Nightmares come in themes.
Feeling chased and chased-by-an-animal remain popular with most dreamers.
My demented dreams make me run away in slow motion.
Death, dying, and falling are common also.
Naked at a party, writing an exam for a course you did not take, and finding out that you are still one credit short for graduation haunt students. Your diploma is a fraud!
Doctors’ Nightmares
Doctors add medical variations to the themes.
I often show up for an emergency shift and cannot find the charts. The electronic tracking board is out of focus and in Arabic. The overhead page mumbles my name.
I am surrounded by nurses whose names I cannot remember; wandering in corridors that lead outside or into boardrooms; and seeing patients who frown and vomit.
Wait a second. Was I asleep?
In real life, doctors fear
- Missing a diagnosis.
- Ignorance about a treatment that everyone else seems to know.
- Harming a patient.
Doctors’ fear ignorance. We live out our careers through awake versions of the sitting-an-exam-for-a-course-we-did-not-take nightmare.
We worry about intellectual nakedness.
As the waiting room fills, and patients’ frowns deepen, we feel like we are running away in slow motion.
Can’t. Run. Faster. Please stop chasing me!
No…not one more thing. Can’t you see the angry mob?
In fairness, some doctors never have the running-away-in-slow-motion nightmare. Or else they have the nightmare and cope with it using immersion therapy and two-hour waits.
New CPSO Process
I volunteered for the new CPSO quality-improvement practice assessment program. I thought I should if I hoped to continue guilt-free whining and complaint.
Actually, I volunteered last year, cancelled due to time constraints, then was put into the system this spring anyways.
I had a random peer assessment years ago, which went well. But it seemed as arbitrary as it was nerve-wracking.
The new program looks like it will take eight to ten hours and several months to complete. It looks better than the old process: cheaper for the college, more expensive for me. Still better overall.
Old Docs
The first two steps made it clear: Males over fifty-five cause problems. Over seventy is even worse.
One of the initial survey questions asked, “Do you plan to retire within the next 1 – 3 years?” I said No.
But after reading about all the terrible things middle-aged male doctors do, I wondered if I should reconsider.
I turned fifty in April. Maybe I should exit before the inevitable?
Maybe that was the real message? Please quit now.
My specialist colleagues often joke about family physicians’ irrational fear of the college.
Why is that? Maybe because, in general practice, there’s more that we know we do not know? Maybe GPs are wimps?
Or maybe the college plays a smaller role in specialists’ lives? I’ve been in practice 20 years and this will be my second ‘random’ review. Many (most?) of my specialist colleagues have not been assessed once. A possible fluke.
Why Regulate?
The CPSO feels different—more humane—under new leadership. I hope it continues. Regulation exists to solve problems, to make things better. That requires cooperation and good will, not panic.
Most doctors’ biggest nightmares focus on failure, ignorance, and not measuring up. A rare miscreant survives in medicine, but all the assessment and regulation in the world will never catch the truly deviant.
Most doctors want to be better. Hopefully the new CPSO approach can do that and avoid nightmares.
Photo credit: PublicDomainPictures
You failed to mention in what way they are better. They “feel” different? What was the outcome of your audit? This post creates more questions than it answers!
Hey Jodie
It’s now a multi-step process. I have completed the first two step: survey and practice profile. My next step is a chart review. It’s much more work, but it feels more like a quality improvement plan. Would I prefer to avoid it? Of course. Is it as bad as the old process? Not yet.
Will keep you posted.
Cheers
You must be joking.
The only people who seek out college positions are physicians with pathologic personalities who always know the perfect answer in theory and yet never seem to have any patients for some unknown reason.
The only way things will improve is if we actually blind the assessors.
Good thoughts about blinding, Satyam.
This new process is all electronic…at least it appears to be so. I will let you know more as it rolls along.
