Plumbers never complain about a plumber shortage. Same thing for bricklayers and accountants. But doctors complain about a doctor shortage, all the time.
We do not have a doctor shortage. We have an artificial doctor shortage caused by shackling doctors.
In some cases, patients cannot access care because government will not pay for technology or operating rooms.
But in most cases, patients experience a shortage because doctors are limited by the number of hours they can physically endure seeing patients. No other service industry operates this way.
Rationing
The state has placed artificial restraints on what doctors can do.
If doctors were woodchoppers, it would be like telling choppers that they can only chop with a child’s axe, and they must do 100% of the chopping themselves.
And they must make a three-page chart about each chop they took, the ones they considered but did not take, and the chops they plan to take next.
Woodchoppers who want to avoid bankruptcy take action. They do not just buy bigger axes. They buy chainsaws and hire work crews.
They keep records only if it helps them improve customer service. Record-keeping for regulators cuts the bottom line. Choppers would either resist, avoid, or ridicule record-keeping requirements. Or, choppers would choose to pursue non-chopping revenue.
Doctor Shortage Nonsense
Each doctor could serve two to three times the current average and do a better job at the same time.
Could a dentist stay in practice with only one chair?
Could an accountant survive with one room and a secretary?
Do bricklayers brick your whole house without an army of brick helpers?
We have an artificial shortage of doctors, which government created to ration care. Government resists more care. All its thought is bent on it. Government wants to know exactly how much care will be provided next year.
Who Wins With Capitation?
That’s why governments love capitation. Capitation puts the cost risk of increased patient demand onto doctors. Doctors must learn to say No to patients, or doctors lose money.
Many champions of capitation insist that patients ask for too much. We should say No to patients.
Fee for service drives greedy doctors to meet ‘frivolous’ patient requests. Doctors and patients are in cahoots. A pox on them both.
But most doctors love capitation because they finally get paid for work that government pretended did not exist.
Or more accurately, government knew that patient visits were only a fraction of clinical work, but the state believed that a $33 fee for a patient visit should also cover checking labs and x-rays, calling patients back, coordinating referrals, and everything else that must happen to support one visit, not to mention management of the practice itself.
I am surprised that some doctors even mention refusal of ‘frivolous’ patient requests as a benefit of capitation. They applaud the ability to refuse requests that they deem frivolous, while getting paid more at the same time.
Great customer service means meeting each customer request with equal excellence and concern. It does not matter what the server thinks. It matters what customers think.
Relative Frivolity
It is odd that some doctors and nurses say with confidence, and at volume, that any patient’s clinical concern is frivolous. Why else would a patient come to see us than because she thought she needed to? Clearly the patient did not think the need frivolous.
Furthermore, arguing that patients would never make ‘frivolous’ requests, if they had to pay for the service, does not prove the requests frivolous in the first place. The patient’s request stands on its own.
If a patient had to pay a fee for every request, no question, some patients would forgo some requests that appear frivolous to us. But that just means the patient made a trade-off between cost and ‘frivolity’.
Even if cost won the trade-off and determined a patient’s action, that does not mean the request was frivolous per se. It just means that cost played a greater role in determining a patient’s action than her own worry about the issue.
Shortage of What?
Doctors have opened wide and not only swallowed. We have gulped the rationing bait beyond our heads and deep into the heart of our profession. Now the hidden hook, disguised by the rationing bait, captures all physicians’ services as a single line item at the Ministry of Health.
Too many doctors have swallowed the rationing hook, with the line. Now ‘frivolous’ patient requests sink with the system.
We need to focus on the right shortage. We have a relative doctor shortage caused by an absolute shortage of freedom. The program of government rationing requires regulation, which creates a shortage of freedom.
A whites-of-the-eyes billing approach guarantees that doctors can never scale up their practices beyond their individual physical capacity to see patients. No dentist, lawyer, or accountant would tolerate such an approach, even if their industries were socialized.
