A New Hope For Healthcare

force awakens[Mea Culpa: The first draft of this post gave the wrong message through my flu-tinged haze. I hope this works better.] 

Fans love The Force Awakens and forked out millions to see it. The newest Star Wars movie played true to its roots and offered hope for something better.

Producers know what to deliver next, as fans wait for the next episode.

Doctors need the same clarity.

Agreed to Walk Together

One of ‘Canada’s best writers’, George Jonas, died this month. He was an ardent defender of freedom, a critic of tyranny.

Jonas said Canada was modern Europe’s transatlantic outpost, “the glossiest, the most sophisticated, and the most up-to-date version of the illiberal state.” (see Beethoven’s Mask)

What does that have to do with modern healthcare? Liberty, or the state, elicits a few patronizing smirks in medical politics.  Liberty is out of style.

Wicked Nonsense?

If government wants to walk south, and doctors want to walk west, is it compromise to walk southwest? Or is that walking in an entirely different direction?

Wicked questions ask, “How can we walk both South and West at the same time?” As much as we love them, wicked questions sometimes lead to absurd ends, nonsense.

Decimation

Doctors bore a decade of deep cuts, clawbacks, and arbitrary caps in the 1990s’ social contract years in Ontario. By the early 2000s, over 2 million patients had no family doc. Those lucky enough to find one often drove over 90 minutes to an urban clinic.

Students avoided family medicine: they even left the country to train in any another specialty.

People talked about the end of family medicine. Doctors took jobs anywhere else but in comprehensive care. It was beyond desperate – hopeless decimation.

Negotiations’ Enigma

From a position of demoralized desperation, doctors came up with a plan to negotiate with government.

1) Find out which direction government wants to go.

2) Get as much as possible out of government for agreeing to the government’s plans.

Compromise worked. Many hail the 2004 and 2008 contracts to have rescued Family Medicine, in Ontario. After a decade of cuts, doctors’ business earnings started to catch up with inflation.

Doctors ignored where the government was headed. Why worry about old-fashioned things like autonomy and professionalism? Legislation, regulation, and simpler contracts seemed irrelevant, quaint.

But 2012 marked a sharp change. The government started cutting and has continued to cut fees every year since, erasing gains from 2008.

Of course, government did not reverse contract details that worked to its benefit. The golden goose took back most of its eggs but left its droppings.

A New Hope

Doctors need a clear vision on where they want to go from here.

  • Do MDs believe in old-fashioned ideas like the doctor patient relationship?
  • Do doctors believe in politically incorrect ideas like liberty, hard work, and reward for delayed gratification?

Doctors need to get very clear about what we believe and figure out an attractive way to package it. We need to invite attacks to our ideas about innovation and prepare to defend them.

Docs are often too scared to discuss system change, because someone might accuse us of being self-serving.

Doctors cannot let government rule by inciting a frenzy of envy each time we try to discuss system innovation. Government owns the congenial myth of wealthy doctors. Let them have it. We’ll never win on that front.

We are paralyzed worrying about what the public thinks. It gets us nowhere. Patients love us when we care for them. No amount of public support will carry doctors through cuts that compromise care.

We need a new hope. We need a vision to fight for: something that doctors articulate, not something that government dictates.

We need hope that stays true to our medical roots, as a profession sworn to help patients and not compromise by letting bureaucracy come before patient care.

Our patients want something to look forward to. Let’s hope we come up with our own vision soon.

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So, You Want to Serve in Medical Politics

parliamentCongratulations! Your interest in medical politics sets you apart from most practicing physicians.

I was asked to share some thoughts for doctors entering politics. I tried to focus on a few favourite concepts.

We can discuss process details, or issues about specific organizations, in the comments section.

No One is an Expert on Everything

You can learn a tonne about medical politics, but you will never be a superstar at everything. Medical politics is not like Biology. You cannot aim for 98% on the exam.

I suppose the OMA President might almost be an expert on everything, for a few minutes, sometime near the end of his/her term. But even Presidents soon find they must defer to someone else.

Do not set out to learn everything. You will despair. Let it sneak up on you.

