Category: Politics

“There are these two young fish swimming along and they happen to meet an older fish swimming the other way, who nods at them and says “Morning, boys. How’s the water?”

And the two young fish swim on for a bit, and then eventually one of them looks over at the other and goes “What is water?”

— David Foster Wallace, This is Water

Max Weber showed us the water. He said that the most rational way to organize human activity, maximize efficiency and eliminate favouritism was with hierarchical bureaucracy.

The father of sociology, Weber gave us Weberian Civil Service. Weber’s bureaucracy controls medicine, education, all branches of government and most large corporations today.

But Mr. Weber was curiously honest about his bureaucracy. He did not disguise its ugly side.

He predicted it would put an “iron cage” on each of us and, eventually, a “polar night of icy darkness.” Max Weber blamed capitalism for pulling us into bureaucracy. He said it created institutions that limit choice in favour of a “technological utopia”.

Healthcare Iron Cage

The Iron Cage is a “technically ordered, rigid, dehumanized society”, a set of rules for all of us.

A Bureaucracy:

• Concentrates power in a few people that are generally unregulated. (oligarchies)
• Breeds on the fixed belief in its superiority. Spawns more bureaucratization and rationalization.
• Turns individuals into cogs in a machine. People focus their careers on becoming bigger cogs.
• Sees people as units of labour to be bought by the bureaucracy. Others dictate the price of your individual services; the value of your accomplishments.

Weber explained that bureaucracy arises from rational design. He believed it was an inescapable fact of reason. But rational bureaucracy produces irrational results.

Health bureaucracies exist to provide care for the sick but limit access to medical services. National health insurance (Medicare) guaranteed doctors payment for all services, but put doctors out of work by closing operating rooms and blocking them from joining practices. Each industry could add its own stories as the same irrationality happens in agriculture, forestry and education.

“No one knows who will live in this cage (Gehäuse) in the future, or whether at the end of this tremendous development entirely new prophets will arise, or there will be a great rebirth of old ideas and ideals, or, if neither, mechanized petrification, embellished with a sort of convulsive self-importance. For the “last man” (letzten Menschen) of this cultural development, it might well be truly said: “Specialist without spirit, sensualist without heart; this nullity imagines that it has attained a level of humanity (Menschentums) never before achieved.”

Protestant Ethic: [Weber 1904–05/1992, 182: translation altered].

No one talks seriously about bureaucracy anymore, except maybe the anarchists. David Graeber, famous for ‘We are the 99%’ from the Occupy movement, has a new book, The Utopia of Rules: On Technology, Stupidity, and the Secret Joys of Bureaucracy. While I disagree with violent anarchists, I plan to read Graeber’s book.

Have we confused bureaucracy with government, the healthcare iron cage with medicine?

Giles Fraser wrote in the left-leaning Guardian, “…the left has assumed that defending (or being silent about) the smothering prevalence of bureaucracy is all about defending the state.”

Medical associations should challenge the healthcare iron cage. We could use the multi-million dollar medical bureaucracies to build ‘iron cage’ committees. Imagine our association bureaucracy fighting government bureaucracy, bureaucracies attacking bureaucracies.

Maybe that’s dreaming. Maybe the healthcare iron cage, too, must lead to a polar night of icy darkness as Weber predicted.

Photo credit: theunsecretshopper.com

Old doctors used to beg new graduates to take over their practice in the 1990s. They offered free rent for a year, all office supplies, 3000 patient charts, a devoted staff and a great parking spot. Some even threw in ownership in a medical building.

They begged new docs to care for patients they had grown to love like family.

But everyone knew that accepting a ‘free practice’ meant slavery. Sorting out complex patients for 80-100 hours per week just to make payments on student debts and mortgages was not worth it.

Middle aged doctors used to sneer in envy. They had paid $200-300 thousand for their practice just 10 years prior. They had assumed that after 20-plus years of student living, massive debts and delayed family life they would accept huge practice debts just to start billing. House, car, student loans….what was a few hundred thousand of practice debt to take on in your early 30s? They had no clue about money.

It all changed in the 1990s.

Governments turned family doctors into a scarce resource.  The glut of doctors predicted by the Barer-Stoddart report turned out terribly wrong.  Government closed medical school spots and created massive doctor shortages. On top of that, slashed fees though the social contract years in the 1990s forced doctors to seek work in emergency departments, hospitals, walk-in clinics – anywhere but in practice. It left nearly 2 million Ontarians without a family doc.

Pressured by voters and flush with cash from federal health transfers, Ontario poured money into Family Practice starting in 2004. Government opened medical training spots. Doctors could finally make a case to open practices. Students started ranking family practice as their first choice again. Over 1 million unattached patients found doctors by 2012.

But it ended quickly.

