Physicians frustrate governments. Doctors think too little about how much care costs and too much about patients who need help.
The Government of Ontario and the Ontario Medical Association arrived at a mediated Proposed Physicians Services Agreement (PPSA) this month. Doctors vote on it on March 22 – 27.
On March 28, we find out whether doctors will accept the agreement or send it to arbitration.
Labour negotiations give government its best chance to manage the $14 billion spent in Ontario on medical services (2020-21). Contracts offer a way to control doctors’ behaviour. Medical services agreements are the heart of central planning in Canada.
A Mediated PPSA
Government does not care about doctors’ incomes, nor should it.
Doctors are at high risk for becoming bossy — especially towards their colleagues. Otherwise kind, rational doctors can become tyrants in the face of chaos and fear.
If we were hunting for bossy docs, we might start with medical leaders and physicians in niche specialities.
External Causes
Leadership carries a high risk for bossiness.
Some medical Chiefs gain humility from caring for sick complex patients. It shapes their approach to leadership. Unfortunately, many forget their failures. Others never learned in the first place.
Many Chiefs of Staff have never seen sick patients at all. But as Chief, they see all the medical disasters and deal with the most difficult doctors. They run the risk of thinking all docs are difficult and basically failures waiting to happen.
Like leadership, some specialities are also more likely to foster bossiness. Niches with low medical risk and high paternalism present the biggest risk. These docs never see sick patients but spend all day giving definitive advice.
However, chiefs and niches do not explain enough. Not all docs become bossy from being chief or a member of a medical niche.
Blaming bossiness on a chief-niche explanation assumes an external locus of control: bossy docs were victims of a bossiness-inducing environment.
7 Reasons Why Some Doctors Become Bossy
We could also assume an internal locus of control. What goes on inside a doctor to make him/her so bossy?
A. Good intentions
Children torture kittens with cute outfits, “Because Kitty likes it.”
Parents torture children with cute outfits, “Because it makes you look smart, dear.”
Politicians torture citizens with things they would never choose themselves — so-called merit goods.
Doctors do the same.
“Of all tyrannies, a tyranny sincerely exercised for the good of its victims may be the most oppressive. It would be better to live under robber barons than under omnipotent moral busybodies.
The robber baron’s cruelty may sometimes sleep, his cupidity may at some point be satiated; but those who torment us for our own good will torment us without end for they do so with the approval of their own conscience.”
CS Lewis
B.Habit
Many doctors give orders for a living.
A group of us asked a young cardiac surgeon about life with his new baby. Had he changed any diapers yet?
In a heavy accident, he said:
“Oh sure. I call my wife. She comes. I hold out my hand, like this.”
He held out hand, palm up.
“Then I say, ‘Wet wipes!’ And she give it.
‘Lotion!’ And she give it.
‘Diaper!…’
Just like surgery.”
C. Prudence
Most doctors are practical. Especially in procedural specialties, we use the shortest path between intervention and outcome.
Barking orders wastes less time than decision by committee.
D. Ignorance
Doctors do not study leadership to become doctors. Aside from loads of math and science, most doctors do not study much of anything else. Medicine demands total commitment without room for non-clinical things.
E. Hubris
Many docs assume they are so much smarter than everyone else that they should be the boss.
F. Arrogance
Arrogance goes beyond hubris. Some doctors cannot tolerate anyone else in control. They hold others in disdain.
G. Maleficence
A few doctors hate their colleagues. They want to cause pain. A position of power, such as Chief of Staff, lets them exercise their wish.
Hubris, arrogance, and maleficence are less common, but we have to admit they exist.
Helpful Bossiness
Many situations demand a level of control which looks bossy. In this sense, bossiness may not be bad in itself, only when misapplied.
It is a bit like debridement. Dead tissue needs to be cut off to save the healthy bits underneath. Cutting too little is bad. Removing vital parts is worse.
Fortunately, only rare wounds need major debridement. Most need a light cleaning or nothing at all. Too often people use bossiness when it is not necessary — like debriding healthy tissue.
Internal Cause, External Opportunity
Pandemic chaos and fear created a petri dish for bossiness. It turned some otherwise rational doctors into dictators.
COVID gave literal or social media microphones to some very bossy docs. Politicians deferred to a handful of experts. No one dared speak against them. The few who did faced punishment.
As pandemic fear subsides and normal chaos returns, we should ask:
Who were the bossiest docs?
Who needs counselling after losing their COVID pulpit?
Can we protect ourselves from bossy docs in the future?
Some docs are just born bossy. They use power to work out their own issues. But we don’t need to let them ruin our lives in the process.
Public health doctors created vaccination mandates and vaccine passports. Doctors tabled the ideas. Politicians followed doctors’ advice and turned it into policy.
Ideas shaped the policy, and policy formed a protest. Public policy made the Truckers’ Freedom Convoy a reality. Prime Minister Trudeau’s response to the protest turned the protest into a global movement.
The historic events of the last four weeks required more than just public health or politics alone. They needed public health plus politics, doctors plus politicians, authoritarian thinking plus authoritarian political response.
Doctors in Authority or Authoritarian Doctors?
Public health doctors follow their own ethic, which other doctors find unethical. Public health seeks to do the greatest good for the greatest number of people. Other doctors try to do the greatest good for the individual patient in front of them.
Doctors who treat individual patients focus on patient autonomy and informed consent above all other goals. Autonomy and consent define what morality means in medicine. It is immoral to treat patients for any other reason than their own good and with their full consent.
Public health doctors, who “treat” populations, ignore autonomy and consent by design – these ideas mean nothing if a vaccine mandate might help the majority. According to public health, we must always do what benefits the majority, even if it causes some harm to a few. Not taking action is itself immoral, if action might benefit the whole population.
Friction between public and personal health is not new. Evidence and open debate have resolved the tension in the past. Well-known riots about Smallpox vaccination stand out as a rare failure, not the norm we should expect.