Everyone is an Expert on Something

Find one thing that interests you: IT, immunizations, HSFR, whatever. Pour yourself into it, even for just a few minutes.

You are now, with almost certainty, an expert on this issue in your local community.

Share what you know. Ask others what they think. Learn more about it. You will be the ‘go to’ person in your hospital or clinic on that topic.

As an expert, you add value every time you share your expertise. Get addicted to adding value. Your addiction will make you crave more expertise.

Your medical politics hobby will soon take over your life as you seek to learn more and more. And you will love it. Make sure your family approves!

Experience Counts in Medical Politics

Doctors perform in a strange play. We train to act with confidence, while knowing we have incomplete knowledge.

We learn to trust our training. Doctors must act with as much certainty as colleagues with years of experience. No matter what grades you got in medical school, every graduate gets called ‘doctor’ and bills the same fees as experienced doctors.

Most of the world does not work like this.

Other industries bow to experience. An MBA does not mean you can run IBM. You need a few decades to learn how to lead.

Of course, some doctors bring an interest in politics from grade school. They volunteered on political campaigns and followed politics their whole life. But they are rare. And even wunderkinds need to value experience and humility.

Experience makes you a better leader, but even more importantly, valuing experience increases your influence and teaches you defence skills. Find experienced leaders and suck every bit of wisdom you can get out of them.

A New Logic

Doctors learn to diagnose and treat. (Let’s forget about the ‘educate and motivate’ of modern medicine for now.) Patients usually give us the diagnosis on history and physical. Then, we treat; delayed treatment is unethical.

Diagnosis works the same in politics, but treatment is completely different. The process of arriving at a political solution means even more than the final solution itself. Many doctors hate this.

If the solution is to ‘do X’, then we should just do it. Why take so long to get it started?

Political solutions require people to buy in to an idea. People need to weigh the risks that a solution presents to their personal vision of how things should work. People want to feel they had a part in crafting the solution.

For many reasons like these, medical politics requires a new decision making process, a different logic.

Obsessed with Issues, Blind to Vision

Doctors never need to think about vision. They accepted the medical vision long ago: doctors help people. The rest of our life is spent fixing particular issues. For doctors, reflection on vision demands flexing an atrophied muscle.

Dug-upIssues are to doctors as squirrels are to dogs: irresistible!

Doctors find and fix issues. That’s why patients value doctors. But after decades of getting rewarded for fixing issues, we often struggle to concentrate on other things.

Medical politics is loaded with issues, important ones. But issues should not define our goals. Doctors need vision in medical politics.

  • Where are we going?
  • What do we sacrifice by supporting this solution?

Doctors need to work, like guide dogs in a park, and stay focused on where we are going, without chasing the squirrels.

Clone Yourself

You should think about succession planning as soon as you get elected. Do you know anyone who:

  • Enjoys being overwhelmed with new material?
  • Gets excited about ideas?
  • Respects experience but strives for change?
  • Has patience for process?
  • Loves discussing vision, not just issues?

Today, strong political forces push doctors away from working as independent professionals, towards employed technicians. We need doctors at the centre of medical politics.

Again, Congratulations on stepping into a fascinating world! Find a mentor and then teach them what you learn. Patients need doctors interested in the weirdness of medical politics more than ever before.

Note: I am not the official spokesperson for any organization. These thoughts have not been vetted. Errors are my own.

photo credit: www.parl.gc.ca,  www.disney.wikia.com

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It’s not a choice: Good quality needs relationships and measurement

photo-joshua-tepperI was thrilled when Dr. Joshua Tepper, CEO of Health Quality Ontario, responded on Twitter to a popular post: Medicine is Relationship, Not Quality Metrics.

Josh has a true heart for patient care and the centrality of the doctor-patient relationship. He is also passionate about quality.

He asked if I would post a response from him, if he wrote one.

I said, “Of course! I’d make it a stand-alone blog post!

So, here is Dr. Tepper’s response. I think it’s excellent and look forward to hearing what you think of it, too.

 

It’s not a choice: Good quality needs relationships and measurement

Pursuing the six dimensions of quality for improved patient outcomes

This blog is inspired by a posting from Dr. Shawn Whatley a couple months ago.

