Shawn Whatley, Author at shawn whatley md

Doctors’ Political Blind Spot

Years ago, my best friend got called out of class to the principal’s office. My friend is smart and sociable. A coral necklace and bushy blond hair dangled around his tanned shoulders as he swaggered down the hall in untied boat shoes.

“I wonder what the principal wants?” he thought. “Maybe he needs my advice on something? Oh, I know. I bet he nominated me for an award!“

With a huge grin, he flopped down across the desk from the principal. “Hey Mr. Warwick! How’s it going?”

Sensing someone else in the room, he twisted around to see his mom frowning from the back of the office. He didn’t get an award. But he’s now a surgeon and medical professor.

Doctors care for patients. They assume medical politics is about improving patient care. Doctors form large organizations to represent the views of dozens of different specialties. They raise issues and try to work out solutions using input from different doctors’ groups. MDs believe clinical facts drive solutions to medical issues.

Like my friend sauntering to the principal’s office, most doctors don’t understand why politicians want to talk. Of course, politicians want to improve patient care. But they want something else much more.

Politicians run for office to shape society. They seek to serve voters by influencing policy towards a particular political vision.

Doctors’ Political Blind Spot

Doctors come unprepared to compete. They pay attention to the wrong things. It’s as if they want the most aerodynamic helmets in a diving competition, or the best golf shoes for downhill skiing. Ontario Medical Association members obsess about whether the right balance of specialties gets elected instead of obsessing over what their representatives think (substantive representation).

Doctors compete for the wrong prize. They assume that politicians want to find the best way to fix patient issues. They don’t realize (or intentionally ignore) that politicians want to find the best ways to advance political agendas by creating solutions to patient issues.

Physicians have a huge political blind spot.

Doctors Want Answers

Many docs ask their provincial associations to respond to articles in journals and newspapers. Most associations only respond to correct factual errors, if a dignitary makes a remark that begs retort, or if they have a policy related to the content in question.

But there’s a bigger reason medical associations cannot respond to media. Most responses require a political opinion. Medical associations aren’t structured to develop political opinions, let alone have one prepared.

So if politicians say we need a powerful, central organizing body to coordinate national healthcare, doctors’ associations can only comment about patient care and health human resources. They cannot say anything about the politics involved in large, centralized bureaucracies running services per se. That requires a political opinion. Medical associations aren’t allowed to have one.

Get Political

A past president of the OMA once told me, “Doctors need to understand that the OMA is a political body. It’s really more like a lobbyist organization.”

I didn’t understand him but finally see what he meant. By the time elected doctors in medical leadership see that the ‘clinical’ issues are not medical but political agendas in disguise, it’s too late. They’ve termed out of office and must move on, and there’s a whole new crop of elected clinicians to convince.

Doctors must get explicit on what they believe about basic political principles. People often talk about being ‘political’ but really mean something like image control or buying voter support. Political opinions dig deeper than media spin and public sympathy. Doctors need to wrestle with fundamental political issues that inform questions like:

Should we reward hard work or should all workers be treated the same?
Do bureaucrats know how to organize clinical practices better than doctors?
Can we drive excellence with more and more regulation or is there a better way?

Doctors must address the political blind spot built into the structure of their associations. If they do not, they will remain only supporters of political change instead of drivers of it. It takes enormous energy to resist the growth of medical bureaucracy even if doctors can see it. And doctors are feeling very tired indeed.

Good Monopolies – Medicare?

Good monopolies escape competition. A service monopoly often implies a greedy, exploitative weed that thrives off a niche habitat of bureaucratic rot and legislative fertilizer.

Peter Thiel wrote about good monopolies in the Wall Street Journal. He uses Google as an example. Despite protests insisting that Google has real competition, it actually owns its market space. And we love it, because Google treats us well. Google knows that great service is the best way to own the whole market. (see also Google’s Utopian Quest)

Nationalization

Canadian Medicare enjoys a monopoly only if it offers reasonably good service most of the time. Escalating wait times and arbitrary cuts to doctors and nurses undermine the Medicare monopoly and tarnish the whole franchise of parliament.

Nationalization evangelists argue that many industries show ideal conditions for natural monopolies. Take the military. It seems logical to have one army; same thing with the courts.

