The Generalist Curse

Questions sting at high school reunions: Are you just a GP? Did you specialize, or are you just a general internist?

It is part of the generalist curse. General surgeons sometimes feel the curse too.

In this case, size matters. Big hospital: generalists grovel. Small hospital: generalists rule.

Generalists grovel out of need, not desire. They grovel to get the scraps left after hospitals fund, build, and promote fancy programs.

Fancy programs fill hospital flyers and decorate fundraising events. Donors want to donate to shiny machines that whir and beep. Clinical care that only requires a brain and a bed does not raise funds.

Generalist Curse

Generalists exist in a space between ‘the miracle of medicine’ and the yuck of medicine. We do things no one else wants to know about. We disimpact octogenarian bowels and lance hemorrhoids. Specialists reattach limbs and transplant people’s faces.

Banality is bad. The generalist’s sense of impostor syndrome mixed with a fear of incompetence is worse. Generalists know they know less about everything than some other doctor.

We might not know the ‘other doctor’, but we know she exists. Generalists are doomed to offer patients a bit less than the hemorrhoid sub-specialist, assuming hemorrhoids are at hand. Continue reading “The Generalist Curse”

Compassion Not Equality – Canadian Values in Medicare

Obama did it. Trump does it. Trudeau does it too. Politicians talk about values as if they know what voters think.

A politician promotes his values to normalize his vision.

Tricky politicians use familiar words and give them new meaning. They use popular support for one thing to build support for something completely different.

For example, since everyone supports motherhood, it shows we support apple pie too.

On his quest for state medicine, Tommy Douglas told a story. Young Tom needed surgery. His family was poor. A surgeon fixed Tommy for free. It was great for Tommy, but what about all the other sick kids? Is it fair that farmers must choose between losing the farm and losing a daughter’s limb?

Compassion Not Equality

Most Medicare books start the same way. The author tells a story about disease and financial ruin, before Medicare. They appeal to compassion and inflame fear of loss. People should never suffer without care or go broke from medical bills.

Canadians agree. We are moved by suffering and loss. And that is where we get tricked. Douglas and company trades compassion for “equality” and fear for “care regardless of ability to pay.”

But compassion is not the same as equality. They are as different as colour and temperature. No one knows the temperature of purple. They are different categories. Compassion and equality are different categories also. It is a category mistake to conflate the two. Continue reading “Compassion Not Equality – Canadian Values in Medicare”

Not Eligible for Payment, but Medically Necessary

Imagine that all bakers were nationalized under the Canada Food Act, also known as Foodiecare.

Selling bread is too important to leave to bakers.

Bakers may sell bread, but only under special rules, unknown to most customers. Customers need protection. They might buy bread they do not need.

If Sally wants bread, Bob the baker must sell only bread. If Sally wants bread and bagels, Bob must give the bagels for free or ask Sally to buy the bagels tomorrow.

Sometimes, Bob feels guilty and gives the bagels for free. Bob tells himself that he has spare time; the bagels might not sell anyways. Bob often forgets about his mal-baking insurance, continuing baking education, and saving for retirement at 73.

Canadian Bakers for Foodiecare say the cost of bagels is already priced into the average loaf of bread.

Furthermore, bakers have a privileged status under Foodiecare. People always want bread. And Canadian bakers do not have to pay for advertising and administration.

Not Eligible for Payment

In Ontario, it is illegal to bill a patient for medically necessary care if the government has decided that the care in question is “not eligible for payment”. Continue reading “Not Eligible for Payment, but Medically Necessary”