A Happy Life in Medicine

41 thoughts on “A Happy Life in Medicine”

1. Shawn,

   Quite enjoyed this piece (for obvious reasons given my own experiences). I’m not sure at this point that changing the business model of medicine or repealing the Canada Health Act and so on will make much of difference in the happiness of the physician population. There are so many legacy issues that aren’t, and to some extent can’t be addressed without a fundamental reexamination of the role of a doctor in the health care system.

   The doctors showing the many aspects of “career pain” you outline entered training beginning in the 1990s. It’s not exaggeration to say that more changed in that decade from the standpoint of new doctors than we often think about. The 90s are the period of increased competition for med school (Bachelor’s degree required, Barer-Stoddart inspired enrollment cuts) and exploding tuition costs. It brought in CaRMS, with career decisions placed in the hands of med students who no longer had the option to retrain in the future without major obstacles (that have now grown to absurdity). It brought femininization of the profession without concomitant system supports and adaptation. And this was the era of GPs pushed out of hospitals and bed closures, and all the problems that have followed from that.

   There’s a lot that definitely can be laid at the feet of recent policy directions by various governments. (Anyone who thinks the Ontario government makes life hard for doctors and patients should take a look at the Atlantic provinces.) Government cuts, stupidity, arrogance, etc. will explain a lot of anger and burnout in previously content doctors in, say, their mid-40s, whose children are old enough to not need mom’s full time attention.

   But we can’t overlook that the dissatisfaction is almost exclusively felt by doctors in primary care disciplines…our surgeon and diagnostic/lab specialist colleagues seem only truly upset with “modifiable” system issues (funding cuts, work volumes, OR time), etc. The changed expectations of the doctor in primary care is something nobody seems willing to examine. It’s a pity, because what we’re seeing in the youngest generation of docs – full-time CAC work, pseudo-specialization – *is* affecting patient care. And government will only respond the way it always has – laying the blame on doctors.

   1. Brilliant, thoughtful comment, Frank. You have obviously thought about this deeply. Readers should check out your book on the topic: The Flame Broiled Doctor.

      Your comments on the 90s are so true. Losing a rotating internship removed choice and flexibility in return for a more prestigious College of Family Practice. The college won; docs lost out overall.

      Whether or not we re-write the CHA, we need docs to feel like they have made a great choice and could change their mind at any point. There are no chains. That goes beyond the CHA, for sure. I think that if doctors were allowed to provide ‘medically necessary’ care outside the government controlled and rationed system, they could vote with their feet and lend support to whatever approach offered the best care. All businesses, especially governments, should succeed or fail based on how well they serve people. Bad service should mean bankruptcy.

      I also liked your comments about primary care. I hope some of our specialty colleagues will share their thoughts also.

      Thanks again for reading and posting! I hope you are well.

      s

2. I agree with informed consent to eager students…

   I have come across a lot of people who thought that they wanted to be physicians as well as parents who hoped for a career in medicine for their young children.

   I have informed them that they would be signing up to give up 10-15 years of their life that they will never get back, train 60-100 hours per week for 2-7 years and go several hundred thousand dollars into debt. If they survive that, they will have the privilege of being free, taken for granted, hated and envied in a system that will erect barriers to them getting care for patients while making sure that they are blamed for decisions they did not make and factors that they cannot control.

   I have changed the minds of almost all parents and almost all prospective medical students that I have come across. My children will NEVER do this…and I am making concrete plans to be out of medicine in the next 6-24 months. This ain’t what I signed up for…

   1. Oh Paul. You have such a way of making things so plain and clear — simply genius!

      The irony is that those with the least emotional intelligence about media/public/political slander have the easiest time ignoring it. But those are the folks that people try to screen out during med school interviews. Schools aim for the most genuine, compassionate, and hard-working people to train as physicians. Then we wonder what’s wrong with them when doctors burn out in the face of unnecessary dysfunction and suffering.

      I know that many readers will be jealous (that is, want what you have) of your concrete plans to exit. You have worked like a dog for decades. You have earned a break.

      Thanks so much for sharing this. Be well my friend.

      S

3. That is an excellent article. Being in the group who was disillusioned very early on, I prepared such that I now only practice medicine as a choice and not a necessity . Which means facing scrutiny sometimes of CPSO but their power is limited as I know I am only here by choice. Hence it dosent control and overwhelm me. Sadly the ones who cannot escape feel the tyrannical powers of MOH , CPSO, hospitals and patients the most .
   At this point I am just “ playing” in the sandbox because once it’s not a necessity for survival , it can be quite fun . I love your analogy about being able to love by choice .

   1. It is so encouraging to hear that you have made this transition, Zoey. This is exactly what docs want to hear. Being able to continue ‘playing’ without any dread or fear that your whole livelihood could vanish based on one silly complaint or unlucky circumstance defines freedom.

