Manage Doctors for Patient Benefit

knead-breadParents can try to control everything their children do, or let them run completely wild. Neither extreme works well.

Politicians can try to control everything in medicine, or let doctors run wild.

Just like parents, politicians tend towards one extreme or another. If we listen closely, most pundits assume doctors should be controlled.

How to Manage Doctors

I spend hours listening to healthcare opinionists: politicians, candidates running for office, administrators, consultants, bureaucrats, journalists, talk show hosts and concerned citizens. They all have different ideas on how to manage doctors. But none of them questions the need for management.

Should politicians and administrators direct physicians like a conveyor belt directs iron ore into smelting pots?

Should the government manage where physicians work, and how they work, in the same way that a General deploys troops?

Surely the best way to meet a patient’s need is for government to tell someone to meet it?

As money runs out and study after study shows that Canadian healthcare under performs, should the government just take charge and tell doctors what to do?

Patient Benefit

Medicine always starts with: What’s best for patients?

Does history show that patients get better service, quality and care from doctors who have little or no choice in where, when and how they work?

Is an employer-employee model the best fit for the medical profession?

Do patients get better access when doctors get rewarded for working long hours, or do patients benefit when doctors must follow strict rules about after-hours availability?

Doctors can fix access problems. If governments will pay for operating rooms and lab tests, the current group of doctors working in Ontario could make almost all wait times disappear.

It might kill the doctors and ruin their families, but doctors could do it. The satisfaction earned in helping a patient, plus a modest financial reward for doing so, makes it very easy for doctors to sacrifice their family and social lives by working harder and longer. Doctors will work late every night, without breaks.

But all this changes when government mandates that physicians sacrifice time with family and friends.

Mandates around bundled care fall under overarching contracts.

For example, family doctors in Family Health Organizations (a capitated model) must provide 3-hour clinics in the evening. Doctors provide the 3-hours blocks; they work hard and might even double book patients.

But doctors do not get paid enough to cover the office overhead for the 3-hour block: Doctors pay to work the evening clinics. Without surprise, docs leave shortly after their mandated clinic ends.

Medicine stands on doctors swearing to serve individual patients. The core of medicine demands that doctors have the independence to advocate for patients and that doctors shoulder the responsibility that independence requires.

Managing medicine by treating doctors as salaried employees, with crisp break times, incomes and benefits, turns medicine into a technical service; no longer an ancient profession.

Freedom vs. Control

Government can govern by allowing people to govern themselves, or it can govern by taking control to instantiate its own plans.

Patients need doctors who are free to manage their practices for patient benefit. Patients need freedom to leave doctors, who do not provide good service and quality.

Patient freedom offers the best way to manage doctors.

Experts used to think patients did not have enough information to choose good care. But recent studies show that patients correctly choose hospitals with good outcomes.

Regardless of how we fund healthcare, doctors must be free to meet patient needs. Doctors need to be rewarded for meeting those needs in proportion to the effort required and value added in doing so.

And patients need to be free to see whichever doctor offers the best service and quality. Utopian designs like Bill 41 will never put patients first.

So, how do you manage doctors and medical care?

The last President of the Soviet Union, Mikhail Gorbachev, asked British Prime Minister Margaret Thatcher:

“How do you see to it that people get bread?”

The answer was that she didn’t(1).

Bakers took care of that.

Photo credit: finecooking.com

 

  1. Sowell, T. Basic Economics, Basic Books, New York, 2015.
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10 Replies to “Manage Doctors for Patient Benefit”

  1. This situation cannot be corrected unless and until we as a profession reject the infringements on our basic civil rights. No other profession in our society is restricted in how and who we work for. I believe that a constitutional challenge is needed to defend physician rights to work for someone other than government. This would break the monopoly on our services – it is an oxymoron to refer to us as individual contractors when we cant work individually without the government.

    1. Well said, Ernest! No one else will champion our cause.

      A conversation with an expert I consider to be ‘doctor friendly’ irked me so much that I had to try to write about the issue. This person talked as though doctors should just be told what to do and where to work. This expert was incensed that docs had any say on where they work and the hours they keep. I realised that even ‘pro-doctor’ experts think of doctors like any other raw material. They assume we should just be ordered around and do what we are told. They have no clue about how this would eviscerate the heart of medicine causing irreparable damage to patient care.

      I don’t think I captured the issue as well as I had hoped in the blog post. But you got the point.

      Thanks so much for taking time to read and share a comment!

      Cheers

      Shawn

  2. Dear Shawn,

    I have had the privilege of working in the continuous improvement field for 30+ years and most recently, and most satisfyingly, in healthcare… generally speaking, wonderful, caring people trying to do amazing things under extraordinary and, sometimes, overwhelming circumstances. So… why isn’t it our current system of healthcare working?

    Generally speaking, maybe it is, but… that isn’t enough. There has been a tsunami of demand coming towards us and one doesn’t need to get into describing the “hows” and “whats of that wave… simply that it is very real and is not going away.

    Much of the language I hear about healthcare is “how to fix” and “how to improve”… Perhaps stated in a politically correct fashion, “How can we free up capacity that can be reinvested in the community”?

    My belief is that we are beyond “fixing” and we MUST consider design… With all of the knowledge, data/statistics and experience, IF we had the ability (and political will) to lay down a white sheet of paper and sketch out a healthcare system, what would that look like?

