Author: Shawn Whatley

The Canadian Medical Association ended its Annual General Meeting in Ottawa today.  After pages of motions, speeches and procedure, I noticed:

Doctors like rules.

They want rules, guidelines and policy to drive change.

• Is that because physicians are paternalistic and think everyone else too stupid to decide without a rule to follow?
• Is it because Canadians prefer rules and doctors just follow culture?
• Perhaps governments listen when citizens ask for rules and guidelines?

Controlling Innovation

New ideas grow in clear soil.  Disruptive innovation breaks rules and paradigms.  Guideline-makers scramble to keep up with new ideas forcing them into new guidelines.  Guidelines support enforced conformity.  Innovation, by definition, grows outside rigid controls or breaks rules to generate new things.

Innovation resists control.  Progress requires freedom.

Loving control

CMA delegates spent 3 days asking for controls and rules on everything from smoking pot to smoking wood stoves.  Delegate motions add up to a long list of things doctors oppose or want controlled.  Very few motions called for freedom.

Physicians supported freedom in affirming doctors’ right to not perform euthanasia if it became legal.  Delegates support doctors’ freedom.

A great society

What will give us the best country possible?  Do we get the best society by crafting dozens of rules about things we oppose and legislating things we approve?  Do we get the best society by continually shaping towards a vision, a utopian dream?

What other countries have tried pursuing dreams of perfection?  Do citizens have better lives in countries with more control, more rules?

Good Intentions

Physicians entered medicine to help patients.  Doctors spend their lives telling patients what they believe will benefit patients.

Governments politicate to help citizens.  Governments make rules they think will benefit citizens.

But patients can ignore doctors’ advice for healthy living.  Citizens cannot ignore the government’s rules. What seems moral and right to advise at the bedside is totalitarian if imposed by the state.

Forcing Good Health?

Canadian physicians petitioning government for rules (often) unwittingly promote a specific political philosophy.  The Canadian Medical Association must consider the politics it unintentionally promotes by seeking legislation for good intentions.

Physicians uphold patient autonomy far above the best medical science.  Doctors might consider whether their love of rules and legislation is an affront to patient freedom and autonomy.  Are we promoting:

Ideas so good they have to be mandatory?

 

Rona Ambrose, then federal Minister of Health Canada, spoke to several hundred doctors at CMA annual meeting in August 2014.

“Facts must guide public policy.  We know medicine is an art and a science, but we need science to guide public policy.” (not exact quote)

What did she mean? Why say it?

• Only facts matter?
• Docs are all logical positivists?
• Science matters more than any other source of knowledge?

Indeed, physicians tend to elevate scientific validity far above information from any other “-ology”; psychology, sociology, history, law, economics… Putting science above and before all else is scientism.  Scientism sees medicine as a technologic endeavour.  Medicine becomes nothing but a technological product.

Bureaucrats know how to control technological products.

“Where ends are agreed, the only questions left are those of means, and these are not political but technical, that is to say, capable of being settled by experts or machines, like arguments between engineers or doctors. That is why those who put their faith in some immense, world-transforming phenomenon, like the final triumph of reason or the proletarian revolution, must believe that all political and moral problems can thereby be turned into technological ones.  That is the meaning of Engels’ famous phrase…about replacing the government of persons by the administration of things”

– I Berlin 1958 in “Two Concepts of Liberty“

The doctor-patient relationship defines medicine; a relationship struck to help patients in need.  Medicine needs to articulate what medicine is.  Saying medicine is nothing but a science applied with artistic care will not do.  Medicine is much more.

Informed Public Policy

If physicians define medicine as nothing but a technological product then bureaucrats will give us an administration of things.  We need to give federal ministers reasons to look for something more to guide public policy.

 

This post appeared in The HealthCare Blog and in A Country Doctor Writes.  Dr. Duvefelt shares his experience in Sweden on salary and how this impacts patients’ experience and expectations.  I include the whole piece from the Healthcare Blog here:

“A long time ago, when I worked in Sweden’s Socialized health care system, there were no incentives to see more patients.

In the hospital and in the outpatient offices there were scheduled coffee breaks at 10 and at 3 o’clock, lunch was an hour, and everyone left on the dot at five. On-call work was reimbursed as time off. Any extra income would have been taxed at the prevailing marginal income tax rate of somewhere around 80%.

There was, in my view, a culture of giving less than you were able to, a lack of urgency, and a patient-unfriendly set of barriers. One example: most clinics took phone calls only for an hour or two in the morning.

After that, there was no patient access; no additions were made to providers’ schedules, even if some patients didn’t keep their appointments, not that there was a way to call and make a same-day cancellation.

As my father always said: “There must be a reward for working”.

But, high productivity can sometimes mean churning out patient visits without accomplishing much, or it can mean providing unnecessary care just to increase revenue. For example, some of my patients who spend winters in warmer climates come back with tall tales of excessive testing while away.

A recent Wall Street Journal article offers an interactive display of doctors who collect the highest Medicare payments. The difference between providers in the same specialties across the country makes interesting reading. It is hard to imagine that many individual doctors are billing Medicare more than $10,000,000 per year.

So it might make sense to insure against paying for excessive care by also demanding a certain level of quality.

But defining quality is fraught with scientific and ethical problems, since quality targets really aren’t, or shouldn’t be, the same for all of our patients.

The scientific community, for example, knows that elderly diabetics with “ideal” blood sugars are more likely to suffer harm or die than those with sugars that are a little higher. Even though the American Diabetes Association has embraced higher blood sugar targets for older diabetics, many healthcare organizations’ quality assurance programs treat all diabetics the same and penalize doctors who individualize treatment goals in accordance with the scientific evidence or common sense.

In almost every area of medicine there are individual nuances that must be considered if we are to best serve each of our patients. It is ironic and very sad that, right now, those who pay us are looking for simple (or simplistic), universally applicable quality targets just as the explosion in our understanding of genetics is promising to usher in the era of “personalized medicine”.

Up until now, the gold standard of scientific research has been to prove which standardized interventions work best for large groups of patients, even if there are subgroups that aren’t helped at all by them.

Who should define the “quality” measures of our work?

The central question for how doctors might be paid for quality in the future hinges on the priorities of whoever holds the purse strings. Insurance companies, if we overlook profit motives that also exist, prioritize population management. They pay for what works for most people, knowing full well that some patients will not get the best care for their individual situations, for example when certain medications are not covered.

Politicians also favor the population view of health care.

If patients pay us directly, they expect us to deliver the care that works for them. If the Government or an insurance company pays us, they expect us to deliver care that meets their standards, because they don’t trust the patients – their constituents and customers – to know what is best for them.

And their focus is to have us do what helps most of our patients, even if some are not helped and some, or many, aren’t happy with what they are getting.

With all the political talk about “Patient Centeredness” during the current health care reform, may I suggest that patients need to be given more choice about how their health care dollars are spent. With limited choice and no responsibility, patients tend to feel entitled and deprived at the same time.

This creates a toxic environment for delivering health care. I have never met a patient who felt in partnership with his or her insurance company – ever.

And I don’t expect to.

In order to maintain what partnership is left today between doctors and patients, we need a cost-quality paradigm that is shared by patients and providers. We also need to foster and maintain a sense of stewardship that is elusive if all that is at stake is someone else’s money.

I think there are ways to achieve this.

Hans Duvefelt, MD is a Swedish-born family physician in a small town in rural Maine. He blogs regularly at A Country Doctor Writes where this piece originally appeared.”

(photocredit: blog.jobma.com)