      Patients get the best service from docs who feel energized, passionate, and free. We cannot hide or fake drudgery. By definition, options eliminate drudgery, because why in world would you continue at drudgery if you could choose something else?

      Excellent comment. Thanks so much for taking time to make it!

      Cheers

4. I was a junior resident , asked to meet management about our lack of access to food at night , cockroaches in our call rooms, broken showers and safety concerns re walking through dark parking lots at night . After a gruelling 60 hours call ( Friday to Monday ) I waited half asleep for management to arrive . And saw them arrive in their fancy suits , Mercedes cars and before they could deign to speak to me , they were served coffee / tea on a silver tray along with cakes/cookies.
   That was the moment my altruism flew out of the window and it was every man / woman for themselves . And I never looked back. I escaped mentally and looked not for what I could do for medicine but what medicine could do for me. And put my passion in other venues too. Sad really , because once upon a time , I really cared.

   1. Wow! Fantastic story.

      I agree, it is tragic. We lose many of our best or, too often, crush those who remain. Still, I admire your courage and ability to reinvent yourself. That’s inspiring.

      Thanks again

5. Good observations Shawn, and the comments as well. Your thoughts about enjoying the practice of medicine as long as one feels they are doing it freely resonated with me. For the first 3 phases of my career spanning about 36 years I did experience that joy of being there because I wanted to. After turning 65, when I had imagined being able to only work when it suited me, but not feeling liberty to do so because of no family docs (yet) to replace me, it has been harder to summon up the enthusiasm (as it is for many things we have done so many times before). Of course that is all in my head, since I am in fact still freely doing what I’ve chosen to do, especially recognizing that I could not think of another career that I would have enjoyed more than this one. So, daily opportunities for mindfulness, appreciating the increased respect shown by patients, and the increased freedom to (also respectfully) speak my mind and to practice within my comfort level, and excuse myself from tedious hospital administration roles.

   1. Thanks Phil

      Great angle on feeling forced to work beyond the time when you’d rather slow down. I suppose this is feeling like you have no choice because of your commitment to your patients.

      You raise another good point about it being “all in my head.” On one hand, we could use that phrase as a dismissal of our experience. On the other, what is life except what we experience in our own heads? Regardless of how our interpretation of work impacts our joy, or lack thereof, I still think that the decision tree existing outside our control weighs heavily on physicians — especially those in mid career with debts, family, etc.

      Great comments! Thanks so much for taking time to share them.

6. For myself medicine was a vocation,

   As a refugee from socialist totalitarianism, my mother and I were taken in ( from post WWII West German refugee camps) by a grand Welsh lady who needed a house keeper.

   At the age of 8 I observed Dr Williams, our Family doctor, on a home visit, changing the dressing on her post mastectomy wound …and that was it, I was hooked.

   After 52 years of medical practice I have not regretted my decision for a second and I particularly loved my professional freedom, a freedom increasingly under threat.

   Aesop told the tale of the domesticated dog and the wolf.

   The dog boasted of how comfortable and luxurious a dog’s life was in comparison to that of the wolf’s, hoping to recruit the wolf to domestication …the wolf pointed to the dog’s collar and when its role became evident he stated “ of all of your meals I want nothing” and he took off .

   It has been a sad sight to observe our domesticated colleagues revering their gold collars and plates full of kibble, giving up their professional freedoms in exchange for them….boasting to their colleagues of their comfortable situations.

   Freud stated that happiness was a state of freedom of frustration….only a child is free from frustration…it is a fact of adult life that there will always be frustration….domesticated dogs are frustrated…I prefer the frustrations of the free wolf.

   1. Fascinating comment, Andris. I didn’t realize that you were up to 52 years — Wow! That is an accomplishment. And to say that you have no regrets is another one too.

      Given your passion for freedom and limited government, I did not expect to hear this from you. But it makes sense…

      I like the wolf also.

      Cheers

7. I am saddened to hear that so many of our colleagues regret the decision to pursue a career in medicine.
   I can’t think of a career that comes close to medicine in allowing us to truly do things that matter on a daily basis.
   The personal satisfaction of making a difference in the lives of our patients and helping them with their sometimes difficult journeys can’t be under estimated.
   No matter how difficult our days our , I am sure that our patients are having an even worse day.
   I have practiced Emergency Medicine for 27 years and realize that the physical challenges of shift work will eventually require me to pass on the baton.
   I savour the opportunity to work now as I know when I leave clinical medicine a part of who I am will be gone as well.
   I have come to some point of solitude in accepting the 8 hour wait is not my personal problem to solve but I can still continue to give each patient I see the best version of myself.
   Our cycle of abuse and recovery which you commented on as we take a vacation to recharge is not the answer.
   Yet I do this myself as well.
   We need to address the issues in the work environment now so that we can continue to enjoy our careers and provide engaged care to our patients.
   We should not discourage our best and brightest from a career in medicine but rather mentor them from what we have learned so that they can discover a way to thrive in a truly meaningful and proud profession.

