Category: Politics

Nurse practitioners (NPs) make twice as much as family doctors per patient. It costs between $130,000-$140,000 to hire one full time NP.  That is, an employer must fund  salary + benefits + salary for replacement staff when NP is on holidays.  This is a standard calculation for all salaried positions in hospitals, industry and private practice.  An NP experiences this as an annual income of around $110,000 plus benefits.

In capitated practices, individual providers roster (enroll) patients into their practice. Clinicians care for their rostered patients and see their colleagues’ patients if urgent needs arise.

Note: capitation pays doctors an annual fee, in monthly instalments, for all the care each patient requires. Docs can work towards earning small bonuses if they meet screening targets. These are bundled into the calculations below.

A full time family doctor (FP) rosters 1,600-2,000 patients, some carry more. A full time NP rosters 300-400 patients and cares for them as their primary provider with a physician serving as back-up. An NP receives the same salary regardless of their roster size.

Nurse Practitioners Pay/Patient

$130,000 income / 400 patients = $325 per patient/year.

If 300 patients, NPs earn $433 per patient/year.

Family Doctors Pay/Patient

$200,000 (net) / 1,600 patients = $125/patient/year.

For 2000 patients, an FP will net around $240,000 = $120/patient/year.

At $125/patient, family docs would earn $50,000 annually to see the same 400 patients as an NP. This equates to $40,000 + 20% benefit package. Per patient, family doctors get paid 38% – 29% of nurse practitioners.

In addition, nurse practitioners

• Do not have headache of paying overhead.
• Do not spend unpaid time managing overhead/office and do not assume legal risks of owning an office.
• Do not prescribe narcotics or controlled substances distancing them from a challenging group of patients.
• Have doctors for backup decreasing liability.
• Leave the most complex patients for FPs to sort out.
• Get lunch breaks.
• Do not take call after hours.
• Can forget the office when they go on vacation.

Many family doctors tell me the NP deal looks attractive. These docs would love a slower pace. If the government offered to pay NP rates for a roster of, say, 500-600 patients with the same benefits, I know many physicians would jump at the opportunity ($325 x 600 patients = $195,000).

But NPs spend so much time with patients! They practice unhurried holistic care. Family doctors rush and treat people like cattle.

Many family doctors would love to practice the same unhurried holistic care completely insulated from any concerns about anything beyond the 7.5 hour work day.

Income Inequality

Some doctors work faster, roster more patients and earn four times as much as an NP. People then assume that all doctors are fat cats.  No one cares about how hard a doctor works to earn a larger income.  Voters see doctors working harder in terms of cheating patients with shorter appointments. They assume that taking longer to provide care equals more care overall.

Doctors feel incensed at the injustice that NPs get paid twice as much per patient.  Marxists feel equally incensed that any worker could earn a much higher total income in the same industry.

Insurance vs. Managed Care

Government has changed Medicare from health insurance into managed care. Central planners obsess over inputs instead of outputs, costs instead of service and quality. Time becomes a key component of any input-centered system. Longer care becomes quality care. Obsession with input combines with an ideological commitment to income equality. Perverse incentives arise when central planners arbitrarily fix incomes to meet chic social promises.

In the end, patients lose out. When one provider makes twice as much per patient for easier work, the lower paid provider adjusts his or her service accordingly. He or she does not do it consciously, but it happens nonetheless.

Nurse practitioners provide enormous value when properly trained to use all their abilities as part of an interdisciplinary team. But they are not cheap. Governments know that.  For primary care, family doctors offer an incredible bargain. Politicians just won’t admit it.

[Photo credit: torontosun.com]

Many physicians think that an ideal doctor should act like a philosophical zombie. They wouldn’t use those words, but popular descriptions of ideal physician behaviour sound less human, more zombie-like.

Philosophical zombies look and act like regular humans but do not have conscious experience or feeling; think more like I, Robot than World War Z.  We understand them entirely in physical terms. Like zombies, doctors should be objective; empathetic but psychologically un-phased, infinitely malleable to their patients’ worldviews.

Zombie doctors follow guidelines faultlessly. They never veer from standards of practice for unscientific things like patient individuality. If planners or legislation call for action, zombies obey without question. If a patient requests a legal treatment, they twirl and mechanically deliver referrals like vending machines serve candy bars.

