Medical Dreams, Doctors & Unionism

GPWe all want free, accessible, high-quality care close to home. Patients want to choose doctors who provide great service and avoid those who do not.

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.

  1. Idealized visions stand at opposite ends of a care spectrum.
  2. Politicians craft healthcare solutions along partisan lines.
  3. 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.
  • Inflexible.
  • 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.

Canadian Compromise

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

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Put Patients First – What Does It Mean & How Can We Do It?

Madteaparty“Then you should say what you mean,” the March Hare went on. 

“I do,” Alice hastily replied; “at least–at least I mean what I say–that’s the same thing, you know.” 

“Not the same thing a bit!” said the Hatter. “You might just as well say that “I see what I eat” is the same thing as “I eat what I see”!” 


Great healthcare systems put patients first; patients hold top priority.  How we view patients impacts treatment.  What then does “put patients first” mean?

  • Do we envision product placement, like ‘put magazines in front of customers’?
  • Or do we mean a ceremonial nod to a notion that germinated Medicare?
  • Or do we mean something like, “Go Blue Jays!”?

Individuals versus Herds

A system cannot put patients first.  A health care system cannot function by considering patients as individuals.  To design a service that cares for 11 million people, we ignore individuals and focus on herds.  We step away from the bedside and envision patients as discrete atomic units or numbers.

Furthermore, systems are impersonal. Only people put patients first.  Systems grow out of complex relationships between organizations, providers, suppliers, regulatory authorities, governments and a crowd of others.  Systems cannot put patients first without intent and effort.

Medicine is ineradicably individualistic.  The doctor-patient relationship defines medicine.   Unless a healthcare system intentionally measures its policies by whether or not it puts patients first, patients will get treated as members of a herd.

Put Patients First

It means we assign or attribute value to patients above innovation, budgets, quality, regulation, efficiency or any other important issue that systems tackle.  Patients must be seen as individuals with unique perspectives, genetic make-up and experience of disease and health; as units of social groups, communities and families; as members of society with complex roles to play in other patients’ lives.

It relates to how we consider patients when we think about healthcare systems and design.  It implies that our thoughts about process and efficiency place patients’ needs and unique expectations before system policy, budgets and regulatory restraints.

A vision for healthcare must start by adopting an intentional, arbitrary standard of putting patients first.  ‘Intentional’ because systems can function efficiently without considering patients.  ‘Arbitrary’ because systems can choose to not put patients first.  Next time we see heads nodding when you talk about putting patients first, make sure we say what we mean.


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Patient Interests Before Healthcare Finance

Patient Interests FirstConscientious providers get tied in knots balancing patient interests and healthcare sustainability.

We worry that Medicare won’t have money for the care patients need.

As the point of access for many patients, emergency providers feel pressured to manage system costs and make up for inefficiencies elsewhere, by putting costs before patient interests.

This has to stop.


Those who congratulate your parsimony disappear when you get sued for not ordering enough tests, providing enough care, or making patients wait.

After a medical disaster, you get no official support acknowledging overcrowding created an environment for bad outcomes.

Providers experience heart-wrenching cases:  mothers dying shortly after childbirth, toddlers who choke to death, kids clipped in traffic walking to school.

Sick patients create bad outcomes.

Sick patients require split second decisions that lie naked to dissection from the armchair of retrospect.

Emergency departments get ‘helped’ with hours of meetings and external reviews from one bad outcome, but no one – not one single person – wants to discuss egregious overcrowding and unconscionable waits that often play the major role in terrible outcomes.

No one.

Societal conscientiousness needs to be matched with our system leaders’ passion for change.  If bureaucrats want decreased emergency department use, they need to work on system redesign such that patients are attracted to seek care elsewhere.

Emergency providers should not bear the responsibility of rationing care for the whole system.

Focus on Patient Interests

Paradoxically, abandoning obsession with system citizenship ends up refocusing providers on patient interests.  It’s the first step to creating a more efficient emergency department.  Costs per case goes down, patients’ length of stay plummets, and adverse outcomes decrease.  EDs function best when we focus on patient interests and ignore fiscal/system peer pressure at the front line.


So, banish guilt.  If it will help your patients, order tests liberally, welcome them back for care, and put patient interests first.  It will improve the system for patients.


Have you tried to be a good citizen and avoided ordering a test?  Have patients ever come to harm as a result?  Please share your thoughts below.

(photo credit: Check out McMaster’s post on Geriatrics training.)

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