   1. Solid comment, Peter. Thank you so much for writing this. You are right: it is a tremendous honour and privilege to serve.

      I think that you nailed it in two ways when you said, “I have come to some point of solitude in accepting the 8 hour wait is not my personal problem to solve but I can still continue to give each patient I see the best version of myself.”

      First, happiness can come — always comes? — in spite of circumstance. The second thing you highlighted, which I agree with, makes me worry. If we find a way to overlook the insufferable “8 hour wait” in order to prevent our own moral distress, how does this help patients?

      There seems to be a paradox in our pursuit of continuing to “give each patient…the best version of [our]self.” We find inner coping mechanisms to manage the moral angst that comes from trying to provide care in a rationed and irrational system. But when does our coping become support for a dysfunctional relationship? Could our desire to do a ‘really good job’ for the one person, who finally gets to see us, contribute, in a paradoxical way, to the abandonment of all the other patients in the waiting room who could not see us in an appropriate or safe amount of time?

      Your thoughts are valid. Doctors pull back to our roots — the doctor-patient relationship — when the world is crashing around us. But many doctors cannot. They feel that the irrational rationed system directly impacts their ability to provide the care they would want for their own family and loved ones.

      I love your ending. I agree. We need to find a way to thrive regardless of the system we find ourselves in.

      Thank you so much for offering such a thoughtful comment. Really appreciate it.

      Best regards,

      Shawn

8. Old doctors have the sense that they are free to do for the benefit of patients whatever their judgement permits/recommends/urges. Young doctors feel constrained by all that they’ve recently been taught–guidelines, political correctness and various hospital and social rules and expectations. Old doctors live in a fool’s paradise because their ignorance of these modern constraints still bites them when they transgress, and then their delusions clear and they see that they have actually been imprisoned without knowing how or when it happened. Young doctors are taught from the beginning that they have to work in a prison cell, but they will be well paid and treated as long as they don’t try to escape (i.e. break the rules). So the Aesop story in the comments, like so many of the Aesop Fables, is totally applicable.

   1. Wow. Profound comments, anonymous.

      If your comments about older physicians are true, which I think they might well be, they explain the habit of older docs to pat new grads on the head and tell them everything will be alright.

      Thanks so much for taking time to read and post a comment!

9. I try to approach people respectfully, understanding there is a logic to their beliefs and perceptions even if I can’t see it. I feel real sympathy for physicians who are so deeply unhappy in their profession, but I also fear being in their care. I find it hard to believe such unhappiness can be so compartmentalized that care doesn’t suffer…at least if we conceptualize care as something more than technical skill.

   I am a non-clinician but have worked in healthcare for 30+ years beginning in hospital administration and have also spent time in government. I actually pursued my career because…get this…I thought no one should ever be sick and alone. Seriously, I actually voiced that sentiment! I’ve spent a good part of my career juggling the competing demands of unions, physicians and government each of whom always professed to be solely interested in patients. I’ve dealt with changes to residency training the origins of which, as far as I know, had nothing to do with hospital administrators or government. I’ve hustled for funds to pay MDs in the face of a constant diminishment of scope of services offered. I’ve also hustled to acquire equipment and been told by MDs who entered medical school 20-years after I began my career that I can’t possible grasp the value of MRI because I am not a clinician. And, for half my career I also worked 60-hour work weeks.

   Thirty years later I have frustrations but I am not bitter, angry or despondent. I still have my original naive-sounding motivation. I accept things are far from optimal and I won’t dismiss anyone’s unhappiness. But to the extent one is open to other perspectives and the possibility there is logic in them, here is mine: there have been huge changes in health care and many of those changes have not been done to us but, rather, because of us.

   Look carefully at the history of clinical medicine or public policy and you will have no difficulty finding remarkable resistance to change. Consider regionalization as it emerged in the 1990s. I am not a huge fan of the outcome but lets be honest…it only happened thanks to the intransigence of hospital boards, administrators and MDs. The major players in Saskatchewan had two chances to act independently before the government stepped in. Government in Alberta told the major players to fix ‘it’ or government would…in the end government stepped in. What would have appeased government at the time? Reduce the duplication of clinical services in urban hospitals. The response from the field…hospital A has always had pediatrics…I’ve only ever practiced at hospital A and don’t want to work at hospital B, hospital A cannot offer emergency services if there is no pediatric department in the hospital…

   Sometimes ‘we’, in the largest sense (e.g., healthcare workers), are the authors of our own individual misfortune and sometimes this extends to successive generations (of professionals).

