Doctors Afraid to Speak Up

Grandma-BettyGrownup children sometimes ask the impossible.

“Whatever you do, Doctor, you must never mention the C-word to Grandma.”

I listen with a concerned frown.

“You know… Cancer,” her grandson whispers.

“Grandma’s scared to death of it,” her daughter says.

“It would kill her if you said anything. Promise you’ll never tell her, Doctor.”

I nod and say, “Maybe we should ask Grandma if she wants to hear the truth?”

Grandma usually takes it quite well. The children were scared to death of cancer, not Grandma.

Patients want doctors to help them understand as much as possible. They want doctors to speak up when something is wrong.

But many people want doctors to hide the truth. A number of docs are campaigning against cuts to medical spending in Ontario. At the same time, other powerful doctors, who work in government, or lead hospitals and medical schools, bully MDs and students to keep quiet.

Be careful,” they say.

Keep writing articles or giving interviews and we might not renew your hospital privileges.” 

“We saw what you wrote on social media. It goes against our rules and regulations. We will dismiss you if you do not keep quiet.” 

“You wouldn’t want to ruin your chances of getting a good residency spot, would you?”

Leaders who get money from government cannot allow their staff to publicize government failures. Does this cover-up benefit patients?

Leaders who bully others into silence do it to protect their income. Patronage demands that we keep our benefactors smiling on us with favour.

Afraid to Speak Up

Free speech is all but dead in Canadian healthcare. Not just limited, weak, or dying: dead.

Everyone on the inside must speak in generalities. Sure, you can report private clinics closing. You can also leak stories to the press, who then write about them second-hand.

But the people who know cannot speak. They dare not.

Here’s a short list of allegations I’ve seen or heard about:

  • Delayed vaccine supplies…were they delayed to coordinate a dignitary’s photo op?
  • Hundreds of thousands of dollars spent on technology that never got turned on, or used for only a few days.
  • Over a million dollars spent in a rush at year-end on unproven programming, “Otherwise we won’t get the same funding next year.
  • Reporting different sets of financials than the ‘real’ ones used to run an organization.
  • Houses built for executives by the builder who won the contract for a public facility.
  • Departments insisting that only the product offered by the company they have a relationship with can be sold in other departments of the hospital.

Allegations can be explained away. The list above avoids breaking laws. But explaining nonsense does not mean it’s not nonsense.

Privilege, patronage, and waste always litter monopolies like garbage on sidewalks. Monopolies have no reason to clean it up.

We could pass a whistleblower law and demand that people speak up when they see waste or unethical behaviour.

But why would someone speak about an organization that pays them? Government might close the operation and put the whistleblower out of work.

We could tell the new patient ombudsman. Could they manage the volume?

We could empower patients. Give them transparency and choice. That way, if someone delayed a vaccine, patients could get it somewhere else, as soon as it’s available. A dignitary would lose a photo op, but patients would get care sooner.

The need for silence grows as healthcare runs out of money. Governments ration services to control spending, but they cannot fix the inherent waste in a monopoly.

Doctors must not publicize details about waste, rationing, and cuts. Voters might panic.

Maybe we should ask voters whether they want to know what’s really going on?

I suspect they would take it quite well. Maybe only the government fears the truth, not the public.

photo credit: about Grandma Betty.


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Why Doctors Should Write

Books in Office 2015Most people dream of writing a book: 82% of Americans according to one highly quoted, but unavailable, study.

At least 6 docs in the last few weeks have asked me about starting a blog.

A quick check of the MD blogroll in Ontario includes: Drs. Barron, Beck, Elia, EllisFreedhoff, Fullerton, LarsenLougheed, Profetto, SingalTepper and Dhalla, Waghmare, Wooder (tell me if I missed you!). Additions: Dr. Menon.

This doesn’t include all the docs who post regularly on the Canadian Healthcare Network (gated).

But it’s not enough. Doctors need to write more.

Why Doctors Should Write

Doctors should shape the public’s understanding of medical care, not non-physician experts. If doctors do not write, others will.

Non-physician experts have interesting ideas about how MDs should work. Physician silence leaves these ideas unchallenged, untested by those the ideas impact.

Doctors should write books, articles, op eds, short stories, letters to the editor, memoirs, history, and more. Academic writing helps, but not enough. Academia freezes around a paradigm and forces writers into an igloo of peer review, editorial independence, and journalistic themes.

Victors write history. Doctors used to rule supreme in medicine. That changed and, in a number of ways, patients are better for it.

