Shawn Whatley, Author at shawn whatley md

9 Steps to Deciding on Doctors’ New Deal

Dr. Darren Cargill offers 9 steps to evaluating Ontario Doctors’ New Deal in this guest post.

I want share a bit of tool I am using to help me decide how to vote on this tentative deal.

Separate the deal from the Liberal Party. If this vote was a referendum on the Liberals, we would all vote “no, No, a thousand times NO!” We would never vote yes. Frankly, we would never accept a deal. The Liberal mismanagement of the province would prohibit us.

Make it explicit who you are voting for. Is this vote for you, a group, for patients, for the future. Voting for you means, “How will this deal affect me, my family, my practice that I have built?” Voting for patients means, “How will this deal affect my ability to care for patients?” Same for a group with more focus on a particular area. Voting for the future means keeping your mind open to possibilities inherent in both the “Yes” and “No” votes.

View both sides of an argument with a dispassionate mind. I had to do this recently with the MAiD arguments. When the SCC ruled on assisted dying in February 2015, I signed up for both sides of the debate via Twitter, email subscriptions, blogs. For those of you who simply can’t invest the time, follow a few opinion leaders on each side that you feel you can trust.

Separate the deal from our ego. By this I mean we will never get a deal that properly values our training, expertise, dedication and commitment. At least not under the Canada Health Act.

Separate the deal from a referendum on OMA leadership. A “No” vote will not bring about change at the top of the OMA nor change at the OMA in general. If you want to change the OMA, you can do this by running for an elected position, joining a committee, get involved. This is not a referendum on Dr. Walley’s leadership as president nor the role of the OMA as our representative. It might be a referendum on the Board as a whole, as they have recommended this deal but the Board is made up of elected officials and decisions by the Board are not unanimous in most cases but moved by majority vote.

BATNA. This is a negotiating term. It stands for “Best Alternative to a Negotiated Agreement.” While most would say this is simply what is most likely to occur with a “No” vote, it goes deeper than this. What does a “No” vote mean for future deals? Is a better deal more or less likely? Is the government likely to move on issues like Binding Arbitration and a fixed PSB or have they been consistent in their refusal?

Forget the ideal “deal.” It simply isn’t there. There is no deal that will reverse all previous cuts with interest, fund unlimited demand, find FT jobs for all our grads, fully fund all growth and population increases and magically fix relativity in a painless wave of a wand.

Have a “goal” in mind. Don’t simply vote “no” and not have a deal in mind. “If you don’t know where you are going, any road will take you there.” If this ISN’T your deal, what is? Is it a higher rate of growth? Is it the reversal of cuts? Remember, there is no ideal “deal” so you can’t have them all. What is the one thing for you that this deal MUST have, if it isn’t there already?

Treat each side with respect at all times. Vitriol and frank “trolling” diminish us as a whole.

I hope this helps. I’ve tried to keep it short and sweet so please excuse the brevity but I think we are all suffering from reading “War and Peace” every night.

Darren works as a palliative care doc in Windsor. He has been published many times in his local paper and plans to launch his own blog very soon. We will share his web address as soon as it goes live. When you see Darren, please bug him to write a book on palliative care!

Photo: Darren and Owen

Leaders as Prophets in Suits

I envy prophets. They just stand on a street corner and tell us when the world will end.

Their message fits on a piece of cardboard. They have low overhead and never have to compromise.

Anyone can be a prophet. You just need a message and courage to share it.

But effective prophets have short careers on the street. People notice them.

Once enough people recognize them, prophets get invited to apply for hospital leadership, or to run for election. After moving from the street corner into an office, prophets find that life gets complicated.

Simple, prophetic messages raise complex questions. For example: How do we prepare for the END? How should healthcare be organized?

Prophets find leadership filled with complexity, ambiguity, and tradeoffs.

Only dictators experience leadership without compromise.

Recently, a Member of Parliament described his dissenting opinion on a major decision to me. The majority often voted against his positions.

I asked how he survives, since Members usually do not get to write dissenting opinions. I wondered: How does he decide to stay and risk being seen to support bad decisions?

“If I leave, then no one will speak to these issues,” he said.

Democracy is Messy

A representative, constitutional democracy must hear all views, and the majority must follow a constitution. It prevents mob rule by majority. The constitution sets rules that a majority cannot break.

What happens when a democracy must make an either/or decision like: Do we go to war?

The country finds out what everyone thinks, not just the majority, a special interest, or elite group. Leaders seek counsel from experts on the issue. The decision must fall within the ambit of the constitution (for example, slavery is not open for discussion).

Then leaders make a decision.

Once the country decides to go to war, it goes together.

Minority Voice & Influence

Minority leaders face two options:

1) Be true to their message and remain a fringe voice.

2) Try to compromise their message to gain access to where groups makes final decisions.

This struggle has played out in every country, and every Boardroom, since humans started working together.

It forces people in leadership to do 3 things:

1) Know what they believe, what they will never compromise.

2) Get comfortable with ambiguity and complexity.

3) Remain flexible, and humble enough to change their mind.

Number 1) sets limits and protects leaders from becoming a sycophant to power. Number 2) develops wisdom and diplomacy. Number 3) keeps leaders grounded, human.

