18 thoughts on “Physicians Can Finally Move Beyond Fees”

1. The arbitration award is revenue neutral. The $460M in OHIP cuts to OHIP insured physician services will adversely affect physicians who render and their patients who receive the OHIP insured physician services that will be the subject matter of the OHIP cuts. Query whether psychotherapy and/or peripheral nerve blocks, for example, will be the OHIP services that will be cut.

   1. Good point and question, Perry. There will be delisting, for sure, but this more fair than slashing or payment-at-nil.

      Thanks for posting a comment!

2. Yes things have to change. But the change is to focus on fees instead of global budget negotiations. You got this one wrong Shawn. This settlement is still sub-inflationary. It only puts limits on how the government can continue to suppress us. The is not the end it is simply the end of the beginning.

   1. Thanks Ernest!

      I appreciate the push-back. You are correct, of course: it all starts and ends with fees. Having said that, I think we are taking a step past the fight over fee cuts. I hope that the discussion over which fees to delist won’t be a fight. But that is precisely why I wrote the post! I wanted to hear whether others think this is a new dawn or more “the end of the beginning”, as you say.

      Sure appreciate you taking time to read and post!

      Cheers

3. Police, fire, nursing, teachers, and postal workers have all faired better with pay and benefit increases. And none had a >5 year period with unilateral pay cuts. We have essentially been co-funding the health care system with our ‘donated’ labour, and now will continue to slide incrementally behind re. inflation.

   We pay tax at a rate that exceeds the concept of contribution and frankly represents confiscation.

   There are two main messages here:

   1. The gov’t can’t afford to fund its entitlement programs. The corollary to this is that physicians are easy political targets re. cost savings.

   2. We are in the midst of a very serious calculation about what physicians are worth to society. I’m not sure we’re contributing much to that process because we simply don’t have leverage – or the leverage that we have won’t be used due to ethical constraints.

   All of the above exists in the context of a new era, represented by the casual disrespect for the physician. I can’t claim that phrase – it was coined by a local GP who noted the change in tone from his patients over the last few years. One can only assume that the constant attacks from gov’t and media have made it culturally permissible for some patients to treat physicians like chattel.

   I desperately want to keep doing this job – this calling? – but I don’t know how. Between the ever present CPSO, the expectations, the entitlement, the metrics, and the last x-years of feeling devalued, it often feels hard to get up in the morning. And yet I enjoy solving problems and genuinely helping people. Maybe there’s a better outlet for those impulses. I suspect many physicians are having this kind of internal dialogue and wondering (fantasizing) about an exit strategy.

   1. Powerful comment, Matt!

      This needs its own post for sure. “Casual disrespect for the physician” – brilliant. It reminds me of Marcuse’s essay, Repressive Tolerance. He argued that society should not tolerate the protagonist. To tolerate the protagonist is to support oppression of the victims in society. Marcuse, like all leftists, saw the world made up of two kinds of people: victims and oppressors. Those captured by this neo-Marxist thinking must attack anyone and any group in society seen to be successful. Success means oppression, by definition, reality notwithstanding. You could come from the most humble beginnings and barely be able to make payments on a Honda Accord, but if you are an MD, you are a member of the oppressor group.

      I remember watching patients, in the 1990s, bring piles of gifts to their physicians around Christmas. I was in training then. Wine, fancy baskets, everything… I do not see that anywhere anymore. I’m not saying that it should happen. I am only observing that society has changed.

      Like it or not, the Toronto Star’s 55-year public relations attack on doctors has taken a toll. Since the 1962 strike in Saskatchewan, the Star has led the chorus smearing doctors. The CPSO has joined the throngs over the last 15 years: Doctors are guilty before proven innocent, allegations are posted publicly, careers are ruined, and docs never get their names cleared.

      Medicare cannot last unchanged. It will collapse. Medicine in Canada will be irrevocably changed with it. However, medicine is bigger than the state. Pockets of the profession will survive. It does not help us here, right now, but at least we can know that what we are experiencing is an aberration in the world.

