Political Vision Must Come Before Negotiation

The movie, It’s a Wonderful Life, is a political thriller, despite all the crying, hugging and cuteness.

At its core, the movie portrays a battle of political visions.

Will George Bailey accept Mr. Potter’s salary in exchange for Mr. Potter’s iron control of Bailey’s Savings and Loan?

Will George stand up for his own political vision, of small loans for his neighbours, or will he sacrifice his integrity for Mr. Potter’s vision of control and serfdom under Potter?

The movie pivots on George’s refusal to accept Potter’s vision of reality.

The following 2 minute, 30 second clip captures the struggle:

Selling Out

Once surrendered, integrity is almost impossible to regain. Some say doctors have surrendered too much already. We gave in years ago: Better to compromise and get a raise than lose a fight and suffer more fee cuts!

Winston Churchill once asked a socialite if she would sleep with him for 5 million pounds.

The woman said, “My goodness, Mr. Churchill…Well, I suppose…We would have to discuss the terms, of course…”

Then Churchill asked if she’d sleep with him for 5 pounds.

The socialite said, “Mr. Churchill, What kind of woman do you think I am?!”

Churchill replied, “Madam, we’ve already established that. Now we are haggling about the price.”

Prostitution has two meanings. Most people focus on the legal definition: sex for money. But prostitution means much more. It also means “the unworthy or corrupt use of one’s talents for the sake of personal or financial gain.

Doctors need political vision to avoid prostituting themselves for a good fee deal. How much will doctors sacrifice for a fee increase?

If George Bailey did not have a political vision for the Savings and Loan before Potter made his offer, George would have signed the deal. But he stopped mid-handshake. Potter yelled at him, “Confound it! Are you afraid of success?!”

New Rules for Negotiations

Negotiations used to be about doctors asking for fees and government deciding how much it could pay. Now, negotiations are about how much doctors will sacrifice for the fees government offers.

Government wants control: hours, access, types of patients and much more.

Government is no longer satisfied to let fees and patient need determine MD behaviour. Government wants to pay for MD behaviour to make embarrassing problems disappear for government.

In this new world of negotiations, doctors must ask:

What is non-negotiable?

What will integrity not allow, no matter how sweet the offer?

Even without details, doctors need a sense of how much they can sacrifice, before they hear Potter’s offer. Doctors need a political vision, before negotiating. Making a deal should not come before crafting a clear political vision.

Apolitical

Over the last year, a number of people have declared themselves apolitical. It suggests they are untainted by politics: They hold a virtuous innocence about political theory. They banter about political ideas, but only the way grownups tolerate babies on airplanes.

Saying you are apolitical is like saying you do not breath.

Saying you are apolitical is like saying there was no ‘in-crowd’ in high school. If you could not see the in-crowd, then you probably were part of it.

Saying you have no political opinion is to have a political opinion. This attitude serves to advance the current political vision of liberalism, which holds that you can do whatever you want as long as you do not hurt anyone, but at the same time, the state should control everything else (libertarian socialism).

Too Political

People bemoan the chaos caused by linking healthcare to election cycles.  Some want a separate governing agency, something like the Bank of Canada.

But “apolitical healthcare” is a political position itself.

Every opinion about each issue in healthcare presupposes a political philosophy. We cannot discuss access, self-regulation, quality, innovation or any other issue in healthcare without advancing a political vision.

“The ideas of economists and political philosophers, both when they are right and when they are wrong, are more powerful than is commonly understood. Indeed the world is ruled by little else. Practical men [and women], who believe themselves to be quite exempt from any intellectual influences, are usually the slaves of some defunct economist.

  • – Lord Keynes

Doctors miss the point if they only address issues and not ideas. Medical politics is about ideas, not just issues.

Premier Kathleen Wynne isn’t just an activist for certain issues. She has a vision of what society should look like. She wants to reshape Ontario into her vision of reality. She wants to reshape how people interact and how people understand their relationship with government.

Political Vision

Doctors need their own political vision. They need a grand sense of what they want their profession to look like in society, even if that vision includes a reality that is messy and wild, like real life.

Doctors should ask:

Do they want medicine to be a technocracy: a monopoly of technicians?

Do they want medicine to be a messy society of innovators?

Do they want medicine to look like an aristocracy with tradition, rules and institutions?

Do doctors want to be serfs, merchants, priests or independent professionals?

Without a political vision for medicine–some defining narrative–doctors will always appear reactive to the vision advanced by the current government. Doctors will continue to spin and wobble, hit by issues that punch from so many directions at once.

You can count on this: Government will seek to build on its own political vision in negotiations.

Doctors must form a political vision and advocate for it without apology. We need to build our medical associations into vehicles that advance our vision.

Right now, our vision is soft. All we want is as much as the government will give so that we can keep seeing patients. That’s not good enough. It means doctors are for sale; nothing is off limits. This approach degrades us. We must stop prostituting ourselves to someone else’s political vision.

George Bailey had a clear sense of how he thought life should work. He knew what to fight for. He knew the battle did not lie with the issue in front of him but with the political vision behind the issue. Will doctors find their limits before government starts negotiating fees?

