Two Kinds of Doctor & Two Kinds of Politician

Two Kinds of DoctorWe find two kinds of doctor: fixers and servants. Both consider themselves healers.

One makes problems go away. The other makes the best of chronic disease. Maintenance and chronic issues frustrate the fixers. Quick fixes, while necessary, feel like Band-Aid treatments to the servants.

Fixers believe in final solutions. On the one hand, they make a living fixing acute issues.  On the other, they wish the issues did not exist in the first place.

Servants know that, no matter how much care they provide, chronic disease is unending. Even the best diet and exercise program will not stop decay. Servants resist decline; they fight to improve function. But servants accept that their patients will wear out and die. Servants seek to make the journey as good as possible.

Public Service

Fixers and servants work in government, too. Fixers believe that the right program will make everything better. They look for silver bullets. They crave utopian designs.

Servants have more modest goals. They realize their efforts can make things good, at best, but never perfect. Their ends are limited and indistinct, whereas the fixers’ ends are grand and crisp.

Healthcare is more like a chronic disease than an acute illness. We should not expect a cure for healthcare in the way some people expect a cure for cancer.

Jeffrey Simpson lamented that healthcare is a chronic condition, in his book by the same name. It shouldn’t be so hard. Why can’t delivering healthcare be more like delivering the mail: crisp, measurable, and suited to bureaucratic solutions?

Assumptions

Solutions start with assumptions. Healthcare frustrates with variety and individualism. While we’ve discussed it many times before, it bears repeating with an example:

We can generalize about the health impact of poverty. But there’s an enormous difference between the poverty of a homeless person in Toronto and a single mom in Northern Ontario. They both might face similar health concerns, but solutions must look very different.

This frustrates planners. We should be able to treat hypertension with strict guidelines regardless of income or location.

But doctors know different. Local, individual problems make a huge difference.

Healthcare requires local, individualized solutions for a chronic condition. The search for grand solutions to fix most healthcare problems will continue to irritate reformers. Their frustration makes them look for someone to blame: often ‘uncooperative’ patients and doctors.

Cause or Effect

Are doctors more like public health workers, looking for the one pump that spews bacteria into the community? Or are we more like old fashioned GPs, who treat acute injuries and palliate chronic disease?

Of course, we need fixers and servants. Doctors must be good at both. But new fixes aren’t as common as before (see The Rise and Fall of Modern Medicine). We spend more time caring for chronic disease, less time fixing it.

We need a system designed to care, and support local service, instead of creating grand solutions. We need the public service to serve patients, not fix them.

 

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Abuse, Not Burnout

Abuse, not BurnoutMany physicians should see a doctor. They are irritable, tired, despondent, unsatisfied with work, and avoiding responsibilities.  They report physical symptoms: headaches, GI upset and poor sleep.

Experts say doctors are burned out:

Abuse, Not Burnout

But one doctor calls BS on burnout. Dr. Pamela Wible, ‘America’s Leading Voice for Ideal Medical Care’, says,

“Please stop using the word burnout. You are not burned out. You’ve been abused. Let’s get the diagnosis right.”

“…medical students and physicians are collapsing because they are suffering from acute on chronic abuse.”

She wrote a popular blog piece: Burnout is Bu-lsh-t.

And she wrote a best-selling book: Pet Goats & Pap Smears: 101 Medical Adventures to Open Your Heart & Mind. (Thank you, Dr. Boyce!)

Despite her outrageous book cover, Dr. Wible makes a solid point. Victims of abuse often report symptoms like burnout.

Symptoms rarely indicate one disease. Fatigue, mood swings and stomach aches can mean almost anything. High calcium causes stomach aches, muscle cramps, and psychosis. But we do not say patients have stomach, muscle or mental problems when their calcium is high. They have a calcium problem.

Diagnosis

Many doctors show signs of burnout. But could it be abuse? If doctors are suffering abuse, not burnout, then calling doctors burned out just blames the victims.

Doctors often serve and recharge by practicing medicine in a developing country. No doctors ever tell how happy they are to return home to catch up on the latest legislation, regulation, and tick-boxing requirements of medicare.

Doctors recover from their symptoms of ‘burnout’ soon after escaping abuse. They go on to work even longer hours with energy and joy once freed to do so.

Waking Up

Disillusionment is good. It hurts to lose a dream, to realize what we thought was true is not. But life under an illusion cannot be full and rich. Dreams feel bizarre.

Many doctors talk about delaying gratification until middle age. The dream of being a doctor pushed them through 24 years of school. It promised relief when they finally got out of debt; finally got out of working night shifts; finally became financially independent; finally started a family.

Gambling on the dream, many doctors lived far below the poverty line, long past medical school. But most grew tired of frugality sometime in residency, in their late 20s and early 30s. At that age, debt works so much easier than pinching every dollar.

So after years of being poor – really poor by every measure of poverty in Canada – doctors finally start earning a decent income. Something almost as good as a school principal.

At this point, they usually take on even more debt. They buy a house and build their practice. The Wealthy Barber taught us that we must earn two dollars to spend one. Debt is even worse.  We must earn $2.50 to pay off $1 plus interest (depending on rates).