      Thanks for sharing such a thoughtful comment!

      1. PS. To your last point, Matt, about an exit strategy. The last post, How to Leave Medicine and Travel the World, by Matt Poyner, has over 4500 views…many times more than the average post. Many doctors want out. They just do not know how.

4. Shawn,
   As usual, you bring out nice discussion. However, I have to disagree one of your points. Doctors did not have a fair fight: there was no boxing gloves on the doctor’s side and the result is obvious. A sub-inflation settlement. I am pessimistic on the doctor’s future fees. There is no political interest in all 3 parties to touch the scared cow: Medicare. Until the system is completely broken down, I do not see any change coming. am glad that I am at the end of my career. However, I feel for the younger doctors who are just getting into the system.

   Good luck to our young colleagues.

   1. Thank you Michael!

      Again, I love it when people offer a different perspective. And again, you are right! The fight was not fair. Your comments about change to medicine even over the course of your career resonate with readers. People tell me this privately all the time. Medicine today is not the same, great career it was even 25 years ago. When 30 year olds hear this, they roll their eyes and think, “Old guy.” But even in the last 15 years I have seen a massive change in tone, style, and expectations.

      It will take much more than an arbitration award to heal medicine…. That sounds like a new blog post!

      Great to hear from you, as always. Thanks again.

5. We cannot trim further fat at the coal face…we are already at the periosteum.

   Lots of fat further up the privileged health care pyramid…with the insulating fat regarded as being untouchable, “ essential” in fact..so its down to gnawing our own bones and that of our coalface colleagues for the rest of us.

   This dysfunctional health care system will survive as long as its battered and bruised foot soldiers manage to drag themselves out of the trenches to fight the fight…one day…they won’t be able to.

   The essentially leaderless foot soldiers of this tyrannical health care system certainly feel lost and alone…the battle may well be regarded as being “ over” where the hierarchies are concerned …but the suffering at the coal face is not…many will not digest the meager offerings with any sense of satisfaction…they will swallow resentfully…there can be no partnership between unequals…unilateral sacrifices will not satisfy those doing the sacrificing.

   The medical hierarchy and the government are completely incapable of building a better health care system for all concerned, for patients and providers, as long as both refuse to acknowledge the global evidence.

   In the mean time the gobbedygook non complimentary quacks are eating the FP’s lunch eg: offering pampered Pap smears ( soon in aisle 9 at Shoppers?) with cups of tea and vaginal steaming for a small fortune…I have few ideas regarding the checking of prostates with a pint of beer and steaming….evidently the modern day oath for an MD degree comes with a vow of poverty….the non complimentary health care professions certainly have not been so foolish …the health care trenches will empty…the quackery aisles will become crowded.

   See you in ailse 9?

   1. Colourful, thoughtful, and nuanced as usual, Andris. I will not add anything other than to say Thank you! Really appreciate you taking time to share. Readers love your comments!! Cheers

6. Shawn.. I too must push back.

   The board gave us scraps. They toss us <1% while with the other hand government has already taken 4.45% away. Of course we hear it's a win for us, but the net result is still NEG over the last half decade.

   We are not a pair of large animals trying to garner mutual respect. As you state, respect sometimes involves mutual fear and the potential for mutual hurt. We are the ones afraid. We are the ones than can and have gotten hurt. There is no fear we invoke onto the heart of government. We cannot hurt them. Thus there will never be mutual respect.

   This arbitration deal just effectively ends the fight until the next contract talks starts. Arbitration is simply a tool we can use to fight this battle. Granted it is one more than what we had before but it only serves our purpose as long as the government believes it wasn't too generous. If it presents an unpalatable deal the next time, you can bet it will be legislated away.

   I've given up clinical practice. I've become disillusioned by the whole process. I've exited stage left. I'm thankful I'm not dealing with the system anymore. With those who remain that I've had discussions with, they're simply doing the minimal amount to get by. There is no spark or light anymore. They are simply biding their time and counting the days. This contract does nothing to change their perspectives.