   1. Thanks so much for posting this, James. You’ve been gentle and thoughtful in your pushback: excellent.

      Your note is long enough to merit a whole blog in response, so for now, I will leave it for readers to comment, if they wish.

      Again, thank you for your years of work. I agree with much of what you’ve written but disagree with some. While you are clearly correct in saying that everyone in healthcare carries some blame for dysfunction, the dysfunctional change is usually applied to physicians’ work experience, while the system planners’ jobs remain unchanged. The planners still show up at 9:00 am (or 7:00 am) and still go home at 5:00 pm (or 8:00 pm!). Regardless of system change, a planner’s job is still planning. But system change turns doctors into data entry clerks, rule followers, and educational coaches, whereas doctors trained, and used to spend all their time on, diagnosis and treatment.

      Sure appreciate you taking time to read and post such a thoughtful and articulate comment!

      Cheers

10. Amongst the freedoms that have been lost is the freedom to switch one’s field…some of the best and most understanding specialists I had the pleasure of working with had been GP’s / FP’s for 5-10 years previously.

    The moderns have to choose their field far too early in their training…one imagines that there must be many that feel trapped in one field when they discovered a passion for another…..another is the loss of camaraderie of the hospital doctor’s lounge and of the fellowship of the the local medical societies.

    Our profession has become sliced and diced and deliberately atomized …. collectivization not being the solution.

    1. Great point. Medicine used to be a wide open profession, both within a speciality and between them. Now we have insane requirements for any remotely creative change to one’s scope of practice (yes, I used ‘insane’ with intention), and enormous barriers to retrain after practicing a few years.

       Even the option to retrain used to sustain doctors in their field for decades longer. “Well, if I really don’t like this, why don’t I just go back and study psychiatry for 4 years?” gave enough sense that doctors still had a real, live choice even if most never exercised it.

       Your last comments about atomization are true also. It is much easier to manage a group of fearful individuals than multiple groups/clubs/associations who can support each other.

       Thanks again for posting!

11. A great post, Shawn, and obviously near to my heart since I have been blogging about this issue also. I am one of those docs about 15 years into independent practice. This seems to be a common time when the novelty wears off and frustrations fester. Most FI physician bloggers seem to be of a similar vintage and this is an issue that we (as a profession) need to grapple with.

    The details of the frustrations may vary as described by many of the above comments, but that theme is a recurrent one. Faced with this, we can either be victims or alter course. Being trapped by a spending/earning problem is still a form of playing victim – we can actually change the equation. Of course, building financial independence and good habits in advance makes it much easier to take control of your work. That changes the relationship with medicine from serf to master. Abundance mentality from a scarcity one. As you point out, many who are masters of their destiny will choose to continue with medicine after reflecting (just do it a little differently). It actually offers much more control than many jobs if you are FI.

    That freedom is sometimes harder though. It means that you feel compelled to spend time considering what you want and don’t want, followed by the courage to actually execute based on that. That execution is also is often counter-cultural to the loud crowd who take the easier trapped/slog/complain route. With this happening about 15-20 years out, it is like a mid-life crisis on steroids. Feels like that to me anyway. Maybe I should just buy a corvette and get it over with 🙂
    -LD

    1. Ha! Loved your closing line to an excellent comment, Loonie Doctor!

       You make sold points. Focussing on financial independence sooner and with more vigour opens up options. This applies to all professions. But I wonder if other professionals feel as locked in as so many physicians do? I see my colleagues in other careers making large career changes every 5 years or so without taking another 10 years to retrain — or even 1 for that matter. I think physicians used to be able to morph their jobs into something much different with less difficulty in the past.

       Thanks so much for posting! You have obviously thought about this. In the end, we all have to find our own way regardless of the circumstances. I just wonder whether the circumstances have to be the way we find them.

       Great to hear from you!

       Cheers

12. Shawn this really resonates with me, and many other docs.

    As we discussed, one doc told me that “Shawn is talking right into my head”. I’ve advised a tinfoil hat, obviously.

    I’ve spent more time in non-medical work over the past few years. I’d guess about 20% of my time is spent working outside of medicine, and perhaps 10% of my net income is generated there. I’m working disproportionately hard to develop that space and I suspect both the ratio of time and income will grow over the next few years.

    Why?

    In the space outside medicine I can innovate, work with highly motivated people, and fundamentally succeed or fail on the merits of my work. Oh – and I can set a price that the market will bear for my services. In short I can satisfy a bunch of needs around entrepreneurship and excellence that I don’t have the freedom, or structure, or resources, or shared values to pursue in medicine (sadly).

    I feel intermittently dysthymic about medicine and have given up any hope of working in a high functioning system. At this stage, per Peter Graves, all I feel I can impact is the care of the patient right in front of me. And trust me – I’ve tried through many volunteer projects within the hospital to improve various parts of clinical and non-clinical services, all of which either overtly fail or atrophy in the face of the burdens and inertia of bureaucracy and mediocrity. I’m not willing to lower my expectations – so the only choice is to build a meaningful future outside of medicine.

