Category: Politics

Everyone knows to avoid politics and religion in polite conversation.  Not any longer. The Supreme Court’s unanimous decision to rescind the ban on physician assisted suicide promises to make politics and religion very popular topics. Here’s some of the coverage so far:

•  CTVNews
• Toronto Star
• Globe and Mail
• National Post

Last summer, the media exploded after a walk-in clinic doctor refused to give a young woman birth control pills. The Toronto Star said that “Doctors who play God can be pastors not physicians.” The Star rocked the College of Physicians and Surgeons of Ontario (CPSO) with, “If the college fails to reassert itself as a self-governing authority, let the provincial government step in to defend patient rights under the Ontario Human Rights Code. Queen’s Park could do that by de-delegating the college’s authority and re-regulating medicine on our behalf.” De-regulation scares the CPSO more than anything. It immediately tackled a rewrite of its 2008 policy, “Physicians and the Ontario Human Rights Code”.

A number of doctors agree with the Star. They insist physicians must submit their personal beliefs to their patients’ requests. If a patient wants a legal, available treatment, then a doctor shall comply or refer the patient to another doctor. Noncompliant doctors should face discipline. In other words, refuse the pill; lose your licence.

These same doctors usually emphasize the role of evidence, science and objectivity in medicine. In their view, medical practice is crisp, uniform and evidence based. There’s little need for doctors to rely on personal ethics or morality in their decision making. In fact, aside from the Georgetown Mantra (Principles of Biomedical Ethics), doctors should leave their personal morality at the door (which is, of course, a moral position of its own).

But experts tell us that medicine isn’t crisp, uniform or even as evidence-based as we would like. Sherwin Nuland, author of the best seller How We Die: Reflections of Life’s Final Chapter, New Edition, also wrote about uncertainty in The Uncertain Art: Thoughts on a Life in Medicine. Whether people call it art, wisdom or clinical judgment, medicine appears less black and white and more often frustratingly grey. It makes medicine an intrinsically moral profession. Even with solid, evidence-based treatment guidelines, doctors still must work to explain, encourage and support patients to carry through with what’s good for them.  Governments started paying physicians incentives based on how many patients doctors convince to agree with current clinical guidelines where they exist. Medicine is not crisp and clear. Physicians require acute moral sensitivity since almost everything they do involves moral agency (see Medicine as a Moral Practice).

Even if we grant that patients’ rights should trump doctors’ beliefs, does this apply to everything? Should doctors comply with every patient request so long as it’s legal and doesn’t hurt anyone else? Should doctors be forced to give narcotics for chronic pain to everyone who asks for them in the emergency department? What about X-Rays and blood work? Many investigations aren’t cut and dried, evidence-based. Should doctors always rescind their clinical judgment in favour of a patient’s demands if there’s no evidence to guide them? What if sex selection becomes legal in Canada? Should doctors be allowed to refuse to help parents choose the sex of their children?

The Supreme Court stressed that doctors “cannot be compelled to assist someone in suicide“. It seems, for now, that doctors’ beliefs might trump patients’ rights. Pending the CPSO update on Human Rights, the College might still force physicians to refer patients for assisted suicide. If patients request it, doctors might have to choose between their medical licence and their Hippocratic Oath: “I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan…”

The federal government has one year to draft new legislation. In the meantime, expect to find politics and religion in conversations everywhere.

photo credit: ctvnews.ca

It seems there’s a bullying epidemic. Sometimes it hits you. You pick up your books, brush off your knees, and smear the tears from your eyes. Do you then:

• Move on?
• Forgive and forget?
• Try to work it out?

Doctors in Canada are watching Ontario and Quebec closely. Quebec took command and control in Bill 20 with legislation against part time practice. Ontario reversed more than a decade of improvements possibly decimating primary care.

Edmund Burke cautioned that, “Those who don’t know history are destined to repeat it.” (pre-Santayana)

Legislation Epidemic?

A lawyer friend added up all the statutes that regulate medical practice in Ontario, going back to 1907. Each statute can have many provisions. Statutes spawn even more regulations, but he ignored all these to make a simple point. He graphed his findings on the right.

If this graph showed Ebola cases, we’d panic. Justice Winkler said bluntly that doctors and government “seemed to be on a collision course”. He said the current approach is not sustainable. Like swimming in a strong current, we don’t notice how far we’ve moved from shore, or the danger we’re in. 

Everyone wants to be the boss but no one wants to take responsibility. The government wants to manage doctors but doesn’t want responsibility for outcomes. Politicians want to direct doctors like employees but don’t want the legal blame when their ‘employees’ under-perform.

How will physicians respond to the legislation epidemic?

Innovation, creativity and excellence in clinical care require freedom to act in the best interests of our patients. Legislation limits freedom. Certainly, some freedoms need restraint. But government has gone from limiting bad behavior to prescribing good with legislation. Well-meaning politicians trust that benevolent authorities can do more good than individual physicians. But, you cannot legislate innovation. Universal care loses benevolence in overregulation.

Doctors’ Response

Physicians are knowledge workers, not assembly line robots. You cannot manage doctors and patient care in the way you herd cattle or pick turnips. We cannot blame politicians for wanting action. If given the chance, doctors might whack with the blunt hoe of legislation too.