Every decision, no matter how minor, forces prophets-cum-leaders through these 3 steps.

Have I crossed the line?

Is this wise?

Am I rigid and blind?

Prophets in Suits

Prophets have life easy. They live in a black and white reality and hope that people hear their message.

Sycophantic leaders have life easy, too. They just identify popular opinion and go with the flow.

But every organization needs courageous leaders with vision. All leaders are prophets in a sense. They are prophets in suits. Leaders without vision should not be in leadership.

We need courageous people, inside every organization, to speak with courage, and to lead with conviction, wisdom, and humility.

We need prophets in suits with courage to stay, especially when their message is not heard.

Sometimes you will land with the majority, at other times not. All people can do is trust that you acted with integrity.

Regardless of the issue, no one wins if people with minority opinions leave every time they sit on the short side of a vote.

New Deal for Ontario Doctors

Doctors got an unexpected surprise this week: The Ontario government offered doctors a tentative contract, in the middle of July.

The board of the Ontario Medical Association (OMA) voted to support the new deal and share it with members.

People have asked what I think about the contract.

The Board voted to let the doctors of Ontario decide. As a Board member, I support the wisdom of the Board in this decision. If I absolutely could not support the Board’s decision, I would have to step down.

I found this decision very hard. I keep learning more about the deal each time I look at it. I’d love to hear what you think.

New Deal

Doctors in Ontario are desperate. After 2 years of attacks, cuts, and slander from this government, doctors beg for stability. This new deal seems to offer that.

Why Doctors Might Like It

No more unilateral cuts – Doctors will cheer for anyone who offers to end cuts. Doctors cannot run clinics, when government cuts payments without warning. No business could handle such caprice.

Co-Management – This contract promises to welcome doctors back. Many find this irresistible. Government has usurped control and progressively shut doctors out of healthcare governance, over the last 40 years.

Modernization of the Schedule of Benefits – This deal proposes to fix relativity (Some doctors bill high fees for easy work; others bill low fees for hard work). Doctors have failed to fix this since the 1980s.

Charter Challenge Protected – This requires lawyers to explain, but they say that this contract will not undermine the Challenge.

Better Than the Alternative – Based on current utilization, the negotiated funding for growth, one-time payments, and two Schedule of Benefits modernizations is expected to keep spending within the planned PSB and one-time payments. We shouldn’t need further adjustments. But if government keeps to its current behaviour, it plans over $1.1 billion in cuts over 4 years of unilateral action.

Why Doctors Might Pause

No Reversal of Previous Cuts – The physician services budget (PSB) sits at $11.452 billion dollars, after approximately $700-800 million dollars of cuts.

Enough Growth? – The government has offered to fund 2.5% growth of the PSB. This means that the MOH has agreed to fund 2.5% more physician services per year.

Note: physicians’ fees stay the same. If a fee was $33 dollars last year, it is $33 this year.

A promise to fund 2.5% more services marks a huge improvement over the 1.25% that government funded last year.

However, growth has been around 3.2% for the last 15 years. Each year, 150,000 new patients come to Ontario, and almost 1000 new doctors start practice. Can anyone contain utilization?

One-time payments – These are expected to cover the difference in funding noted above, but only if growth is contained at 2.5%. Doctors could earn an almost 0.8% annual bonus, if all doctors work together to find permanent savings in each year of the contract.

Shifting Risk – This contract seems to give government the predictability they wanted in the PSB. Is that reasonable? Does this increase the likelihood of reconciliation if growth goes beyond the 2.5% + one-time payments? How will this be handled and will there be winners and losers?

Hard Times

Doctors in Ontario have faced cuts of up to 30% net, since 2012. At the same time, they struggle to find care for their patients.

For example, patients wait up to a year just to see an orthopaedic surgeon, in my area, and another 9 months to get their hip replaced. On top of this, government has cut hospital funding for the last 9 years and also cut over 1400 nurse positions.

Doctors are tired. They want a contract. A contract seems to provide predictability and lets doctors apply for loans to purchase equipment that patients need for care.

Members Decide

Doctors need to ask: Does this contract offer something good for patients and doctors in Ontario?

Doctors will not get a raise. Inflation will eat into their earnings. But doctors will get certainty for 4 years. Doctors will not get unilateral action.

What will patients get?

Do the pros outweigh the cons?

What will government do if doctors do not accept this deal?

What options do doctors have?

Doctors face a huge decision, possibly the biggest decision of their careers. They need to ask hard questions about: certainty, growth, rationing, and relativity.

Doctors need to do whatever they can to inform themselves.

Doctors needed something concrete from government. Members needed to see this contract, and the Board is wise to trust members with the decision.

The OMA Board has committed to inform members through special meetings and information sessions. Physician leaders across the province should be able to answer questions from their colleagues.

The current situation was unsustainable. Can doctors trust government again? Please ask hard questions. Let’s hope patients like how this turns out.

photo credit: www.brittanica.com

Note: OMA communications and negotiations reviewed a draft of this post. They offered helpful edits and re-focussed the content on the deal. I added a few comments and made final edits after that. I assume responsibility for all errors.