Shawn Whatley, Author at shawn whatley md

Doctors Decide Future of Healthcare May 1st

Like a scene from a teen dystopian flick, doctors in Ontario face a major decision. Do they stay on the government train that speeds deeper into bureaucracy? Or do they risk a jump for dreams of change?

Doctors must decide next weekend.

Do they believe that government knows best?
Do they really believe other countries outperform Canada?
Do doctors want more of the same, more central control?
Do they want substantive change?
Do doctors want to jump off the government train?
Is it even safe?

Doctors must choose, and they need an association to lead them.

Apolitical?

Some try to discuss healthcare and pretend the issues are apolitical. But even a short list of issues forces us to examine our political perspective:

Choice – Do we think patients should choose their physician or be assigned one?

Control – Should physicians find creative solutions to meet their patients’ needs, or should a central authority plan and implement solutions? Can we force complex systems into a complicated design?

Equality – Should worker’s compensation patients and veterans get early access to tests and have reserved beds in long-term care, or should everyone wait in the same line?

Excellence – Should patients get the best care from the most highly trained physicians, or should patients get most of their care from nurses and RPNs?

Access – Should elderly, rural patients have to drive over an hour into town to get simple blood-tests and ECGs, or should doctors be allowed to provide the service close to home (should it be funded)?

Rights – Should doctors accept arbitrary government cuts, or should docs have legal options to fight back? Should it be illegal for MDs to work outside Medicare in Ontario?

Services – should Medicare cover everything from infertility treatment to sex changes, or should it limit treatment to life-saving therapy and chronic disease?

Each of these, and dozens more, forces us to examine how we think society should function. Everyone wants great healthcare, but we differ on how to get it.

Doctors Decide Future

Doctors must choose. Not deciding is a choice for more of the same. We can stay on the government train and hope it’s headed for Elysium. Or we can jump off. Despite what our hearts tell us, change is actually more like stopping the train or choosing a different track.

I hope doctors realize the opportunity they face at the council meeting on May 1st. The puree of Green-NDP-Liberal-Conservative council members stands at the door of the train. They will have to choose. Can they?

Superlative Healthcare – The Small Office

Politicians dream of efficient healthcare. Patients look for service, access and quality. Physicians want freedom to deliver outstanding, high-quality care designed around patient needs, not bureaucracy. We all want superlative healthcare.

It already exists. Or at least it could, if we let it.

The secret does not lie with integration, IT, collaboration, transitions of care, prevention, oversight, quality management, screening, or all the other things you hear about. These all help and are necessary. But none of them can do everything.

The Secret to Superlative Healthcare

The small doctor’s office offers the best hope for patients, politicians and providers. Here’s an example:

A physician showed me her clinic recently. She holds the mortgage on 1000 square feet in a newer professional strip plaza and renovated it to hold up to 3 physicians (only 2 currently). Twenty-foot ceilings allow for a mezzanine. It is simple, clean, bright and attractive. She works 6 days per week, with one full time and one part-time secretary. A massage therapy clinic leases a mezzanine and offers easy access for her patients.

She knows all her patients – has a relationship with them – and wants to see them healthy. Her patients know she’s devoted to them. She shows it.

But she also wants efficiency. She knows that waste means fewer resources for her patients.

Owner Operator

If her patients need mental health services, in-office nursing care, or any other allied health service, why would we design a system that sends patients away from an office like hers?

If we funded this physician to hire a healthcare worker, we have every reason to expect that she’d apply the same expectations of patient-focused, high-quality, efficient care for the new staff.

Would she tolerate

Long breaks between patient visits?
Notes that require more time to write than time spent with patients?
Leaving appointments open on the schedule?

Never.

She would expect the same focus on patient service and efficiency that she applies to herself. Wasted resources mean fewer resources for other patients.

New Programs

So, why do bureaucrats insist on creating new behemoths, with weighty tomes of policies and procedures, so that allied health can ‘integrate’ with primary care, in a separate location? How does this help patients? Every new solution seems big, and wasteful.

Of course, not all offices run like the one described. But many do. The ones that do not, go out of business or move into government run clinics.

Superlative healthcare starts with small physician businesses. Ideology prevents government from ceding resources or control to physicians. Government wants to control as much as possible. It needs resources for the bureaucratic giants it designs and runs.

Small is Good for Patients

We do not use the excellence that already exists. Let’s let physicians lead and design care around patients’ needs. Let’s push government into a supportive role and let the front-line professionals meet the needs of patients they know and love.

Physicians could replace the work of many bureaucrats if they were allowed to manage resources through their own offices. The secret to superlative healthcare isn’t radical. It’s obvious. But it might require fewer bureaucratic jobs.

It’s difficult to get a man to understand something, when his salary depends on him not understanding it.

Upton Sinclair

photo credit: cnn.com

New Doctors & Unwanted Advice from Older MDs About Fee Cuts

After 10-15 years of university, new doctors have spent most of their lives feeling inferior to MDs in authority. Students often feel undermined but learn to make teachers look good without being obsequious. Nuanced flattery is a survival skill.

New doctors have spent 12,000 hours in training but continue to hone their skills for the first 5 years of practice. Graduates often take as many years to shed their deference of older doctors. Many never do.

Dr. Nadia Alam, a new doctor, wrote:

however, i’m curious. what do you say to those [older] docs who insist that “things are so much better than they used to be when every family doc was fee-for-service?” or, “i get paid a lot more now than i ever did before — i daren’t complain!” or, “i remember a decade ago when there were 20% fewer docs and we were paid 300% less than what we are now. we have made enormous gains. we should be grateful for our privileged position.”

i’ve only been in practice 5 years. i admit, i don’t know the entire history of medical politics in ontario. and i too hear the talk of pendulum swings etc etc. i’m still furious at the government’s bullying tactics. if the government were to negotiate fairly on equal grounds, i would not be as pissed off or disappointed by them as i am. but i also get frustrated at the complacency i see among fellow colleagues when i try to bring up healthcare reform — i almost feel as if i’m being patted on the head like a fussy child: “there, there, give it a few years and you’ll come around.”

I discussed this with a mid-career physician.

He nodded and agreed things were bad for new doctors. “But they can still bill fee for service,“ he said. “That’s what I had to do.”

I mentioned that the A007 has barely changed for 10 years at $33 per visit. Inflation made A007 largely irrelevant as fee for service (FFS) got left behind to primary care reform. Premier Wynne axed the reforms. To suggest new grads could return to bill 10 year old fees that were woefully out of date 10 years ago is heartless and cruel.

“There just isn’t enough money in the system,” he said. “We have to cut somewhere.“

Even if FFS was a viable option, a mid-career MD should have enough sense to see the panic new grads face at digging out of $200k of debt using $33 per patient. On top of this, older doctors have never experienced unilateral legislated cuts like these. Despite attempts at analogy, this is unprecedented. If older doctors cannot manage outrage on behalf of new grads, maybe they should choose empathic silence?

Society defines itself by how it treats its most vulnerable.

Premier Wynne attacked new graduates. She attacks those who cannot fight back. If we will not decry the Liberal barrage on new graduates, older doctors might be better off keeping quiet.

photo credit: fhs.mcmaster.ca