We must think deeply about this. Principles and logic never change opinions arrived at by emotion or ideology. Doctors’ heightened sense of fair play and natural aversion to political engagement hamstring the work ahead. Doctors will always find people who need their care, but will physicians be allowed to provide the care patients need? Doctors want desperately to partner with politicians finding solutions, but at what cost?

Doctors-and-patients know best what patients need, not politicians and bureaucrats. This firm moral resolve, and nothing less, underpins a great healthcare system.  Only resolve promises relief from the legislation epidemic in Canadian healthcare.

photo credit: theguardian.com

Will fee cuts do anything to doctors? Certainly, fee cuts hurt patient care and new graduates. But will legislated fee cuts make any difference to established family doctors?

A few mid-career physicians say they don’t expect any real pain from cuts. Others doctors just carry on in over-worked ignorance of anything political. But some physicians are extremely concerned. We might think of these doctors as marginal customers.

Marginal customers are shoppers who hover in indecision before purchasing a product. They are price risk averse. Companies work hard to help marginal customers commit to a purchase. Businesses don’t waste much energy on committed customers who do not, or cannot, change products easily.

A big group of family doctors behaves like committed customers. They stick with office practice and have no easy alternatives. For them, fee cuts demoralize and irritate but will not change what they do for a living.

Another group of family physicians never works in an office. They practise emergency medicine or palliative care or some other medical pursuit. Fee cuts won’t change their careers either.

But many family doctors have a small practice as well as other medical duties. They often work in small or rural communities providing a range of services beyond office care. They balance their ideal of an office practice, where patients are given extra time and attention, and other work such as public health, long-term care, education (unpaid) or whatever else their community needs. But office overhead never sleeps. Even when doctors work outside their office, overhead keeps generating bills. A cut to fees for office work changes financial balance sheets.  Non-office work ends up subsidizing office practices, even for docs who work in groups.

Over the last 2 weeks, many readers have shared comments, sent emails, or told me personally how fee cuts impact them. Here’s what they say:

1. Amanda (shared her comments on an earlier blog post)

…I am a family physician in a small town in Ontario and am working other positions (public health, university teaching) to be able to subsidize the cost of keeping my family practice office open. I am definitely one of those docs who is pulling the provincial average down and cannot afford to keep money in the corporation by incorporating or income split as my spouse is a teacher and it would not benefit our tax situation. I adore my job, I love teaching future physicians and believe family medicine is the backbone of our health system. I never thought, however, that I would spend so much time worrying about money after having been in practice 15 years. I have considered closing my practice several times because my overhead runs upwards of 60-70% some months. I can’t cut my expenses anymore and am not willing to sacrifice the quality of my patient encounters to push people through faster.

I know none of this is news to you… I feel validated and among outstanding company in reading your articles and comments. I wouldn’t change my career and feel privileged and blessed to be a small town family doc but believe the government and media are not being accurate in their portrayal of our situation….

…Our small town has lots of unemployment, low education levels and families struggling to put food on the table. I am so thankful and recognize my blessing and privilege in being able to do what I love and be paid anything for it. But – I fear I can’t continue providing this needed service if I can’t keep putting food on my own children’s table….

2. Anonymous Family Doc

One doctor worried that any hint of being forced to reconsider her office practice might cause panic in her community. She has young children and works 40 hours per week. She pursues an idealistic goal of unhurried, holistic care. This keeps her income very low compared with colleagues. Her fixed costs remain. The fee cuts will hit her net income at least 30%.

 3. Doctor on Twitter

Dr. M shared that she has 2 young kids and works office based family practice plus ED. She worries whether fee cuts make her office unsustainable.

4. Small Volume, High Needs Doc

Another family doc is approaching the end of his career. He manages more complex/high-needs patients than average. He sees a small number of patients each day but spends more time with each one. His income-to-overhead ratio balances on a razor’s edge. Small changes to gross income produce exponential changes to his net income. Fee cuts force him to seriously consider whether he can keep practicing.

5. Emergency Doctors

A few family docs, who work a number of shifts in the emergency departments, have indicated they will increase their ED work and consider closing their offices altogether. I expect this number to increase.

6. Near Retirement

Primary care reform re-invigorated family practice for many older doctors. They could finally step off the fee for service treadmill. Adding 10 years to the end of their career has helped reduce the number of patients without a doctor from 3 million down to 900,000. Expect these doctors to revisit their original plans and look again at retirement.

Rebuttal

Many people shrug, so what? Businesses go under all the time. It weeds out the weak and leaves the strong. Besides, most doctors probably fall into the ‘committed customer’ group. They have to keep working no matter what the government decides.

Unlike failing businesses, these ‘marginal customer’ family practices provide an invaluable service to their local communities and offer a great example of what outstanding care might look like in less than ideal conditions.  The physicians who attempt to provide an idealistic form of unhurried, holistic medical care often provide role models for the rest of us who scurry around in practices that have grown too large.

 

People need to understand how fee cuts change healthcare. Physicians will work to minimize the effect, but cuts will harm patient care.  Losing small family practices won’t just decrease access to care, it will impoverish the whole character of healthcare in Ontario.

photo credit: theguardian.com