    The shame of it…. is that I’m at the peak of my effectiveness as a doc and I could contribute more – but there are structural constraints that make it too much of a battle to be personally worthwhile.

    1. Powerful comment, Matt. Well said indeed.

       I especially liked your paragraph: “In the space outside medicine I can innovate, work with highly motivated people, and fundamentally succeed or fail on the merits of my work…” I think that this is key.

       Also glad to see you comment on all the effort you’ve put into improving the system. So many docs do this, and yet docs are apparently still the reason the system doesn’t work better.

       I sure appreciate you taking time to write. It will help other docs see that there is opportunity beyond our irrational rationed system (my new favourite name for it).

       Great to hear from you. Be well, s

13. I’ve delayed posting on this topic,waiting to read some responses…..this is close to my heart.
    It is ludicrous for anyone to suggest that docs unhappiness is a problem of their own making.
    When you’re the only game in town,you can dictate ALL the rules to the players who don’t have a choice to play elsewhere….their choice is to play by their rules,or not at all.
    The only reason I have enjoyed the last 10 yrs of clinical practice is because I developed a non ohip source of income which allowed me to reduce my volumes(and not worry about the pittance I was getting compared to the endodontist,oral surgeons etc).Physician ‘burnout’ rates are going to dramatically increase unless a parallel private system develops,allowing CHOICE of practise for docs(and patients for that matter).The irrational rationed system that we have is the sole source of this angst … make no mistake.

    1. Thanks for this, Ram. Solid and cogent as always. Glad to see you push back on the blame-the-doc narrative.

       Even if we just started with choice inside the current public system, that would help. But I also agree, we need a hybrid system like every other developed country in the world.

       Thanks again!

14. As we often hear at conferences, I will start with my biases. I am not convinced that we need to toss the CHA in the toilet and start again. While I have read about a variety of different systems around the world, I’m not convinced that I have seen a compelling argument that that free market can apply to medicine effectively. As physicians we all believe at some level we are better than most others and know more than others and can therefore develop something “better” than what the “system” can.

    So we will agree to disagree on my foundational biased, but I believe that we can agree that there is a deep malaise amongst “mid career” physicians. (I apologize for my use of “scare quotes” but they just seem to work for me). Let’s say docs over ten years in practice but under twenty years. Those of us between forty and fifty five. I find my senior colleagues (I am fifteen years in) have a bit of rose coloured glasses. Yes, they admit that there is a malaise or even a cancer in the profession but they still have a glossy hope based on experiences and expectations that aren’t real any more. I’m not sure it is freedom to change. When you look at family medicine, I think there is actually an almost unprecedented freedom to define yourself. Pick your CAC and you can switch from a generalist to a specialist with relatively little work. Sports med, palliative, elderly, ER, academic…..

    So if it isn’t flexibility to change, what has made so many of us (especially in primary care if you read the burnout literature) frustrated and depressed. The research says that autonomy or more accurately the mismatch between your expectation of autonomy and your perception of your autonomy, is one of the biggest predictors of burnout. Traditionally medicine has had great autonomy. Our ancestors set the agenda of their own practices, they controlled most of the clinical direction of the hospitals and they dictated the direction of medical education and socialization/cultural definition of medicine. For a whole litany of reasons, we have abdicated this influence to the government and the health administrators. Your solution is to look to privatization. I get that, but it is not the only nor perhaps even the universally best option. Is there still a way to regain that influence within the public system?

    Z Dog, posted an interesting video months ago about moral injury as being a root of burnout. The concept of moral injury comes from the military but it applies to us as well. It’s a disconnect from what we know is “right” for our patients with what we can reasonably provide for our patients. In the two tiered system, it’s so easy to just jump to the private system where we can do whatever the patient “wants” (or more accurately what the patient is willing to pay for). But what does that leave those of us who stay behind in the public system. A greater disconnect between what we should and what we can do. Ultimately you might all be right and simply leaving behind this mass to the “Saint Theresa’s” of our profession might be the only answer but where does that leave us that aren’t entrepreneurs like Matt (hey, Matt I think you owe me some ski lessons still, come down to BVSC this season and I’ll trade you a few beers for some tips).

    I want to do well by my patients but that means that I need the autonomy to do so. Managed care, guideline based practice, algorithmic care? They are not best for my patient nor do they make me feel worthwhile nor do they connect me in that intangible way that allows me to work even when the system is using my genitals as a punching bag.

