[Mea Culpa: The first draft of this post gave the wrong message through my flu-tinged haze. I hope this works better.]
Fans love The Force Awakens and forked out millions to see it. The newest Star Wars movie played true to its roots and offered hope for something better.
Producers know what to deliver next, as fans wait for the next episode.
Doctors need the same clarity.
Agreed to Walk Together
One of ‘Canada’s best writers’, George Jonas, died this month. He was an ardent defender of freedom, a critic of tyranny.
Jonas said Canada was modern Europe’s transatlantic outpost, “the glossiest, the most sophisticated, and the most up-to-date version of the illiberal state.” (see Beethoven’s Mask
What does that have to do with modern healthcare? Liberty, or the state, elicits a few patronizing smirks in medical politics. Liberty is out of style.
Wicked Nonsense?
If government wants to walk south, and doctors want to walk west, is it compromise to walk southwest? Or is that walking in an entirely different direction?
Wicked questions ask, “How can we walk both South and West at the same time?” As much as we love them, wicked questions sometimes lead to absurd ends, nonsense.
Decimation
Doctors bore a decade of deep cuts, clawbacks, and arbitrary caps in the 1990s’ social contract years in Ontario. By the early 2000s, over 2 million patients had no family doc. Those lucky enough to find one often drove over 90 minutes to an urban clinic.
Students avoided family medicine: they even left the country to train in any another specialty.
People talked about the end of family medicine. Doctors took jobs anywhere else but in comprehensive care. It was beyond desperate – hopeless decimation.
Negotiations’ Enigma
From a position of demoralized desperation, doctors came up with a plan to negotiate with government.
1) Find out which direction government wants to go.
2) Get as much as possible out of government for agreeing to the government’s plans.
Compromise worked. Many hail the 2004 and 2008 contracts to have rescued Family Medicine, in Ontario. After a decade of cuts, doctors’ business earnings started to catch up with inflation.
Doctors ignored where the government was headed. Why worry about old-fashioned things like autonomy and professionalism? Legislation, regulation, and simpler contracts seemed irrelevant, quaint.
But 2012 marked a sharp change. The government started cutting and has continued to cut fees every year since, erasing gains from 2008.
Of course, government did not reverse contract details that worked to its benefit. The golden goose took back most of its eggs but left its droppings.
A New Hope
Doctors need a clear vision on where they want to go from here.
- Do MDs believe in old-fashioned ideas like the doctor patient relationship?
- Do doctors believe in politically incorrect ideas like liberty, hard work, and reward for delayed gratification?
Doctors need to get very clear about what we believe and figure out an attractive way to package it. We need to invite attacks to our ideas about innovation and prepare to defend them.
Docs are often too scared to discuss system change, because someone might accuse us of being self-serving.
Doctors cannot let government rule by inciting a frenzy of envy each time we try to discuss system innovation. Government owns the congenial myth of wealthy doctors. Let them have it. We’ll never win on that front.
We are paralyzed worrying about what the public thinks. It gets us nowhere. Patients love us when we care for them. No amount of public support will carry doctors through cuts that compromise care.
We need a new hope. We need a vision to fight for: something that doctors articulate, not something that government dictates.
We need hope that stays true to our medical roots, as a profession sworn to help patients and not compromise by letting bureaucracy come before patient care.
Our patients want something to look forward to. Let’s hope we come up with our own vision soon.
Lots of powerful food for thought here. The medical profession, along with other health professions, should be engaged in a continual search for innovative change that will improve patient care and enhance the value that we all receive as taxpayers for our investment in healthcare in Canada. Just one note of caution in response to Dr. Whatley’s fine blog – resist the temptation of demonizing governments and public servants. Back in 1979-80 I served as President of the Saskatchewan Medical Association and it was an era in which the SMA constantly attacked and berated the government. I did so very effectively as SMA President and was proud of my work. In subsequent years the SMA discovered that it could better serve patients by working collaboratively with government. As I look back on press clippings from my fierce attacks on the government in 1979-80, I am embarrassed. I used to (very unfairly) label most public servants as nameless members of unproductive bureaucracy. But some years later, through service in a leadership role in which I worked with such public servants, I came to appreciate their worth and recognized that they were as committed to good patient care as I was as a doctor. While sometimes both governments and the medical profession will act in ways that alienate one another, we need to establish and sustain mutually respectful working relationships.
Very thoughtful, generous advice, Dr. Kendel! Thank you for sharing it so gently.
Villains make great writing. But villainizing does not solve problems. Wise advice indeed; I will take it to heart.
I sure appreciate you taking time to read and share your thoughts. Readers love the comments – especially when comments push back so thoughtfully!
Thanks for all you continue to do for healthcare in Canada.
Highest regards,
Shawn
I wonder Dr Kendall what was the ratio of healthcare bureaucrats to patients in those days? Todays bureaucracy dwarfs what it was in the 80’s. We have needless redundancy and layering that ends up serving no useful purpose but to burn up resources that ought to go the provision of care for patients. Yes that includes Doctor’s Salaries. I agree with Shawn about public opinion, it is not as important as our association makes it out to be. Public opinion is why the OMA’s attempts at leveraging government to our advantage is so anemic. If we took job action, the public might be put out with us, but afterwards they would be right back in our offices seeking our care. The second-tier of allied health professionals are not capable or trusted enough to replace us. People want doctors and are miffed that they pay taxes thinking they are buying healthcare when what they get are tons of wasted boondoggles and endless self-serving bureaucracy
Great comment: strong, articulate, and clear.