Premier Wynne blocked entry into family practice this spring and cut fees at the same time. She created an artificial shortage of places to work. She turned a patient roster into a commodity again but for all the wrong reasons.

Family Practice For Sale

Cirrus Consulting Group serves medical practices. Josh, from Cirrus, commented this morning under the Medical Residents Talk About Cuts post.

“As I have read many of the comments going back and forth I felt compelled to provide some insight. I work for a management consulting firm in midtown Toronto, Cirrus Consulting Group, that specializes in everything being discussed here. We work with individuals and groups, both in FHG’s/FHO’s/FHT’s and FFS to ensure that their practice is running efficiently and effectively. We often find that family physician in Ontario are not paying close enough attention to their ‘business’. We work closely with the physicians and their staff to make sure that they are being paid appropriately for the care they are providing. As a boutique firm, we are able to provide hands on attention to all our clients with in person meetings and access to our team of experts at all times.

I would encourage all of you that are practicing family medicine in Ontario, regardless of your payment model, to check out our website and get in touch with either myself or another member of our team to speak about your situation and ways in which Cirrus can assist you.

To get into a little more detail about the topics above – we are currently seeing a significant amount of interest for the purchase and sale of family practices in Ontario. As it was mentioned, there is value now for a roster of patients and a spot in a FHO, whereas before, anyone could join so it didn’t make any sense to purchase. As for value, purchasing physicians are guaranteed income for the first 6 months after taking over and in our experience, this relates to the average sale price of about $150-200K, even though I would expect the sale price to be higher with such demand.

Overall, Cirrus can help with all aspects of your practice from the start of your career with income projections and setup, to the end of your career with practice valuations and retirement. I look forward to speaking with many of you and your colleagues about your individual situations and how Cirrus can help optimize your practice.

Please check out – http://www.cirrusconsultinggroup.com and my direct email is jsteinberg@cirrusconsultinggroup.com

Practices take work to build and have intrinsic value. But their current value rests on the wrong reasons.

Practices should be valuable because doctors had to work to build them. Practices should not have value because governments ration spots to practice. Ontario has it backwards…while patients wait with little choice in who they get to see.

Government cannot manage healthcare by itself. Selling spots in family practice is only the beginning. Patients will soon find they have to hang on to their family doctors for dear life or risk not finding a replacement.

Politicians should be held accountable for their decisions, not just at election time. Let’s hope Premier Wynne and Minister Hoskins start working with doctors instead of against them soon.

photo credit: www.cirusconsultinggroup.com

Most doctors hate politics and bureaucracy. Doctors do not compete for limited spots in medical politics the way students fight for spots in medical school. Doctors who serve in politics are different. They have unique tastes.

If you are a normal doctor, or you happen to know one, please encourage them to volunteer time in medical politics. Tell them to go to a provincial association meeting or apply for a spot as delegate to the Canadian Medical Association (CMA) council next year.

Normal Doctors

Normal working doctors usually cannot spare the luxury to debate health policy. They do not question why the system functions as it does. They can’t afford the time.

Normal doctors might have between 5 and 25 years of experience. They aren’t new grads, and they aren’t ready to retire. They take care of patients and fill call schedules. They manage offices and staff, spouses and children/dependents. Normal doctors don’t have much time to volunteer, teach, write blogs, Tweet or do all the things that distract some of us.

Medical associations need normal doctors. 

We need mid-career physicians who wouldn’t otherwise be involved. We need to hear from the silent workhorses of healthcare.

Provincial associations always attract a group of doctors frustrated with government meddling in clinical practice. They demand answers to illogical rules and regulations that ruin efficiency and harm patient service. These doctor-businesspeople end up injecting a bit of sanity into discussions about high-minded political debate. But they rarely attend national meetings.

Associations must communicate something that regular physicians can support. National associations must speak for Canadian doctors, not just those who apply to be delegates to annual council meetings.

After periods of questionable relevance, all of a sudden the CMA has become critically important, even though many doctors do not belong to the organization. The following issues demand nation attention:

• Bullying by provincial governments
• Authoritarian regulatory colleges – a coast-to-coast push to dictate physician behaviour; starting in Ontario and Nova Scotia
• Failed negotiations
• Redefining medicine from “Do no harm” to “Cause death, if patients request it.”
• Unchanged patient wait times
• Seniors’ care
• And much more

We need regular doctors to provide relevance and focus, not just dreams and idealism. We need practical working doctors; people who’ve battled through years of uncoordinated, bureaucratic, over-regulated care. We need you to keep us grounded on patient service, patient need.

The latest phase of Medicare finds governments and courts defining what it means to practice medicine, what defines good care. We need professionals who practice great care everyday to help guide the change. If we don’t get your input, regular doctors might not recognize medicine tomorrow.

photo credit: ca.news.Yahoo.com