Abundance vs. Rationing
The current crop of Canadian doctors could provide all the care that Canadians want, with zero wait times, for most patient needs. Absolute shortages of sub-specialists would remain in some areas, but even current sub-specialists could increase productivity if freed to do so.
We could have doctors competing for patients, all within the publicly funded system, without adding one more doctor to Canada. Government would need to take off the shackles. But government will not release the doctors, because spending on health care would explode.
As long as government artificially restricts doctors’ services in an attempt to ration care, patients will continue to feel like there are not enough doctors. But in the meantime, we should stop talking nonsense about a doctor shortage.
Photo credit: Pixabay.com
Let me hire PAs and NPs and let them see patients and not force me to OTN every single hangnail in order to get paid. Pay me what I deserve for 27 years of experience, and if you can’t do that, then at least pay me what my 23-year old plumber gets which is $200/hr. $33/complex problem is just not enough to keep me in the game, and like many doctors I’m looking for greener pastures and an hourly salary for punching a clock. In other words, Respect = End of Doctor Shortage.
Solid comments, Jodie! Kudos to your plumber, also.
Artificial restrictions create artificial scarcity, which is exactly what government wants on its irrational road to rationing.
Thanks for posting!
My view is that there are factors creating a shortage that aren’t related to the actual number of physicians in the province. You can’t tell a small community in Northern Ontario that there isn’t a shortage because they don’t have enough in town. However the geographic service model that is prohibited by guidelines around adopting tech mean the physicians in Ontario that have time can’t help those Northern Communities. Also the expectation that one must physically be with the doctor no longer holds true.
Until we address physician resource planning and efficiency (tools, communication) and make a plan to allow the most productivity and in turn appropriate compensation for physicians we will be relying on the argument that the only solution is more physicians.
Great comments, Kevin!
Agree. And no doubt, there are some communities that are so small they will never support certain kinds of docs. But on the whole, we could offer double or triple the number of medical services without increasing the number of docs. Competition in urban areas would drive more docs to work in smaller towns.
Simply brilliant Shawn! “We have a relative doctor shortage caused by an absolute shortage of freedom..”. Took me a while to unpack that little line but it truly sums up all the current realities in our festering health care systems. The single payer can no longer afford the promise of free, universal, untethered health care. The single-payer sets the bait… The unsuspecting physician takes the bait, drinks the Coolaid, looses all professional autonomy and morphs into a provider of rationed care. Tethered by the machinations of the desperate single-payer, with the assistance of medical colleges, regulatory bodies and associations focused on self-preservation, the physician-patient relationship is sidelined and ultimately dies. Bewildered patients, hung up on the promise of free, universal and untethered health care loose access to physicians and to health care that was delivered as a standard only a few decades ago. Everybody blames the doctors or in the least that there aren’t enough doctors. Nobody admits that this is all about rationing care. The festering will continue as long as the unsustainable promise remains.
Well said, Paul!
Your whole comment was excellent, but I especially like this: “The physician-patient relationship is sidelined and ultimately dies.”
“Nobody admits that this is all about rationing.” In the UK, people write textbooks about rationing and discuss it as though it were a normal and essential feature of socialized medicine. For some reason we do not see that in Canada. Rationing makes politicians panic. So they blame doctors instead.
Thanks so much for reading and posting a comment!
Cheers
In a free market there are no shortages of anything unless there is a natural disaster underway….Adam Smith’s invisible hand working its miracles.
Putting natural disasters aside, whenever there are shortages of anything one will find the very visible bob nailed boots of hubristic governments , of their all knowing central planners ( with no skin in the game) and of their bloated, clumsy, plodding, pedantic kasfkaesque bureaucracies.
Governmental ham fisted interventions , price controls inevitably lead to loss of equilibrium (shortages of anything normally leading to price increases with surpluses leading to falling prices) , subsidies ( if it moves…tax it; if it keeps moving regulate it ; if it stops moving subsidize it) , regulatory burdens all leading to disaster as demonstrated in socialist countries with Venezuela being just the latest statist disaster…a fundamentally rich country, rich in natural resources, oil, minerals …rich in agricultural land and forestry…with fish teaming off shore…a capable and skilled population now starving with millions escaping for refuge in neighbouring less centrally planned countries…Venezuela having universal health care guaranteed in its Constitution is now unable to provide even a band aid.