I fear losing any public support we might have by waiting as cuts continue to compromise our ability to provide care. Given Wynne’s cuts last spring, I have to seek work outside my clinic – a bit like a farmer having to take a job off the farm. It decreases access for patients. Not what I had planned. Until I can roster more patients, I’m stuck getting work elsewhere (I have 600 patients rostered).
You make great points about the number of bureaucrats, the inability of other ‘providers’ to replace everything we do, and the fact that this happens amidst waste and cover-ups.
As always, great to have to share a comment! Thanks so much for taking the time to do it. (I still hope to get to posting pdfs)
Best regards,
Shawn
I find it disappointing when medical colleagues describe all personnel in our health ministries as “bureaucrats”. This is a pejorative term. One of the dictionary definitions of “bureaucrat” is “an official who works by fixed routine without exercising intelligent judgement”. That is a very unfair and inaccurate characterization of the many intelligent and hardworking public servants I have met in Ministries of Health during the course of my career. I used to use the same flippant and insensitive language until I actually got to meet and work with many of the people whom I formerly described as “bureaucrats”.
In respect to the issue of waste, there is surely considerable waste of time and money in our healthcare system as there is in most complex systems.Such waste can be found both within non-clinical and clinical domains of our health system. Some waste is actually generated by poor medical judgement and inappropriate medical decision-making. We should strive to identify and reduce/eliminate waste wherever it is found. However we must resit any inclination to discount the value of a whole subset of personnel in our system by suggesting that their work invariably constitutes a waste of resources.
I often hear claims that our healthcare system would be infinitely more efficient and cost effective if it were run by doctors.There is some evidence in the health services literature to support the thesis that engaging doctors in senior health system management roles can yield efficiency gains.Some of the very impressive large integrated systems in the US, like Kaiser Permanente, do serve as excellent models. However, the impressive process efficiency and quality outcomes in systems like KP are also largely attributable to shared values and goals among all personnel including all medical clinicians.
It is noteworthy that the highest elected leadership role (Minister) and and the highest appointed role (Deputy Minister) in Ontario’s healthcare system are currently filled by physician colleagues.It would be wonderful if there could be alignment between the values and goals of these two distinguished physician colleagues and the entirety of the clinical medical workforce in Ontario. I can’t offer any magic plan for achieving that alignment. But I am certain of one thing. That goal will never be achieved by dismissing these colleagues as “bureaucrats” and publicly castigating their professional judgement and values.
Thank you, Dr. Kendel, for taking time to share some more!
I can see why you would find the term ‘bureaucrats’ offensive given the definition you shared. We need bureaucracy and bureaucrats in the best sense. I’ve always understood bureaucracy to mean what it was originally intended, and as used by Max Weber, et al.: a body of non-elected government (or corporate) officials (see Wiki). Just because we need some level of Weberian bureaucracy, does not mean we do not have too much already.
We often hear pundits talk about whether we have too many doctors, or whether they cost too much. We separate these concerns from the pundits’ personal feelings about whether doctors are lazy or unkind. So too, we should be able to discuss bureaucrats-government-workers-public-servants without indictment on their personal work habits or character. I have always tried to separate ad hominem from de facto argument.
A number of recent books tackle the role and nature of the ‘public service’. Is there such a thing today? How has it changed? How do non-stop election cycles with 24-7 media coverage change the nature of the public service?
Your use of the ‘highest elected leadership’ and ‘highest appointed role’ carries a veiled reprimand of anyone who dares to question the behaviour of such a high office. I appreciate your call to respect, professionalism, and assuming the best in others. It is precisely these virtues that lead many doctors, including myself, to question the moral standing of some of our elected colleagues who repeat blatant untruths in the popular media. Respect, after all, is tough to earn and easy to lose.
Again, I really value you taking the time to comment. Your perspective, as an experienced, expert outside observer, holds tremendous weight. I can only imagine that you have plenty of pressing issues to keep track of in your own province. Ontario’s concerns probably do not take up the bulk of your day. As a result, we cannot expect you to know the details of what has happened, and continues to happen, here in Ontario.
These discussions impact people. That’s what makes them so important and so powerful to discuss!
Thanks again for taking time to read and share.
Highest regards,
Shawn
Thanks for your thoughtful response to my reflections.
I want to assure you that I do not feel that colleagues in senior leadership roles sought be exempt from criticism. We should, however, not lose sight of the fact they are colleagues and seek,whenever possible, to work collaboratively with them.
You are quite right that I’m not in a position to be fully informed on all of the ongoing dynamics in Ontario. I just hope, for the sake of the patients and colleagues in Ontario a resolution to this impasse can soon be found.
Again, very well said, Dr. Kendal.
I share your desire for collaboration and your hope for a speedy resolution. Wise advice to repeat.
Thanks again!
Shawn