Shawn is a family doctor, health care leader and an active member of health care’s social media sphere. He does a nice job of bringing a range of different views to the forefront.

In his blog, “Medicine is Relationship, Not Quality Metrics,” Shawn shares the perspectives of two physicians who feel that the doctor-patient relationship is more relevant to good patient outcomes than quality metrics. He quotes Dr. Michel Accad, who says that measuring quality-related outcomes “actually makes quality worse.” He also shares the perspectives of Dr. Michelle Vilcini, who talks about what she sees as one of our collective failings: “trying to measure things that can’t be measured.”

I’ve had a few people ask me via Twitter for my thoughts, so here they are.

First and foremost, it is a false dichotomy to see this as an “either/or” choice. A good doctor-patient relationship is actually one aspect of quality; it is captured within the concept of being “patient-centred” – one of the six recognized dimensions of quality, as defined by the Institute of Medicine. The six dimensions, including safe, equitable, efficient, effective and timely care, have been widely adopted as a framework for quality here at Health Quality Ontario, where I work as President and CEO, and elsewhere. Patient-centredness is also the cornerstone of the College of Family Physicians medical home model.

The importance of patient-centredness is also reflected in a blog by Dr. Ashish Jha, a physician and health policy researcher. In one posting, Ashish reports the results he got after he asked his Twitter community for a one-word response to the question, “What makes a good doctor?” The top five responses were “empathetic”, “good listener”, “compassionate/caring/kind”, “humble” and “competent/effective.” His conclusion: “Most people assume that physicians meet a threshold of intelligence, knowledge and judgement and therefore, what differentiates good doctors from mediocre ones is the ‘soft’ stuff.”

There is no doubt that the “soft stuff” – being patient-centred, and nurturing doctor-patient relationships – is part of quality.

But there are a couple places where Shawn and I might have some differing thoughts on the matter.

With regard to the suggestion that we can’t measure the doctor-patient relationship, Shawn suggests that there is no way to accurately gauge the encouraging friendship between patient and provider. But I’d point to the many ways in which the primary care field is increasingly trying to measure that relationship through surveys that target the experience of the patient. There are examples of patient-centred metrics in the Primary Care Patient Experience Survey and the Commonwealth Fund Survey, two among many, which ask for ratings on aspects of the doctor-patient relationship. These surveys can clue individual providers and entire teams into some of the more subtle areas of their care that need improvement. It’s worth noting that there has also been at least one study suggesting a troubling link between patient satisfaction scores and the propensity to prescribe opioids and/or unnecessary testing. This speaks to a need to measure patient experience in addition to other dimensions of quality, such as safe and effective care, and it leads to my second point of divergence with Shawn’s posting.

Building a strong doctor-patient relationship and concentrating on patient-centredness is just one dimension of quality and good care. But care also needs to be safe, equitable, efficient, effective and timely. Naturally these dimensions overlap, and a strong patient-centered relationship will make the other dimensions easier to achieve, but I feel we must be conscious of all six dimensions – especially when discussing improving patient outcomes.

Finally there is the suggestion in Shawn’s work that having a good doctor-patient relationship means you don’t need “a bunch of numbers” to measure it. In response to that, I’d go back to Ashish’s Twitter exercise. One of his Twitter followers responded to Ashish’s question with the following comment: “If your doctor doesn’t use the best data available to them to take care of you, do they really care about you?” Quality metrics and relationship building are connected more than we might think. Of course we can and should comfort, support and listen to our patients. But we also need to let them know when they are due for a Pap smear or a colorectal cancer screening test, or when a cholesterol-lowering medication might increase their chances of living to see their grandchildren graduate from high school. These are the metrics that make a difference.

I’d argue that we shouldn’t try to choose between good relationships or measurement – one is a dimension of the other. Similarly we should be cautious in suggesting that important things like the doctor-patient relationship can’t in fact be at least partially measured. We’d be doing a disservice to our patients to dismiss all quality-related outcomes when data about our practice can help us provide better care.

Thank you to Dr. Irfan Dhalla and Anna Greenberg for providing their input and advice on this blog.

 

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