Sometime in their late 40s or early 50s, doctors expect to arrive, to be debt-free, to loosen up a little and enjoy life. But depending on how many kids (and spouses) they have, doctors often end up delaying this dream, too.

Over the last year, doctors tell me that they find it harder to make a living. Not maintain their posh lifestyle.  To make a living. Just when doctors thought work would get easier, they have to find new jobs, work overtime, and downsize their middle class lifestyle and expenses.

Doctors are frustrated. And with good reason. Even if doctors were earning huge incomes, which many do not, 10 years of heavily taxed earnings, after 35 years of poverty and debt, hardly balance out.

Treatment

Recovery starts with facts. It starts with the right diagnosis. Recovery will never come by telling doctors to maintain better mental health, or to get more exercise. It certainly won’t come from the common response, “Well, you chose to become a doctor!”

Recovery starts when doctors wake up from the dream. They need to find other doctors who feel the same.  Thousands of doctors are waking up to understand, in a personal way, that they cannot run a business when government has too much power and control.

This is not just a rant about political theory. It’s a reflection on current events. This will happen again, no matter what truce doctors may sign. Government will get desperate, again, and treat doctors like they have no civil rights.

Will doctors make the right diagnosis? When will they call this abuse, not burnout, and get on with treatment?

 

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The Root of all Quality

bobby mcferrinDon’t Worry, Be Happy betrays deep wisdom in a simple package. Of course, we cannot be happy by telling ourselves to be so.

The song’s brilliance lies in redirecting our focus. It distracts us from real tragedy and makes us smile.

We do not become happy by focusing on happiness. We find happiness by looking for something else. Happiness sneaks up on us as a by-product of the search.

Quality by Design

System planners manipulate behaviour. For example, product placed at eye level sells more, and kids eat less junk food if cafeterias place healthy options first. Systems influence quality. Check out: Nudge: Improving Decisions About Health, Wealth, and Happiness.

System thinking pivots on fascination with The System. It cares much less about individual people inside the system. System thinking solves many problems. But people have uncanny skill at cheating systems, sometimes without even trying.

Babysitting Quality

WestJet treats its pilots like big boys and girls. WestJet does not babysit its front line professionals.

Same thing in university. Many students feel shocked that professors have no interest in spoon-feeding like teachers did in high school. Students soon develop responsibility for their own performance, or fail by mid-term.

Many students form study groups to clarify issues and encourage each other toward higher marks. For them, study groups work.

The Root of all Quality

Medicine is about people, not things. No amount of planning for quality and safety gets around individuals making decisions. And people make decisions for many reasons. Rules, reward, values, concepts, fear of punishment and social pressure can all influence our decisions.

Individual behaviour determines quality, and everyone wants to control it. Government controls rewards; regulators control rules and punishment; educational colleges promote concepts and values (e.g. CanMEDS).

But they all miss the glue that holds these together: relationship. Relationship trades on all spheres of influence.

Professional Relationships

Social structure, stability, and power come from small groups of connected individuals.

Groups of two to four physicians, who meet together regularly to discuss cases, share concerns, and offer support to each other, would create a culture of quality. Community doctors rounding on their in-patients used to meet like this all the time.

NOTE: Groups would need to rotate members every year or so. Quality would suffer if small groups of low performers met together for years.

If system planners wanted to do something really radical, truly innovative, they might encourage small, autonomous groups. Clusters of physicians could keep each other encouraged, accountable and passionate about quality and innovation.

Small groups would out-perform anything that a central authority could put in a guideline or regulation. Physicians who meet and talk together could apply cutting-edge research and knowledge to immediate patient needs. No central authority could ever come close to regulating that kind of service and care.

Small autonomous groups of physicians would make most current regulation redundant, almost comical.

Culture builds from the ground up. Leaders need to nurture, recruit, and develop outstanding culture creators, but ultimately leaders hand over the growth of culture to individuals.

Subversive Groups

Small teams are subversive. By their very nature they have ideas that will not be identical to those held by leadership. This makes some leaders panic.

Any intermediary power, or organization, that forms between the individual and the state, threatens Leviathan. Weak leaders worry about autonomous small groups.

Many large hospitals have gone out of their way to make the doctors’ lounge smaller or less accessible. They do not want doctors talking with colleagues. But informal groups form the basis of culture, society itself.

Square Pegs in Round Holes

Mandating group practices will not build culture. Doctors might organize groups for financial advantage, attend required meetings, but never enter into the relationship building required for culture. Meetings do not create culture. Relationship does. Government cannot build or mend local relationships with practice reform.

Quality does not flow from measurement, rigour, and reporting. These things identify gaps and quantify improvements. They can influence change, but they do not deliver quality per se. We need to learn how to get quality and not just identify when it’s there.

Quality: a Meta Result

Quality, like happiness, comes by focusing on something else. It comes with effort. But quality is more of a second order, meta-result that starts with culture built on relationships.

Blunt regulation, arbitrary legislation, and unilateral action obliterate culture. They drive doctors to despair, to sing Don’t Worry, Be Happy.

photo credit: bobbymcferrin.com

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