    I was recently speaking at a meeting in Regina. The other main speaker and I were chatting in our down time. We bemoaned the change from physicians to technicians. Trusted learned professionals to clock punching automatons. We have given up the relationships with patients and colleagues that have defined medicine since Hippocrates for an EMR defined “best practice” that our patients won’t follow anyway because it doesn’t take into account their reality. My dad has DM and my mother just had a STEMI and now has CHF. Between them they have thousands of dollars a month in medication costs. They are now over 65 so they have provincial drug coverage and before that my mother had residual benefits from a career as a teacher to pay. But how many patients simply don’t have the money so end up in the ER and then the inpatient unit. We tune them up and then toss them back to the wolves of the free market to ….. devour.

    So we need autonomy and we need relationships. That is what made the previous generation work for 50 plus years and still fight to not have to retire because they loved medicine so much.

    I have recently been forced into a practice change to “Homeless ER mercenary” from a “traditional rural GP” practice by a complex set of local politics. I am more the master of my own destiny to be sure but I still feel less connected with the profession. I spent fifteen years fighting the system from within. I sat on the committees and had the leadership roles. I defined myself this way yet poof, in a few months politics can take that away. You are left with that individual patient as has already been mentioned. Most of the time that is still enough for me, but I still feel that the system has to change. I just can’t figure out what that change looks like nor if there is a place for me in the transition nor the new reality of whatever future system we adopt. Perhaps that as much as anything is why I struggle to define my place in this profession and find my “happiness”. But perhaps suffering is the only true reality as the Buddha said. But I think perhaps modern healthcare reality is more complex than even the Buddha could comprehend.

15. Dan ….
    Wow …. that was a long post !!
    Your fundamental bias of loving the CHA came through in your angst.
    Contemplate this ….. the only other country where it is ILLEGAL to pay for a doctor’s services privately is North Korea (Cuba recently changed).
    Why has NO OTHER system/country in the world copied our 30th ranked(OEDC) irrational rationed system ?
    Docs need to say the emperor is not wearing clothes…

    1. The most effective , efficient and world class health care systems of our planet are ALL symbiotic public private systems… North America’s dysfunctional health care systems cannot to be in the world class league….both resemble the “Curate’s egg” ( Punch 1895) ….” good in parts”.

       Our own deep state elitists blame the increasing stench of the H2S on the rapidly shrinking edible, uncollectivized , portion of the egg.

       As for the CMA , its Board generated such stench that it repelled and will continue to repel members away from that once noble organization , an organization that completely lost its way and has hurtled into the SJW abyss.

       1. Love it!

          Andris, I always learn something from you. I sure appreciate this especially about your comments. I had not heard of the ‘Curate’s egg’ — what a wonderful picture. And then to have you apply it to the shrinking edible, uncollectivized portion…very well applied.

          Thanks again

16. Dan, wait…. did you say beer?

    1. Thanks Dan, and also thank you Ram and Matt for your replies (even the short one 🙂 )

       Dan, you’ve written a long and excellent post. I cannot do it justice, but I will attempt a very short reply. I normally would not risk pushing back this much. But you seem to be very articulate and hopefully will take this as banter between two guys on the patio somewhere.

       We agree on far more than we differ: our system needs to do better, especially for our most vulnerable patients; we will always need a public system of some sort; physicians have become technicians in too many cases; and life has suffering. I also loved your comment about mid-career docs vs. older ones. There’s more we agree on, but I thought I’d throw that out there.

       I must push back on your misrepresentation that I said we should “toss out the CHA” and pursue a “free market”. We need to update the CHA for sure. Everyone from across the political spectrum agrees with that. I never said toss it out and start over. Having said that, the CHA is a federal finance law, not a health care law (I know you know this…just saying it for other readers). The free market has failure points AND the government has failure points. Zealots in either direction each have ideological blindness. Right now, the government-is-good-and-can-save-us-while-doing-no-wrong zealots have won control. They’ve been able to pursue a 50-year experiment. But the experiment has shown for over 2 decades that the most vulnerable people in our ‘fair’ system fair the worst. Privileged patients get better access and more of it. We have lost the moral high ground. Canadians deserve better.

       You said, “Your solution is to look to privatization…” No. I did not say we should stop the public system and privatize it. My thoughts on what we could try would require its own blog, but again, I do not believe that a completely free market approach will not save us. And I also do not believe that the government monopoly will not save us either.

       You repeat the fallacy that giving patients options will mean the slow death of the public system: “But what does that leave those of us who stay behind…?” Funding for the public system, regardless of whether it is a monopoly, is a separate issue from it being a monopoly in the first place. The fallacy is sometimes called integrating concretes along nonessentials. Monopoly (monopsony) is one issue. How much the monopoly is funded is a separate issue. There is no reason for the government to not increase the quality and access to care in the public system AND allow people to access care in Canada instead of driving to Buffalo for it.

       I do not understand your comment about “How many simply don’t have money…”, when we have ODSB, Trillium, and other public insurance programs for low income citizens.