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14 Replies to “Political Vision Must Come Before Negotiation”

  1. Effective negotiation strategy is based on clarity and consensus about your envisioned future and core values. Ineffective negotion strategy is based on reaction to the other party’s envisioned future and values. The most effective negotiation strategy is for the parties to agree on an envisioned future and values and then problem.solve the best way to get there.

    1. Glenn,

      How come you can always summarize a whole page of my rambling into 1 or 2 sentences? Brilliant!

      I love the idea of shared future and values. Sure hope this happens…

      Thanks so much for taking time to share a comment!

      Shawn

    2. When the goals of both sides are the same or even relatively close then compromise works. If they are not then “Might is Right.”A war is only over when BOTH sides say it is.

  2. In prostituion one sells themself for money, presumably as much money as they can get. The buyer and seller agree on what is exchanged. In a sense they are even footing and hence come to an agreement. Our negotiations with government aren’t quite the same. On our side, the conscripts argue and desire freedom, on the government side they want to deny us our freedom and pay us peanuts. In fact they would like us to pay them, see the fPSA. Arguing for money isn’t prostitution, accepting the government’s interference in our profession is prostitution. Our goals and interests are not the same. We want to make money by practicing our valued profession in the way we have determined is best. The government wants to be elected, and meet some arbitrary number in a budget that was arrived at without considering if that budget is enough to meet the needs of the population. They are not interested in the population as individuals, just as votes. We are not on the same page and further we have not defined what is on our page. We haven’t done the logical thing by asking ourselves ‘what do we want?’.
    I am not political because I wont sell my allegiance to a party that then stabs us in the back. I want us to be suprapolitical if I can coin the phrase. To be above politics but feared by all politicians. If only we could realize that we have value and are not begging for table scraps and minor adjustments. We want change, we want to be compensated according to our real value. If the government cant afford that in their arbitrary budget number, then they should let the public make up the difference in co-payments for use. The Canada Health Act lays it out pretty clearly it states that if the province bans extra billing then we have to have binding arbitration. The province banned extra billing but never gave us the ‘guarantee’ of binding arbitration. Clearly if we dont have BA we must have Extra Billing. Its right there in the CHA.

    1. This is a fantastic string of comments, Ernest!

      I really like this line: “Arguing for money isn’t prostitution, accepting the government’s interference in our profession is prostitution.” In the same paragraph, you raise another excellent point: Government is “not interested in the populations as individuals, just votes.”

      You raise a great discussion about being political. Thanks for opening this topic. I agree with you about political parties. Parties often have very little to do with the philosophy whose name the party adopts. Liberals are no longer the party of liberty. Conservatives often want to conserve big government, the very thing they are supposed to distrust. We need to get at the ideas themselves, not the parties that assume to campaign under a particular flag.

      For example, you share many of your political views in the two paragraphs you just wrote. You believe that buyers and sellers should agree on prices, not a guild, monopoly or cartel. You believe in freedom of work and freedom of association. You believe in hard work and reaping the rewards thereof; in serving people as individuals; in integrity and honouring your word (“stabs us in the back”); in democracy; in living up to one’s commitments; in logic, reason, honesty and much more. In fact, you lay out a very robust political vision. If doctors could start even with what you’ve just written, we’d have something to rally around.

      This is my point about political vision. We need to get at the ideas you present here, debate them and then agree on what’s non-negotiable. The problem with our current situation is that–believe it or not–many doctors do not agree, or have not thought about, the ideas you present.

      Thanks so much for digging into this! You brought out exactly what I’d hoped would surface. I’m not calling for discussions about political parties. Two parties with the same label could hold opposite views. Sometimes a Liberal party looks more conservative than the Conservative party and vice versa. We can’t discuss parties. We need to discuss exactly the ideas you’ve raised in your note. And we need to do it before negotiations.

      Thanks again!

      Shawn

      1. Hi shawn
        As always a beautifully written piece. Until last year I was not interested in the politics of medicine, I was just trying to make my way through my day and offering the best I could to my pts. However when I realized my fees had been cut by 30% I could not hide my head in the sand and hope for the best. Once I realized how duplicitous and outright illegal the government was behaving, it finally sunk in that I was no longer on the top of the game. I was simply a cog in a very big wheel and had zero autonomy. This spurred me into action and I am now elected to council. At my age, I never expected to be fighting with government and my organization to maintain even what little autonomy remains. I am older,I should be getting into retirement mode but I graduated medical school at 43 years old so I’m still paying off my student debt. I will likely never retire and that is fine because I love my job, I went into medicine because it was a craving that nothing else could quell. That is why this hurts so much. It is not only about money, it is about respect, professionalism, equality with other professionals and autonomy to do what is right between me and my patients. The government has no position in my exm room ! Let me say that again… THE GOVERNMENTHAS NO POSITION IN THE EXAM ROOM!! It is as simple as that. That is what we really want and that should be our core value. It is simple for everyone to understand. It is our patient doctor relationships which sets us apart from any other profession and is the one thing this government is hell bent on destroying. We need to have consensus between doctors and when you remove all of the noise about “governance and relativity and bill this that and the other”, what we really want is our doctor patient relationship and the freedom to practice our very special skills. Not the most eloquent response but I am just so passionate about this. We are literally in the fight of our lives!!

