How honest was the people’s noble son
    The world, however, did not wait
    But soon observed what followed on
    It’s honesty that brought him to that state
    How fortunate the man with none.”

    So, time to plan the bottom line responses to current Canadian governments and we must all heed the potential consequences. Be honest, Be Brave!! Don’t be bought!

    1. Great comments, Stephen.

      Thanks so much for suggesting James’ book. I haven’t read that one. Solzhenitsyn’s message would not get much of a welcome in Canada these days. I worry that too few of us find time to read through these ideas. We find them impractical. I believe that they are crucial to helping us understand why government presents the programs and services it chooses to offer. They do not come out of a vacuum.

      I’ve been thinking more about Alinsky. Rules for Radicals might offer ideas for us, too. I agree, the methods won’t appeal to many docs. But I suspect many MDs are open. I’m not sure I can bring myself to follow his ways. It’s good to know the playbook for community organizers but I’m not sure I want to be one of them.

      Thanks so much for taking time to share a comment! (And I loves the verse you shared…tragic.)

      Shawn

  6. ” Without a revolutionary theory there cannot be a revolution”.

    “Theory is a guide to action”. ( both Lenin).

    Philosophers have hitherto only interpreted the world in various ways, the point is to change it”. ( Marx) .

    We must take a page out of the Marxist social justice warrior manual…we need a revolutionary theory to redirect the health care system away from its present non evidence based direction and in the direction of a proven evidence based symbiotic public/ private health care system that treats all parties fairly.

    1. Brilliant comment, Andris!

      Your vault of quotes is impressive indeed. I’m not surprised that Lenin would connect theory and practice so closely. I believe that we need to do the same with healthcare, as you suggest. Having said that, we must be careful with our audience. Some people really hate theory of any kind. Although I disagree with Keynesian economics, I like this quote from Keynes: “Practical men who believe themselves to be quite exempt from any intellectual influence, are usually the slaves of some defunct economist.”

      Thanks again for taking time to share!

      Shawn

  7. Hi Shawn,

    I have to say that I am a little reluctant to have faith in the new leaders of the OMA … however, believe me when I say that I certainly want to!

    From my viewpoint, once Ontario doctors were required to become paying members of the OMA, the OMA itself became a rather lengthy arm of the government that up until significant changes last summer seemed to be the case. Please prove me wrong and offer faith in the OMA again. I do know that other “grass roots” doctor organizations are forming but although these serve a more honest interpretation of the wishes and intentions of Ontario doctors, they also run the very real risk of dividing, and diminishing, our political influence.

    The recent BAF pretty much removed any leverage we had in terms of putting significant pressure on the government(s) to listen to our voices. Thus, “voting with our feet” seems to be the last remaining measure of influence we have … we should utilize it.

    I believe (and have so for some time) that the period of honest negotiations and discourse has passed. The influence that we have is not with our own voices but with the voices of our patients. Teacher unions have been successful because the students (and parents) place the pressure on governmental institutions to make change and demand respect from governing bodies. We can do the same with our patients. I do not suggest that we ignore those with urgent/emergent medical issues but we can certainly “delay disposition” of those that do not fall into the aforementioned category with information packets explaining why the delay has occurred. Nice? No. Necessary for influence? Yes.

    Furthermore … with recent proposed changes in the US, lack of agreement with the Ontario government, and proposed federal tax changes (the timing of the BAF and federal tax change announcements should suggest that fair negotiations are unlikely to occur anytime soon) should prompt the OMA to consider developing a system of assisting those that wish to relocate given the current political and economic climate. The US is a very large market with many great opportunities for employment, career advancement and living opportunities.

    Anyhow – somewhat of a rant from a post-shift recovery arm chair discussion and ultimately … my “2 cents” …

    Sean

    1. Thanks Sean!

      I really appreciate you taking time to share. A big challenge, as I see it, is to try to offer options for all docs. Some naturally want to protest. Most avoid conflict. A number of docs are adventurous and will relocate, but many cannot. Our mission, if we choose to accept it, is to make life better for docs (and through doctors, patients too). That is a big mission! We need your help to make it happen.

      Right now, as we fight back on the federal attack, we need 20,000 – 30,000 letters. Politicians respond to popular opinion. They care about nothing more. We need to show them that a huge number of their constituents are not happy with these changes.

      Thanks for taking time to share your thoughts!

      Best

      Shawn

  8. Not being a Keynesian I nevertheless have a favoured quote from him :” When the facts change, I change my mind. What do you do , Sir?”

  9. When the facts change we have to change our strategy.

    I recall a British officer dropped with his Chindit special forces team by parachute some 20 miles from the target in Burma ( WWII versus the Japanese) , on the wrong side of the Irrawaddy River saying ” we are where we are, we go from here”….there was no point hurling curses at the pilot…we, as a profession should move from here…the facts have changed, the circumstances have changed…but our goal of professional freedom , of professional survival and ultimate victory hasn’t.

  10. Shawn I agree that letters and meetings with MPs are the best first step towards improving the situation in Canadian health care. However if these fail, and it would seem there is a high likelihood they will, can the OMA and CMA propose some tangible next steps to reassure physicians there is more than talk and meetings planned. Some form of job action would seem necessary provided it does not impact patient care. Meaningful pressure couls be generated if physicians stopped non clinical activities such as administration, teaching, etc.. I believe the QMA used such tactics in Quebec 15years ago and had the support of the public.

  11. Hi Shawn – thank you for your leadership.

    Can the OMA/CMA provide some insight into next steps if letters and meetings do not suffice. I believe the QMA ran a high impact job action campaign in the 2000’s that did not affect patient care. They ceased non clinical activities such as education and administration.

    Thanks
    Luke

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