If there was a genuine shortage of medical practitioners in Canada their wages would be going up so attracting more into the profession to relieve the shortage, instead their number and incomes have been deliberately suppressed….there is , on the other hand, a glut of governmental health care bureaucrats , their wages should be coming down to relieve the glut…instead they have been artificially puffed up.
We have a bizarre situation in Canada…a long column of medical practitioners eager to provide their service…a second long column of patients eager to receive that service…and a gigantic governmental bureaucracy designed to prevent the twain from meeting, standing as an obstruction between them.
Sure appreciate your writing, Andris:
“…central planners (with no skin in the game)…”
“We have a bizarre situation in Canada…a long column of medical practitioners eager to provide their service…a second long column of patients eager to receive that service…and a gigantic governmental bureaucracy designed to prevent the twain from meeting, standing as an obstruction between them.”
Well said indeed.
Thanks again!
Well said Shawn.
However,before we look to gov’t to remove the ‘shackles’ and free docs,we must look within,and get OUR OWN ASSOCIATION ie the OMA to free docs in Ontario from the shackles of indentured ‘membership'(pseudoranding).Only then will the path to freedom begin ….
When Pat closed her practice, two of the doctors that took her some of her patients was a surgeon and a haematologist. Both doctors were from Africa and really nice guys. However, the were only given FP billing numbers and couldn’t practice their specialty. The surgeon was allowed to do surgical assists though. This would be a joke if it wasn’t tragic.
Interesting…
I imagine that they had to write qualifying exams? Maybe they chose to only write the family practice exams?
I would say they had to write exams, since they were both disappointed that they weren’t practicing their specialties I would find it surprising that they chose to write FP exams. They both went to med school in the UK so I can’t say definitively what the problem was.
FMG’s have to do more than write and exam. They essentially have to go back and complete a Canadian residency and then write the college exams.
Thanks Ernest!
Another great post Shawn.
Rationing. Artificial shortage. Make it look like it is not available just because you don’t want to pay for it !
(Hey, Yo : If you can’t pay for it, just admit it and get out of the way !)
We are in a night-mare ! we know exactly what is wrong, but we are paralyzed. unable to awaken.
And just as we bemoan our fate, the largest economy in the world is on the cusp of a takeover by time-warp socialists ! Amazing.
Best,
Gordon Friesen, Montreal
http://www.euthanasiediscussion.net/
Exactly. Well said, Gordon. “Make it look like it is not available just because you don’t want to pay for it!”
Thanks for reading and posting a comment!
Well said Shawn.
However,before we look to gov’t to remove the ‘shackles’ and free docs,we must look within,and get OUR OWN ASSOCIATION ie the OMA to free docs in Ontario from the shackles of indentured ‘membership'(pseudoranding).Only then will the path to freedom begin ….
Our “ association” has drunk the statist koolaid and has been transformed into a flock of compliant sheeplike woke snowflakes , kowtowing to whatever hare brained policies (perpetually lacking any evidence) that the self interested political class and their ever self serving bureaucracies regurgitate.
Andris,
As usual, I really enjoy your comments.
I have to push back a little on this one. The OMA is only as good, courageous, and strong as the people who step forward to serve in it. If you see too many “sheeplike woke snowflakes”, then we need to recruit/encourage other kinds of members to serve. If all the docs in Ontario have become enamoured by big government and woke endeavours, then we have a different problem, but it is still not the OMA’s per se.
Sometimes it takes incredible chaos to purge a system and begin a rebuild. I believe we are on the rebuild portion of the OMA cycle right now.
Thanks again!
Having spent 14 years on Council spread over the decades I could not help noting the negative changes of its membership.
My high light was witnessing Ben Trevino , “ the Rainmaker” labour relations lawyer who had won a 40% increase for BC’s doctors and then a 20 % increase for Saskatchewan’s physicians leading the charge at Ontario’s Council in 1982…we stood on our chairs, punching the air and went on strike…the Council was composed meat eaters in those days and the strike was won.