       Finally, I was surprised at your comment about “Unprecedented freedom to define yourself…” Maybe this is true in a very rural under-serviced area. In any reasonably sized community, you cannot simply choose to do EM after doing FP for even 5 years. Most reasonably sized EDs require EM, or extensive experience. But regardless, you cannot start doing cosmetics, or minor surgery, and you definitely cannot return to retrain in Plastics or Psychiatry like people used to.

       Again, thanks so much for your comment! I feel bad mentioning a few of the things I disagree with when we agree on so much. Seriously, you made so many great comments. And if you are a friend of Matt’s, you must be a great guy.

       Cheers

17. We actually agree even on some of the nuances of what we disagree on at the macro scale.

    For example you critique the zealots who cling to the status quo, particularly to the CHA. Any group at the extreme has a huge risk of loosing the ability to objectively assess what they have set there extreme views against. Those who believe in the basic principles of the CHA still have to be willing to accept it as a living document that needs to grow and change to adapt to new times and new needs. It’s about finding a middle way between the most zealous supporters and the most zealous objectors.

    In terms of the paralleled stream system, I find it hard to see the government continuing to fund the public system at the level it previously was if many citizens no longer pay for care via taxes but instead by there debit card. Unless the second system is on top of the core public system. I’ll try to clarify. Everyone would receive the current level of care funded governmentally. You could then via additional insurance or your own payment, somehow add the second layer of access, service, perks, whatever on top of the basic. I am not quite sure I can envision how that functions but that is another thought experiment. So in summary, I would say that a fully paralleled system could easily see a drop in the public side but with careful design and a little bit of regulation you might be able to come up with a two tiered design that still supports core care fairly well.

    ODSB and Trillium are pretty limited. The deductible for Trillium is $1500. That’s a lot if you are working poor, no benefit making $30000/yr at a minimum wage job. ODSB means your fully off work but yes, does cover most significant meds.

    When I look at the number of GPs leaving true generalist practice to pseudo-specialize, I again wonder if it is really so hard to change direction. Of course if you want to do the big jump and become a radiologist, you are pretty much out of luck. So I would accept that GPs are somewhat limited in changing scope but it still happening fairly widely. Specialists are for more limited obviously so I think the academic and admin sides become their only possible change of pace which is difficult and leads to disheartenment. So again we actually agree more than we might have seemed.

    Finally I must disagree that being friends with Matt bodes well for my character. I think it suggests that I may be somewhere between a well meaning rogue and full bore ideological scoundrel.

    1. Another thoughtful, well-written comment, Dan! I am smiling at your last comment. Yes, scoundrels and rogues indeed.

       You’ve made some excellent points, again. Thanks so much for posting them. If nothing else, I hope it gives readers a sense of the depth and richness of this discussion. I was relieved, but not surprised, to see you wrestling with how we might take our system beyond the rigid one-size-fits-all we currently pretend to have; ‘pretend’ because the rich can go south and the well-connected get privileged access.

       Sure appreciate you taking time to read, comment, respond…simply brilliant. Readers really enjoy the comments.

       Enjoy your weekend!

       Cheers

18. Here’s a comment from another website. I’ve left it anonymous, but I thought it so well put that I just had to repost it. Enjoy.

    “This piece really hit me in the “feels”, as my daughters would say.

    It hit me particularly hard, as my daughters are looking to me for advice as to whether or not they should make the sacrifices necessary to go into the profession.

    I never thought in a million years that I would hesitate to recommend that they enter medicine as a career.

    I have had a wonderfully happy career for the past two decades, but I would be foolish to not notice the erosion of the profession at the behest of Government.

    The fact is, that being on the public payroll – while it has had its benefits – also has the dark side in that eventually, the “bill comes due”.

    Governments can no longer afford comprehensive health care without limitations – so they are forced to make some tough and unpopular decisions:

    a) Pay Physicians and Health Care Workers less
    b) Induce and maintain wait lists and limit access to care
    c) Limit the autonomy of Physicians, whom Governments regard as the “apex predator” of health care dollars.

    The result is a professional catastrophe for Physicians:

    Average age of entry to Med school (Alberta) is 28-32 with multiple University Degrees needed and age 40+ upon graduation with $400k debt. Record numbers of successful med school applicants are now declining med school admission for good reason. These “kids” aren’t dumb.

    Unemployment at record numbers for graduated Canadian Surgeons and Other Specialists as Provincial Health Care Authorities “circle the wagons” to desperately stretch every possible health care penny.

    Increased and unrealistic expectations of Physicians to work more hours, underwrite health care using personal resources and face increased and unreasonable scrutiny at the behest of increasingly draconian Provincial Colleges that necessarily dance to the puppetmasters’ marionette strings held by Government.