        1. I disagree, Sam. Yours was a MOST eloquent response!

          You packed in your story about life change, your vision for care, and why this all matters into one coherent comment. Brilliant. You speak for many doctors. We just want to see our patients, and our patients want that too. Patients don’t want bureaucrats dictating care.

          Your passion inspires! Thank you so much for taking time to share this. I hope it inspires other docs who’ve spent their careers ignoring medical politics. We can’t ignore it any longer.

          Looking forward to seeing you at council. Please come over and say hello!

          Talk soon,

          Shawn

        2. I am glad to hear that are continuing the fight, Sam. The last straw for me was the government’s disrespect of ALL Ontario physicians who feel and act as you do and so I retired one year ago.

          As one who has always tried to act ethically, responsibly and do the best for my patients as well, I will continue to fight for the rights and dignity of my profession in my retirement for the same reasons that you have so eloquently stated: “[It hurt] so much. It is not only about money, it is about respect, professionalism, equality with other professionals and autonomy.”

  3. There can be no consensus, but for boadest possible items, when the shop floor has members with distinctly different agendas. The OMA attempts to present itself as a representative for a group of tradesmen with as little as 3 years of medical school in common. Its akin to plumbers and glass blowers banding together.

    The process of seeking a negotiated agreement has failed to meet shop floor needs. In part this is due to the “vote count” of acceptance. As agreement is approached horse trading deletes lesser interests until by some margin an understanding is deemed acceptable and applied to both parties.

    With this approach matters affecting a large group not serving as an obstacle to an agreement are sacrificed. In case you don’t get this point, let me simply state counting votes and weighing importance of minority interests is not the same.

    To paraphrase the Honourable Kim Campbell, some things can not be resolved by voting. And, I would add, never can be. Unfortunately the same process repeated in perpetuity will not lead to a different outcome.

    The OMA should be dismantled and groups with sufficient commonality should assemble to address their specific needs. Without such reformulation the concerns of minorities as simply dismissed as dissatisfaction with outcome. Some matters such as relativity or fee schedule modernization can not be adequately addressed.

    1. Thanks for sharing such a thoughtful comment, Ed. You raise some excellent points!

      Mob democracy is just as tyrannous as a dictatorship or oligarchy. We should resist it. I believe that representative democracy based on a constitution of shared set of values works best to protect minority interests. It also protects us from the tyranny that comes from the concentration of power.

      Your points about having more than one medical voice deserve debate. Many docs in smaller sections still feel that they are better off if they can get the behemoth collective to attend to the needs of the small sections, too. If all members of a section want to secede and form a new organization, I think we should hear their argument. In the past, I’ve found OMA Council to be very responsive to small sections who organize themselves well enough to get their message heard.

      You aren’t the first person to raise this. I think we should debate it and not pretend it isn’t an issue. I think small sections would be better off being part of a representative democracy based on a constitution. That’s why I’ve been calling for a political vision, in other words, a constitution. But if this is not possible, I don’t blame people for making the comments you’ve shared.

      Thanks so much for taking time to share such a thoughtful and difficult problem!

      Best regards,

      Shawn

  4. By demanding that the common goal should be an evidence based world class health care system, ie a hybrid symbiotic public/ private health care system as per the world’s top rated systems, it would put the government’s feet ( and those of the ideologically driven statists) to the fire.

    The WHO had last rated Canada’s health care system as being #30 in the world with the USA at #37 and with Colombia rated at #26 being the top in this hemisphere,

    With France’s hybrid public/ private health care system rated as being at #1 in the world , one wonders if its territories in the Americas: Martinique, Guadeloupe, French Guiana, St Pierre and Miquelon, St Martin and St Barthélemy all of which enjoy the same status as France with its laws and regulations , it would place them as enjoying the #1 health care system in the Americas?

    1. Great points about evidence, Andris. We don’t have any argument if we compare our performance to other countries.

      Having said that, just because other countries perform better does not mean we should try to copy them exactly. Human systems usually reflect the culture of the humans working inside them. I firmly believe that we need change, but I also believe that we need a ‘made in Canada’ approach. There are things about many of the European countries’ approaches to governance that makes me cringe.

      I agree, though, we should start with the evidence. Our performance is embarrassing.

      Thanks again!

      Shawn

      1. Certainly we should not slavishly follow the policies of the top ranked health care systems of the world ….but they should at least rhyme.

        But ” evidence based” is a hammer that we should be using….there is nothing evidence based about Bill 41, about LHINs and Mini LHINs….there is no evidence that the huge number of health care bureaucrats that we have and plan to have is appropriate….Germany managing its more effective health care system with a health care bureaucrat to citizen ratio of 1 per 15,000 Germans to our Canadian 1: 1, 400 ratio.

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