Category: Politics

Getting voted off the island is like being thrown under the bus, except more people do it to you.

The reality show, Survivor, gave votes to players so that the majority could send losers off the island, out of the show. Everyone got a secret ballot in the war of all against all.

Survivor is democracy in action, right?

Doctors and Democracy

When everyone votes directly on issues, we call it direct democracy. When we elect representatives – who are supposed to represent us, not their party – we call it representative democracy.

Voters send representatives to parliament to speak for all of us, doctors included. Politicians speak for everyone in their riding, not just the mob that funded their election campaign. Politicians are supposed to have ideas of their own and not just parrot their party leaders.

We elect politicians to speak for doctors and protect them like every other minority group in society.

Democratic Despotism

Over 150 years ago, Alex d’Tocqueville warned about democratic despotism. He described a kind of despotism that grew from a too fervent or uncritical devotion to the sovereignty of the people. Despotism arises when the majority democratically blesses a despot in trampling on the rights of others. (What Tocqueville foretold: a despotic democracy.)

Democracy fails when politicians ignore the rights and freedoms of minority groups.

Rights, Duties and Handouts

Do rights mean handouts, freebies? Do doctors have rights?

Everyone demands his right to publicly funded services. Most of the time, rights are just another way to take something that is not yours without calling it stealing.

Rights relate to our understanding of liberty. In his famous essay on liberty, Isaiah Berlin said that positive liberty assumes someone else provides for it. Positive rights (liberty) put duties on someone else to meet the demands of the rights in question.

If you demand the right to education or healthcare, then the government has the duty to pay for it.  (People used to talk about education and healthcare as privileges of citizenship.)

Positive rights demand handouts.

When doctors complain about government trampling their rights, they do not mean positive rights.

Berlin described a more basic kind of right: the right to be left alone, to not be attacked or have your property stolen.  Negative rights (liberty) let you form free associations and act according to your conscience. They include the right to live free of tyranny and oppression; the right to pursue and practice a career in the way you see best.

Negative rights demand the right to be left alone.

Mobs, Doctors and Democracy

The founders of Western democracy feared mobs like the Jacobins in the French Revolution. Advanced societies speak for minorities the mob would otherwise devour.

This means protecting the rights of the weak. But it also means protecting the rights of special people who develop rare genius, like Steve Jobs or Bill Gates. If we allowed mob rule, Jobs and Gates would have had their successes stolen by the majority, long before we got to enjoy their inventions.

Western democracies were designed to protect the rights and freedoms of all from the tyranny of the majority, and the state.

Doctors – Time to Fight?

Doctors have been voted off the island. They’ve been thrown under the bus while other groups get contracts –  teachers, nurses and police.

No one else gets cuts, four years in a row. Doctors are ignored by politicians and most of the media.

Is it right that:

• It is illegal to practice medicine outside of the provincial insurance plan?
• The Province of Ontario cut MD fees in 2012, 2013, 2014 and 2015?
• Premier Wynne will claw back fees doctors billed for seeing patients who needed care?
• Ontario blocked new doctors from practicing in the team models they were trained in, and expected to fill?
  • New docs were sent back to fee for service (FFS). Team care is to FFS as Tim Horton’s is to a private doughnut shop.
• The CPSO demands ‘effective referrals’ even if doctors believe it will not benefit their patient? The CPSO can take away their license for refusing.
• The CPSO restricts doctors’ right of association?
  • They demand MDs start doctor-patient relationships with all patients who walk through the door – if patients fall within the scope of a doctor’s training – even if doctors do not believe they will be able to meet patients’ demands and expectations.

Failed Democracy

Modern society requires you to fight for your rights. Doctors cannot depend on elected representatives. MPs do not know the issues and cannot (or do not want to) understand them. Medicare has grown up and changed.

Doctors, democracy has failed you. Stop expecting patients to care about fee cuts. Stand up and fight. Write letters. Challenge government usurpation of care. Prepare to fight. A lawsuit will not save you. Claw-backs are looming on top of the >25% loss in your net income since 2012.

If you plan to keep practicing in Ontario, all doctors will have to fight for their rights: to care for patients, to fair treatment by government, to free association and to free enterprise.  What are you prepared to do?

 

“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