Patients never have to worry about zombie doctors acting unprofessionally. Zombies only do what zombies do, without any variability. Zombie doctors learn ethical guidelines and apply them with computerized regularity. They do not have opinions, debate nuance or wrestle with inconvenient social dilemmas. Zombie doctors do what they’re told and always act in patients’ best interests as defined by the social collective.

The zombie defence might explain why Canadian doctors supported the Sexual Sterilization Act between 1928 and 1970. Patients unfit to reproduce – for example, people with low IQ, no money, alcoholics – were sterilized against their wishes, sometimes without their knowledge during an unrelated procedure. Zombie doctors explains how the head of the Toronto Psychiatric Hospital served in the Eugenics Society of Canada during that period and received the Order of Canada.

But do patients really want zombie doctors? Or do we want doctors to act on strongly held personal morals?

Doctors denounce, and refuse requests for, female genital cutting even though most jurisdictions don’t prosecute parents who take their young girls out of country for the procedure. Most doctors denounce sex selection even though there are no laws against it in Canada (Globe and Mail, CTV News). If sex selection and female genital manipulation became legal, we hope most physicians would refuse to have anything to do with either of them.

 As Dr. Margaret Somerville, the founding director of the Centre for Medicine, Ethics and Law at McGill University said recently, “Do you really want to be treated by a doctor who doesn’t care if he thinks that he’s doing something unconscionable or unethical or immoral?”

There will always be some tension between the moral convictions of an individual medical professional who adheres to his or her own worldview and the different procedures that are legally available in a pluralistic society. (National Post)

Clear laws can help. But Martin Luther King Jr. reminded us to, “Never forget that everything Hitler did in Germany was legal.” Just ‘following the law‘ is known as the Nuremberg defence.

Life is great when other people do what we want them to.  But utopian dreams blur imperceptibly into nightmares.  A civilized society should not force anyone, including doctors, to do what they find morally reprehensible, even if it is legal.

Physician assisted suicide (PAS) is fundamentally confused. Other societies throughout history have supported physician assisted suicide, euthanasia, abortion, infanticide and much more. That does not mean Canada should. We might consider the following irreconcilable issues:

1. Doctors spend massive amounts of time and energy convincing patients to not kill themselves. It is materially impossible to differentiate nihilism from depression from hopelessness. The Dying-With-Dignity crowd promotes a false image of the typical patient requesting PAS: idealistic, articulate, and simply looking for relief when faced with the prospect of death.

2. Physicians take the Hippocratic Oath. They do it for two reasons. First, they want patients to know what they stand for, to offer patients a standard of accountability. But more importantly, the oath rests on the presupposition that moral neutrality does not exist. No one can pretend to stand as an objective oracle of medical wisdom devoid of cultural interpretation and nuance.

3. Assisted suicide can fail or not go far enough. Assisted suicide necessitates laws to support euthanasia so physicians can intervene to complete the suicide for patients left near dead from their attempt. Is that what society wants?

4. The rhetoric supporting PAS sounds exactly like abortion. Initially, abortion required special outstanding circumstances, second opinions and was supposed to happen rarely. Now, abortion is routine, uncomplicated and no reason seems slight enough to get one. The Netherlands experienced the same change in frequency, approach and reasoning over the years since PAS became legal.

5. Most patients do not want suicide. By orders of magnitude, the majority wants great end of life care. Those who pretend that frail elderly patients will not feel pressured to pursue PAS in the face of huge burdens placed on their families for elder care mislead to the point of cruelty.

6. What do patients want? Do they want physicians who hold to strong moral values and will share those views graciously? Do patients want physicians who will remain a source of strength, support and encouragement when their own resources run out? Or do patients want physicians who pretend to be objective, morally neutral and blind to the issue? Do patients want a physician who can care for them even when the physician sees the world differently?

7. After the media about forcing physicians to provide or refer for any and all publicly funded services, what protection do we expect for physicians’ own human rights? The College of Physicians and Surgeons has already taken direction from the Toronto Star to consider forcing physicians to act against their moral judgment.

As the libertarians, individualists and death-with-dignity celebrations die down, I hope Canadians will consider the consequences of legalizing physician assisted suicide. Let your MPP know what you think.