For the most part, doctors want this too. The trouble comes with how to make it happen. It tangles our visions of ideal medical care, politics and doctors’ collective action into a massive challenge with a scary future.
There are 3 parts to the challenge.
- Idealized visions stand at opposite ends of a care spectrum.
- Politicians craft healthcare solutions along partisan lines.
- Doctors collectively respond to the solutions.
Lets start with two visions of medical care:
Medical Dream #1
- Salaried doctors with pensions and benefits.
- Standardized visits.
- Protocol-ized treatment.
- Maximum decision support.
- Quality by design.
- Doctors as clinicians, not managers.
- Doctors diagnose and treat.
Medical Dream #2
- Doctors as small business owners.
- Individualized patient visits.
- Individualized treatment informed by evidence.
- Quality by incentives, flexible design.
- Doctors as professionals in the fullest sense, not solely clinicians.
- Doctors diagnose, treat, lead, oversee and manage.
Of course, the dreams overlap and blur into dozens of options. Those who support vision 1 tend to believe we should fund it with higher taxes, lower fees for high billing doctors and lower incomes for MDs overall. Vision 1 requires greater government control.
Problems with #1
- Doctors become clock-watchers attuned to breaks and quitting time.
- Wait times soar.
- Not sensitive to individual patient need.
- Docs see fewer patients; need more docs = higher costs/patient
- Demoralizing to professionals.
- Doctors stop thinking and just follow the rules.
- Removing input makes physicians ignore system issues. Why bother?
Problems with #2
- What patients want is not always the same as medical need.
- Many doctors hate business.
- Might reward cutting corners.
- Busy doctors earning high incomes inflames public envy.
- Individualized therapy costs more than guideline-based treatment.
Faced with different medical dreams, politicians work to blend the best of both approaches, slanted toward their political ideal, all in a socialized setting. This compromise works okay when times are good but falls apart under pressure.
Picture a 250 lb. football player and a 100 lb. ballerina as a team in a three-legged race. Inevitably, the brute throws a sweaty arm around his partner to carry or drag her to victory.
As government runs out of money, politicians swing doctors into their bureaucratic axillae to get things done.
As Good as It Got
In many ways, we have lived through healthcare utopia. Medicare used to let doctors work like local grocery store owners, while bureaucrats coordinated supplies and infrastructure. The College of Physicians and Surgeons contented itself with catching the really bad guys and leaving grocers to their vegetables.
Times have changed. Government now wants to run the grocery stores, and the College wants to go through the grocers’ laundry. Brazen reporters demand politicians do their bidding. Politicians click their heels and obey to avoid a drop in public opinion polls.
A Brute of Our Own
In the face of power imbalance, eventually, someone fights back. The ballerinas of the world find their own brutes to team up with the footballers. Ontario’s doctors will do the same.
Police, nurses and teachers’ unions win consistent raises while doctors get 5 years of cuts. Despite tyranny, inefficiency, and entitled greed of some union bosses, many doctors want a bossy, greedy, mercenary union to fight for them. They would love to have union reps fight every little workplace grievance. Doctors want a gorilla to fight all the other (unionized) stakeholders in the system.
Public sector unionization rises above 74% in Canada. Political campaign managers estimate 30% of voters are union members. As dependancy ratios continue to creep up, voters will support parties that promise handouts.
A big, fat Ontario Medial Association Union is almost inevitable in this environment. It will flex and bloat and crush everything. It will support governments that wink at big labour with higher taxes. It will shape Ontario’s future, not just for healthcare.
A well-funded union of 35,000 physicians will ensure all change swerves left towards bigger government and more control. Political parties will only win if they kiss big labour. It’s unclear whether this will help healthcare, but maybe it’s what Premier Wynne planned all along?
photo credit: GP Contract Changes May Hit Services, Says Doctors’ Union TheGuardian.com