Category: Politics

Like a scene from a teen dystopian flick, doctors in Ontario face a major decision. Do they stay on the government train that speeds deeper into bureaucracy? Or do they risk a jump for dreams of change?

Doctors must decide next weekend.

• Do they believe that government knows best?
• Do they really believe other countries outperform Canada?
• Do doctors want more of the same, more central control?
• Do they want substantive change?
• Do doctors want to jump off the government train?
• Is it even safe?

Doctors must choose, and they need an association to lead them.

Apolitical?

Some try to discuss healthcare and pretend the issues are apolitical. But even a short list of issues forces us to examine our political perspective:

Choice – Do we think patients should choose their physician or be assigned one?

Control – Should physicians find creative solutions to meet their patients’ needs, or should a central authority plan and implement solutions? Can we force complex systems into a complicated design?

Equality – Should worker’s compensation patients and veterans get early access to tests and have reserved beds in long-term care, or should everyone wait in the same line?

Excellence – Should patients get the best care from the most highly trained physicians, or should patients get most of their care from nurses and RPNs?

Access – Should elderly, rural patients have to drive over an hour into town to get simple blood-tests and ECGs, or should doctors be allowed to provide the service close to home (should it be funded)?

Rights – Should doctors accept arbitrary government cuts, or should docs have legal options to fight back? Should it be illegal for MDs to work outside Medicare in Ontario?

Services – should Medicare cover everything from infertility treatment to sex changes, or should it limit treatment to life-saving therapy and chronic disease?

Each of these, and dozens more, forces us to examine how we think society should function. Everyone wants great healthcare, but we differ on how to get it.

Doctors Decide Future

Doctors must choose.  Not deciding is a choice for more of the same. We can stay on the government train and hope it’s headed for Elysium. Or we can jump off.  Despite what our hearts tell us, change is actually more like stopping the train or choosing a different track.

I hope doctors realize the opportunity they face at the council meeting on May 1st. The puree of Green-NDP-Liberal-Conservative council members stands at the door of the train. They will have to choose. Can they?

After 10-15 years of university, new doctors have spent most of their lives feeling inferior to MDs in authority. Students often feel undermined but learn to make teachers look good without being obsequious. Nuanced flattery is a survival skill.

New doctors have spent 12,000 hours in training but continue to hone their skills for the first 5 years of practice. Graduates often take as many years to shed their deference of older doctors. Many never do.

Dr. Nadia Alam, a new doctor, wrote:

however, i’m curious. what do you say to those [older] docs who insist that “things are so much better than they used to be when every family doc was fee-for-service?” or, “i get paid a lot more now than i ever did before — i daren’t complain!” or, “i remember a decade ago when there were 20% fewer docs and we were paid 300% less than what we are now. we have made enormous gains. we should be grateful for our privileged position.”

i’ve only been in practice 5 years. i admit, i don’t know the entire history of medical politics in ontario. and i too hear the talk of pendulum swings etc etc. i’m still furious at the government’s bullying tactics. if the government were to negotiate fairly on equal grounds, i would not be as pissed off or disappointed by them as i am. but i also get frustrated at the complacency i see among fellow colleagues when i try to bring up healthcare reform — i almost feel as if i’m being patted on the head like a fussy child: “there, there, give it a few years and you’ll come around.”

I discussed this with a mid-career physician.

He nodded and agreed things were bad for new doctors. “But they can still bill fee for service,“ he said. “That’s what I had to do.”

I mentioned that the A007 has barely changed for 10 years at $33 per visit. Inflation made A007 largely irrelevant as fee for service (FFS) got left behind to primary care reform. Premier Wynne axed the reforms. To suggest new grads could return to bill 10 year old fees that were woefully out of date 10 years ago is heartless and cruel.

“There just isn’t enough money in the system,” he said. “We have to cut somewhere.“

Even if FFS was a viable option, a mid-career MD should have enough sense to see the panic new grads face at digging out of $200k of debt using $33 per patient. On top of this, older doctors have never experienced unilateral legislated cuts like these.  Despite attempts at analogy, this is unprecedented. If older doctors cannot manage outrage on behalf of new grads, maybe they should choose empathic silence?

Society defines itself by how it treats its most vulnerable.

Premier Wynne attacked new graduates. She attacks those who cannot fight back. If we will not decry the Liberal barrage on new graduates, older doctors might be better off keeping quiet.

 photo credit: fhs.mcmaster.ca

Most rulers love popular advice, not honest criticism. Popular advice mixes two parts flattery plus one part suspicion plus 3 parts repeat-what-the-ruler-already-said using your own words. Great rulers despise it.

Medicare almost never has great rulers. Most politicians like to hear experts that congratulate accomplishments (flattery), question doctors’ motives (suspicion) and decorate party platforms with voice-overs from academics.

Doctors must learn to kowtow or get ignored by government. When clinics struggle to pay office staff, doctors must hold their nose, bite their tongues and offer popular advice. Doctors must kowtow to politicians to be included or face being left out of healthcare with left-overs.

Doctors Kowtow

Politicians and bureaucrats enjoy life when they don’t have to waste time engaging doctors. Whether it’s Health Links or Primary Care reform, government has a long resume of coming up with grand solutions, excluding doctors by design.

“You’d better be on the agenda or you’ll be on the menu!” Experts advise.

Do physicians compromise to get on the agenda? Do they avoid speaking out against inefficiency, waste or injustice?

Too often, doctors keep quiet to get included in a process. They reason it’s better to keep quiet about injustice than risk being thrown out of the inner circle.

Workers vs. Stakeholders

In successful businesses, workers speak up to improve operations. Employees risk their jobs if they keep quiet about waste or inefficiency. Companies must innovate or lose out to competitors who do.

In nationalized monopolies, workers speak up as citizens to improve their own lot and the interests of the stakeholders they represent. Stakeholders risk their lunch invitations to Queen’s Park if they speak out about waste or inefficiency. A nationalized monopoly does not need to innovate. It cannot lose.

Whine vs. Challenge?

At every level, Canadian healthcare encourages kowtowing and whining instead of rigorous challenge. Everyone tends to support the party line for fear of being left out of the political process. Ultra-sensitive to voter opinion, politicians would rather hear popular advice and keep their public image untarnished than hear rigorous challenge and risk re-election.

Now, more than ever before, Medicare needs doctors to be recklessly honest. Yes, reckless. Ontario’s doctors have nothing to lose right now, and patients have everything to gain. As things get worse for patients from Wynne’s cuts and underfunding, voters will lash out at government and doctors. They will demand to know why doctors didn’t speak up about mismanagement. They will despise doctors’ attempts to placate politicians.

If political rulers truly care about Medicare, they will welcome critique from outside groups. They will detest popular advice and flattery. They will refuse to listen when doctors kowtow, and doctors will refuse to try.

photo credit: economist.com