    I don’t mean in any way to cast the Government as the public enemy – quite the contrary. Their task is impossible: Continue to fund the health care monster that is rapidly becoming unmanageable – or dismantle health care and rebuild it in a political dichotomy that will almost certainly take a 180 turn every 4 years to perpetually undermine any sort of progress.

    Perhaps it is far better to enjoy the last available few years of relatively enjoyable and rewarding autonomy in Medical Practice, and to advise my kids to go into a career in Law or one of the other Professions – any of them is not dependent upon the public purse and its administration.“

19. In my present situation , as I ease out of my practice, I come into contact with young ( mainly male ) millennial doctors….hundreds of thousands of dollars in debt , still living with their parents or in small apartments/ condos, unable to afford to “date” and fearful of marriage because of the high divorce rate being very aware of the unfortunate financial sequelae of divorce.

    Young male and young female colleagues each have their own problems…with the female, seemingly more able to find a satisfactory companion than their male equivalents….the “ sweeping left and right” phenomenon is rampant…although they do same to take more vacations than did previous generations , taken often in groups.

    One notes that , within modern society, the male incel community is on the increase with all of the accompanying psychological difficulties …with all the medical College rules and regulations regarding contacts with members of the opposite sex, the difficulties are compounded…one wonders if anyone is studying the phenomenon?

    Older generations of medical professionals have support systems , families, children and grandchildren …one fears for the younger generation within our profession who lack them.

    Perhaps I have a distorted view of the realities

    1. Very interesting comments, Andris.

       I am not well versed in the issues you raise around men and women and their preferences in medicine. Overall, I think patients have appreciated have greater opportunity to see female doctors, if they choose.

       This is one of those topics that is already handled by many other authors/blogs/sites, etc.

       Thanks again

20. Andris , I find quite the opposite. Male Physicians are seen as good providers in society and tend to find it relatively easy to marry and have a stay at home wife who could be much younger. Women docs on the other hand have the unenviable position of being limited in their choices as they get older due to the length of our training ( as generally society and women themselves expect a man closer in age ) and also women becoming the breadwinner in many cases makes them very vulnerable as statistically for whatever reason domestic violence is significantly higher when women earn more than 65% of the family income . Many female doctors have had little dating / life experience due to the demands of our profession and marry destructive men who then resent their incomes and end up taking alimony and leave the women penniless. ( Maybe it’s society judging these men , whereas it dosent judge housewives , and then the doctor wife takes the brunt of his hurt ego).
    Men have “ wives” at home to support them whereas women docs are often single moms . I won’t even go into the gender pay inequality .
    I ask you to read a book by our colleague – Smart , Successfuk and Abused -by Dr Angela Mailis and you may see another side.
    We women docs have seen it since med school days how good a “catch” a male doc is considered ….. and many find quite lovely women who devote their lives to them and in turn get to be the “ doctors wife “ and have a comfortable life .
    Not so privileged being a female doc believe me !

    1. Zoey!

       Thanks so much for responding and offering a reference. I was really hoping someone would jump in and help. This is great. I hadn’t thought of all these issues around impressions, expectations, dating, resentment, and so on.

       I worry about the whole discussion becoming all about pay — I am far more interested in the social issues you raise.

       Thanks again!

21. Zoey….the “stay at home , home making, doctor’s wife , raising children” was certainly true in my era, 40-50 years ago…but no longer , these days, other than amongst those in the high paying specialties .

    Fees have been going down, expenses have been going up alongside the cost of living…the standard of living of the average grass rooted medical professional is in retreat in comparison to their peers in the other professions , in businesses and the public service….fewer and fewer enjoy the luxury of affording a stay at home spouse these days.

    As mentioned in my post , perhaps my view is distorted in my present work environment ( much like that proverbial frog at the bottom of the well) as a geezer amongst young millennials I take an interest in their trials and tribulations, their debts and love lives…their increasing fear of marriage and divorce…you pointed to toxic spouses…one suspects , for obvious reasons, that there might be more envious males than females.

    There are only two causes for hatred…fear and envy…the fearful and envious male spouse being capable of extreme toxicity.

    A friend of mine , a successful specialist, has a wife who is one of the top divorce lawyers in the country…we joke that there is no danger of him ever initiating a divorce.

    Jordan Peterson touches on the subject of the trials and tribulations of female lawyers…having aced their exams, and having moved up their professional ladder, highly competitive, hitting partnership in their early 30’s sacrificing all in the process in particular where relationships are concerned…experiencing existential struggles and a desire for a balanced life…if spouseless , they find that the number of potential eligible mates available to them has shrunk, their male peers being either married or , if single, having a choice of potential wives from a vast field of age 23 +.

    I happen to have a few such single female lawyers in my practice , and am aware of some young female doctors going through the same difficulties.

    It’s tough and rough out there…I’m glad that I’m not young these days…”sweeping left or right”.

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