Looking to other services, large swaths of uninhabited Canadian countryside make basics like travel and telephone a challenge. But people need these basic services. We ought to provide them in the name of compassion, of Canadian values.

Apologists pause at this point in their sermon.

With right hand on chest, they remind us of our success when we all laboured together under the war measures act. They leverage our patriotism and national pride as reasons to support nationalized monopolies in education, health, transportation, hydro, phone and every other service they can imagine.

Queue a few bars of John Lennon:

Natural Monopolies

Forty years ago, Medicare fit the natural monopoly narrative. Widely separated communities defied even the most ardent laissez faire capitalists to come up with a true market. It’s pretty tough to have meaningful healthcare or educational choice in Atikokan.

Canada looks different since Tommy Douglas first sermonized about Medicare. Our population is larger (18 million in 1960 vs. 35 million today) and older (average age mid-20s in 1960s vs. 41 yrs old today). We travel more, and do so more easily. The number of Canadians exploited by niche monopolies based on geographic isolation has decreased dramatically. Retailers cannot gouge customers in Shebandowan like they used to. Everyone has eBay.

Same Motivation, Different Reasons

The arguments supporting nationalized services thin and fade with improved technology and population growth. Canadians do not need a national airline anymore. Privatized ones offer better service and quality for a fraction of the cost. We do not need nationalized telephone service or nationalized railways today.

No nationalized telephone service in the 1970s meant Nipigon went without telephone. Now Nipigon has cell phone service as does Marathon, Terrace Bay and all the other communities over the North Shore.

NOTE: Just because nationalized telephone outlived its usefulness does not mean we can do away with government. We need politicians and bureaucrats to do the work that only they can do. We just don’t need them to run telephone or airline companies anymore.

Despite all that has changed, our motivation remains the same. Compassion dictated that we nationalize services in the 1950s. Compassion now dictates we improve Medicare by allowing competition to improve services just like we did with air travel, telephone and mail. Healthcare stands to improve with a bit of competition.

Is Medicare a good monopoly today?

photo credit: bussiness2community.com

Stealing Millions from Patient Care

Ben Franklin told a young tradesman, “Time is money.” In an age of distraction, everything takes time. Economists call it opportunity cost. Do you stay out late after dinner, or prepare for the next day? Is an eMBA worth the effort?

Successful businesses know that new work costs money. Either old tasks go undone, or you hire staff to tackle new projects. Corporations go broke if they don’t pay close attention to how workers spend time on the job.

Stealing Millions from Patient Care – One example

Our team received a final notice from our site admin. Every physician must complete a survey, or we lose funding for our electronic medical record (EMR). The survey had close to 100 questions and took 2 hours to read carefully and answer accurately.

[Full disclosure: I love EMRs, IT and clinical tools of all sorts. I think we need more informatics, not less.]

Over 11,000 Ontario physicians on EMR x 2 hours = 22,000 hours of clinical time spent on 1 survey.

= 9.6 years (22,000 / (50 hours per week x 46 weeks per year)).

= $3.252 million for 1 survey [9.6 years x $340,000 (average gross billings)]

Of course, time spent away from clinical care saves the government money. Docs get dozens of similar non-clinical requests.

Administrative Off-Load

Efficient hospital-based medical groups remain on high alert to admin off-load. Hospital administrators love to build arguments for why a specific administrative task requires an MD (e.g. RM&R forms for community nursing, Transfer forms for mental health patients).

It saves hospitals money. If they can convince docs to do something, it means they don’t have to hire staff using hospital funds. MDs get paid from OHIP, not hospitals.

Laziness and Efficiency

Vice often drives virtue. Laziness makes us to look for easier ways to work. My Scottish Granny might have harrumphed, “You find shortcuts so you can do MORE work, not less!”

Ok. But we still don’t spend our time looking for ways to make work harder. Unless you’re a bureaucrat. Bureaucracy slows things down, resists change, ‘manages’ innovation.

Bizzaro World

In nationalized services, governments save money by slowing down their most expensive assets. They save by shutting down MRIs, closing operating rooms and shackling physicians with as much non-clinical work as possible. Up is down and down is up in Bizzaro world.

$3.25 million dollars of potential patient care wasted on one survey is only a shaving off a lumber pile of waste. If politicians were serious about efficiency, they would insist on freeing up doctors so patients could receive more care.

But more care costs money; who wants that?

photo credit: currencyguide.eu