   This isn't the last episode in a series. The series continues. But it's played so long that its at the point were the series is weird, lost and sad and we don't want to watch it anymore.

   1. Solid comments, Rob. And to you also, Thank You for pushing back (Getting a lot of that with this post!…excellent)

      I really liked what you said here: “This isn’t the last episode in a series. The series continues. But it’s played so long that its at the point were the series is weird, lost and sad and we don’t want to watch it anymore.”

      As always, you are right in so many ways. This ruling IS sub-inflationary. It does NOT get us out of the hole we were in. It does nothing to convince doctors that they should celebrate their valued position in the eyes of the system controllers.

      Having said that, I felt that this ruling was better than expected. Did you expect more? Most docs I’ve heard from say that they were pleasantly surprised that the across the board cuts were reversed and that a hard cap on the PSB was off the table. Most docs were not celebrating, but they also “nodded and raised their eyebrows” that the ruling tasted less foul than expected.

      Overall, your point is well taken. This contract does not fix the malaise in medicine. Time for another post! 🙂

      Thanks again.

7. The Curate’s egg cartoon from Punch magazine 1895 come to mind.

   Bishop to Curate at breakfast “ I’m afraid you’ve got a bad ( boiled) egg”…Curate’s response “Oh No my Lord. I assure you that parts of it are good”.

   That’s as positive as I can get…will the grovelling profession swallow that rotten boiled egg ?

   The only difference today is that the Bishop is trying to convince the curate of its deliciousness.

   Will we get to vote on the egg?

   1. We don’t get to vote on arbitrated eggs: boiled, rotten, or otherwise. I suppose we could debate how much of the egg is still edible, but isn’t that how it goes with arbitration? Did we expect that we would love everything about the arbitration egg?

8. It will take a generation of physicians to heal the current wounds (assuming that the healing started now which is of course a ridiculous assumption to make). But a continued exclusive focus on government and on money will extend that time line even further.

   As a profession we are burnt out. Full stop. We gripe about money and even about work load but at least the individual burnout literature (as I’m not sure there is any collective group burnout literature) tells us that such complaints are usually surrogates for the real problems. Lake of autonomy, mismatch between expectations of respect and the perceived reality of respect, less tangible measures of gratitude and appreciation from patients and government, etc. People will work long, hard hours if they feel like it matters in some greater way.

   But guideline based medicine, pseudo accountability, poorly implemented EHR/EMR, focus on poorly applicable business models like LEAN and Six Samurai leading to a feeling of alienation and lack of input in the system design, a poor understanding even amongst ourselves of the real role of a physician as a healer as opposed to a google search, a breakdown of the basic social contract of bilateral respect that is foundational to the therapeutic relationship (that’s so complex that it could be a book in its own right), poorly thought out infighting within our profession and between us and the other helping professions like nursing, education and first responders, a culture of fear of the wrong things and ignorance of what we should really be afraid of, a culture of convenience instead of responsibility and dozens of other much more important factors than money.

   So yes we need to talk about money. We need it to function as a profession and as a health system. We need to find a way to deliver satisfying care at a much lower cost (which likely means redefining how we measure care and perhaps even cost). There is no more money either public or private to inject into the system. This is the basic first principle that discussion must be based on. There is no payment model that can heal the current rifts in the profession is the second point. We need to open our eyes to a radically changed new reality of defining satisfaction and happiness within our profession and with our patients. Am I optimistic that we can achieve such grand ideas…..let’s just say my wife and I have been discussing a variety of strategies for our family that don’t really on me in traditional practice models. Still in medicine. Still even in clinical medicine. Just different and hopefully a bit more shielded from some of the above angst. Nothing firm just yet but a lot of thinking.

   1. Wow. Powerful post, Dan. Well said indeed. I liked how you ended with hope for something better.

      I agree with everything you said. People do not realize how demoralized their doctors feel. They also do not realize how it impacts care.

      Thanks so much for taking time to read and post such a thoughtful comment! Cheers

   2. Dan – your second and third paragraphs were… everything.

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