I was not on Council in 1986 when, like idiots, Council believed that all it had to do was to replicate the ‘82 strategy….the Ontario government had studied the ‘82 strike from every angle and had devised counter moves…the ‘86 strike was crushed …Council had self gelded itself and was never the same again…the meat eaters were eventually replaced by compliant tofu eaters more concerned about removing plastic water bottles from Council chambers…. I returned to Council to witness the 2012 debacle where Council was conned out of its socks by the government negotiators…the result …utter snowflakization with Council dancing to the government’s victory tune.
I should have mentioned that the RAND formula was one of the key moments that allowed the government gained to gain complete control over the profession.
There have been episodes , over the years, when the membership attempted to “ kick over the traces” as Shawn well knows from personal experience, but the Ontario government managed to retain control.
Thanks again for this, Andris!
Was the 1982 job action a full strike or just rotating job actions? I realize that this is still a form of strike action, but I never hear it talked about very much. All we ever hear about is the “horrible”, “immoral” strike of 1986.
Thanks again!
Rotating.
That the profession won the ‘82 strike has been suppressed in the collective memory of the profession following the shellacking of ‘86…no one talks about it….Sun Tsu would not have approved of the lack of strategic and tactical thinking of the part of the ‘86ers who had simply brushed off the dust off the ‘82 manual in the naive belief that the government had not studied it from every different angle and formulated counter measures.
The energy of ‘82 , the grassrooted pressure , had built up within the vibrant doctors’s lounges of the hospitals of that era…from the active local societies of that era…both of which, the hospital lounges in particular , having been deflated and diminished by the powers that be.
Independent medical social media will have to take their place…the medical magazines ,official and unofficial, having been penetrated by the censoring dark side.
Thanks again for this, Andris! (I missed your excellent reply…sorry for not responding sooner.)
I can’t argue there, Ram. I do not agree with force for anything. Organizations run best when they earn support and win trust from those they want to serve. I’ve been smacked down by many docs who I otherwise agree with on most things. They argue that we’d have too many free-riders. I guess I see the risk of free-riders as smaller than the risk of an organization being able to stay in business while offering sub-optimal service.
To be clear, I believe the OMA is doing much better lately. But as long as it exists on a business model that guarantees income regardless of service, I worry about how it can maintain excellence without individuals exerting extraordinary effort to keep the organization focussed.
Thanks again for your comment!
The root cause of all the rationing problems is the restriction on physicians to choose to work outside of the public system. I can think of no other profession or citizen type restricted in this manner. This is a constitutional problem and the only solution is to challenge it in the supreme court. This is a restriction on personal freedom with far reaching consequences. In short, if there were an option outside of the public system, the government would have to compete on services and fees. They would also be free to de-list what they don’t want to pay an appropriate price for, freeing up more of their taxes for other things like bribing people with their own tax money to vote for them.
Good point.
We’ve seen that the courts feel comfortable compromising physicians’ right because we are deemed to be privileged. So the courts have abandoned the classical liberal notion of blind justice and equality before the law. Lately, they take the stand that they will decide whose rights deserve legal protection and whose rights society can ignore. This is not freedom.
Thanks for posting!
I am delighted that it is finally said aloud that the doctor shortage is artificial.
In “statistics” they talk about number of doctors per 10,000 or a million population. As if you count diseases, someone with five diseases is sicker than someone with four… What is left out is the number of hours they are allowed to work… Lots of money is wasted if eg cancer surgery is delayed, since the cancer will not go away, it just gets more expensive to treat. Let alone that you die… Nobody looks at that kind of waste…
Thanks for bringing it up!
Great comment, Leda!
Governments and bureaucracies love to focus on inputs. It’s like staring at how much we are pressing down the accelerator pedal on our car. But only outputs matter. People care what speed the car is moving, not how hard we are pressing the pedal.
Thanks for taking time to read and post a comment!
Cheers