    Would we need all of the local, regional and provincial redundancies that exist today? Would we have a “universal” health record system aligned with out philosophy of universal healthcare? Would there be a nationwide pharmaceutical registry that could provide real-time statistics on the distribution of prescription drugs? Would we build monolithic healthcare structures or take a decentralized, localized approach? Would we abolish “assigning” patients to MD’s and choose a “next available” model, thereby eliminating the waste and patient care quality issues associated with the batch model existing today? Would we have a strategy and enabling system for caring for the aged and infirmed at home, thereby keeping them out of institutions?

    With 60% of all tax dollars now going into healthcare and that still not being enough, dramatic change is needed. I fear we lack the leadership at the provincial and national level to make that happen so “fixing” existing processes in a model that will never be capable is a fools errand and the public as well as care-providers at every level will continue to suffer.

    I have a huge respect for the good people working in and across healthcare in Canada… heroes who are asked to work in an environment that is often out of control and with processes and systems, in my opinion, that are more often not capable to do what needs to be done, demand or otherwise. And we wonder why classes on “how to manage stress” are a routine offering in that field?

    I don’t have the answers… I don’t even have all the right questions, but I appreciate people like yourself continue to “prod the beast” and provoke discussion, Shawn.

    Wishing you a very safe and happy holiday season and a fulfilling 2017 and beyond.

    best regards,
    Rod

    1. Thanks so much for taking time to share such a thoughtful, thorough comment, Rod!

      I cannot do justice to all the issues you’ve touched in your note. I hope readers take the time to go through them.

      You started your note with continuous improvement. I think we spend too little time talking about how things are run on the inside, for example, how does a hospital really function? We need to consider whether leaders have the freedom to make obvious improvements at the local level. We need to run our publicly funded system more like a business and less like a Soviet car factory.

      Thanks again!

      Shawn

      1. to continue, if not a soviet car factory, then Toyota and the LEAN model…where suicide was rampant. the profession of medicine already has cultural practices of organization and coverage, and a ‘verstehen’, a lived knowledge. as an example, the ‘first come first serve’ is classic new managerialist organizational model, and that business model when it tried to understand ‘care’ created call centres. i’ve never felt cared for by call centre care, nor by the likert scales i get harrassed with, knowing that the employees also get harrassed with them. medicine’s verstehen knows that a great deal of healing is in therapeutic relationship, and ‘first come first serve’ ends up creating social worlds that are even sicker, alienated, lonely, with the attendant cardiac conditions etc. better, as Shawn says, to make this a ‘ground up’ theory, capturing with methods from anthropology, what medicine already knows, before it is gone in the neocolonialism of neomanagerialism. like forceps, if that knowledge is suppressed, it doesn’t easily come back.

        1. Wow. Brilliant comment, Siobhan!

          I must look into Vertehen more. Excellent.

          Thanks for sharing!

          Cheers

          Shawn

  3. I am not sure where you get the idea that FHO doctors don’t make enough in night clinic to cover their overhead. In our family health team our overhead is fixed so it makes no difference. Furthermore early on when we set the team up we decided that if a doctor saw another doctors patient in night clinic that the doctor who saw the patient would be paid $25 from the capitated doctors money. That way there is an incentive to see your patients in clinic rather than not and have them go to night clinic for someone else to see. When you add in the ten dollar bonus to see the patient in night clinic you get 35 dollars per patient. We average 6 pts an hour in night clinic so you get paid $180 an hour to do night clinic. You lose some of that paying out other doctors to see your patients but if you are available during the day you don’t lose much. A friend in another family health team tells me they charge $75 an hour for night clinic overhead but the doctor gets paid OHIP rates to see patients in night clinic from the doctor whom the patient is capitated to. They have the same reasoning you should be rewarded for being available for the patients who are rostered to you. We all do this because we understand physician behaviour. Nevertheless we still see FHO doctors work less hours on average than FHG doctors because the small bonus you get to see your patients (10 percent of the fee schedule) isn’t worth it. If you are highly available it is because you care. Doctors are like everyone else many do care but some don’t. If the ministry had been smart they would have put in lower capitation rates and a higher bonus (maybe 50 percent of the fee schedule) to see patients IMHO.

    1. Thanks, Len!

      You describe an arrangement that aligns doctors’ interests to meet patients’ needs. At our FHO, we have no agreement for seeing our colleagues’ patients. And we pay $75 for admin support. And we pay $20 for parking. The 10% of the fee schedule that I bill does not cut it, by a very wide margin.

      Doctors lose the opportunity to work a shift in the ED or anywhere else, by fulfilling their after hours duties. Docs compare the opportunity cost of 3 hours for zero (or very low) pay versus 8 hours somewhere else.

      All in all, especially the way we have it set up with our group, the after-hours duties represent a HUGE lost opportunity.

      Thanks again for taking time to write!

      Shawn

      1. Don’t forget that part of the deal of getting the capitation money is doing the night clinic. So we are paid for it but after a year or two you start forgetting that and it starts to feel like a burden. Sort of like getting a new toy at Christmas and a month later it provides only a fraction of the joy. When I went from capitation from fee for service my income went up 30 percent and I am working the same number of hours maybe a few less. I used to average 5-6 pts per hour under fee for service now I average 4-5 pts an hour. My notes are better. They need to be as the college seems to be increasing more and more what they want to see if they audit you. As per you post there are a lot of pressures on docs in capitated models to do other things rather than be productive seeing pts. When we were fee for service the incentive was to be more productive and we made the calculation of how much risk we could tolerate be being quicker. That being said I believe that there is risks inherent in docs not seeing pts in a timely manner or not knowing their patients because they don’t see them very often. I guess I am lucky in that even with all the discouraging things I see I still like seeing patients at least most of them. Merry Christmas!

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