But pendulums can have very long arcs. The pendulum continues to accelerate away from physicians defining medical care. It might not change direction for a generation. Maybe it’s a trajectory, not a pendulum?

Planners view doctors as just one actor in a cast of providers. Medicine does not stand alone. Primary care includes everyone from pharmacists and nurses, to social workers and dieticians. Doctors need to stand in line to speak about patient care.

Still Unique?

And yet, patients still want to see their doctor. Someone needs to serve as most responsible ‘provider’. Everyone wants to give orders, but no one wants to take the blame.

Confidentiality shrouds medical care. Even when a team works on a patient, it happens behind the curtain; those outside see only blurry images around a stretcher. Policy experts attempt to put flesh on the shadows, but they never get behind the curtain.

Doctors should write in an attempt to reveal the heart of medicine. Writing shows how medicine looks compared with experts’ visions of a perfect system.

How to Write?

It has never been so easy to create content. Even if you hate typing, voice recognition transforms an hour of rambling into a short chapter. You can dictate, copy, cut, paste, and rewrite a short chapter in less time than it used to take to hand-write a 2 page letter.

Unfortunately, content creation is not writing.

“Re-writing is where the game is won or lost; the essence of writing is rewriting.”

– William Zinsser On Writing Well, 30th Anniversary Edition: An Informal Guide to Writing Nonfiction 

All writers need to read this short book, at least twice.

Writing is hard. It forces us to think harder than we want to. It feels like a tough clinical problem, which shouldn’t surprise us: writing and thinking fill medical practice.

Where to Start?

Start with what you know. Pain, frustration, and loss make powerful prose. Steal themes from great novels and make your writing fit the pattern. Write every day. Treat it like a serious job. Do not quit when times are good.

Patients notice doctors in the news, when negotiations fall apart, but rarely otherwise. This must change.  We need strong communication from doctors, even more in between contract talks.

While 82% of people want to write a book, only 15% do it. Doctors should write to help people understand what clinical care means, to offer insight on how solutions fit with the heart of medicine, and to shape the future of care around patients’ needs, not political designs.

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Necessary Ignorance

3 stoogesOne of the smartest men I knew had a grade 3 education.

He followed politics and current events. He toyed with bookish pastors who dropped by to convert him. He could build a house, fix a car, grow and store anything edible, and much more.

He embodied Heinlein’s vision:

A human being should be able to change a diaper, plan an invasion, butcher a hog, conn a ship, design a building, write a sonnet, balance accounts, build a wall, set a bone, comfort the dying, take orders, give orders, cooperate, act alone, solve equations, analyze a new problem, pitch manure, program a computer, cook a tasty meal, fight efficiently, die gallantly.

Specialization is for insects.

Never Enough Measurement

We discussed measurement in Medicine is Relationship, Not Quality Metrics.  It sparked a thoughtful guest post: It’s Not a Choice, Good Quality Requires Relationships and Measurement.

Measurement hogs the microphone in healthcare. Anyone who questions measurement gets labeled a Luddite. They must favour ignorance, or anarchy.

Before we dismiss the Luddites, listen to their question:

Can we trust our capacity to measure everything we need to make great decisions?

Each day, 320,000 patient visits produce millions of data points in Ontario. In one day.

Measurement starts to look like a teacup scooped from an ocean of information.

Those who question the role of measurement want more information, not less. They do not disagree with measurement per se.

Necessary Ignorance

The economist Hayek said that everyone has a necessary and irremediable ignorance.

Rational decision-making demands knowledge of available and relevant facts.

But it is impossible to know all the ‘millions of facts, which in their entirety are not known to anybody,’ Hayek said.

Hayek believed we make better decisions using widely dispersed fragments of knowledge, not better quality knowledge for a few smart controllers.

( Ref. T. Sowell, A Conflict of Visions: Ideological Origins of Political Struggles).

Brilliant Elites vs Ignorant Plebes

“How much measurement do we need?”

Heretics question the primacy of measurements in decision-making. Spreadsheets and scatter-plots leave too much unmeasured.

No one is smart enough to control a whole industry using primarily measurement and audit. We need the billions of data points from all patient care decisions.

Millions of decisions made every day offer a better source of information. Front line doctors and patients possess and create information with every choice they make.

A small group of elites will never know this ocean of information, no matter how big their brains are.

We all want a great healthcare system. True greatness comes when system leaders embrace their necessary ignorance.

Certainly, keep measuring. But we should put more trust in the unmeasurable information guiding patient care at the front lines.

Doctors and patients are uneducated in policy and politics. But they are not stupid. Perhaps we should listen to them. Let them make more decisions using information that system planners will never know.

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