One thing I’ve found out: family docs ARE assessed and reviewed more than our specialist colleagues. The CPSO reasons that the specialists have the hospitals hovering over them, so there’s less for the CPSO to do. Wow. This makes for an extremely unfair situation. Having hospital administrators hover, who you know and work with, is very different from having physicians who work for the college come and review you.
Thanks so much for posting. I will let you know how this goes.
Cheers
“The only people who seek out college positions are physicians with pathologic personalities who always know the perfect answer in theory and yet never seem to have any patients for some unknown reason.”
I get what you are saying but we cannot continue to accept the status quo. I swore that I would rather do unspeakably bad things to myself before I ever occupied a position on CPSO Council. We need people to run for CPSO Council who are the exact opposite of what you write above. As one who has stuck my finger in the eye of the CPSO whenever I get the chance, welcome patient complaints because I WANT combat with the CPSO and opposed any of their recommendations with good effect…I am running for a CPSO Council seat in 2021. I cannot stand the CPSO…but sometimes ya just gotta get inside to see what makes the machine tick and try to figure out how and if you can fix it. And I am a fee-for-service walk-in clinic doc who currently sits on the OMA Board.
We cannot have the scenario like we had in Toronto where physicians who fit exactly what you say above we acclaimed to be on CPSO Council. That perpetuates the problems and further entrenches the poor culture against physicians in the CPSO. I personally cannot stand for that any longer…
Great reply! Oh that would be so fun to be in the room listening to your first council meeting, Paul. I heard that they were trying to shrink the size of council… 😉
Oh, I am sure they are. They better do it quick. Doesn’t matter…it will not stop me. If they want to stop me, they had better take my license away ‘tout suite’. Or they can mount a campaign against me the way the OMA did when I ran for a Board seat in 2005. OMA knew I was coming at some point and they did not want me at all. It took the uprising in 2016 to get someone like me into the OMA Board to learn how the OMA ‘ticked’. Rolled up my sleeves got to work right away and fixing the OMA has been my singular focus ever since. When I leave in 2021, there will be an entire new and different OMA from the one I encountered in 2017.
CPSO…in the words of my favourite WWE wrestler ever…”You’re next!”
Love it! Can’t wait to see what you do next.
” Those who can …do; those who can’t …teach; those who can’t teach….administrate; those who can’t administrate …run for public office “…then the Peter principle kicks in where they rise within the hierarchy until they reach their level of incompetence….and it is they who reached this level that have their hands on the levers of power and are at the wheel of HMCS Canada as it struggles to survive the hurricane that was on the radar in December 2019 but ignored on the advice of their equivalents at the WHO in Geneva, Switzerland.
I do not agree…yet. As you have seen from your past political incarnations, the problem often lies in the history, the culture and the staff.
History has shown the CPSO inserting itself into every single aspect of medical practice. A read of the policies (all of them) will show that there is very few facets of practice that their metastatic tentacles have not invaded. There are very few stones unturned. The CPSO, lest we forget, even unapologetically ‘reviewed’ and inappropriately clawed back payments to physicians for the government. With our new registrar, they have even had the gall to come out and demand a halt to prescribing of certain impotent and dangerous medications to treat COVID-19. The issue is not that they were right…research has proven that they were. It is that they have never done anything like this in memory and this reveals an entirely new wave of control of physicians that the CPSO may see fit to use in the future.
The culture is one that is entrenched over decades of having an insecure, autocratic registrar whose sole reason for mistreatment of doctors was to maintain the facade of self regulation. It was always ‘going to be so much worse’ for physicians if it wasn’t the CPSO wielding the truncheons it was said. This culture has led to the expansion of regulation into all aspects of practice and micromanagement of physician behaviours. It is lack of faith in physicians and the view that physicians are dangerous and should not be left to their own abilities that has led to more rigid control over time. Some physicians do heinous things and should be dealt with more harshly than the CPSO does sometimes. These are the things that make headlines and lead to the public and media view that the CPSO protects physicians. Then there are physicians who make errors or have poor outcomes that are contributed to very much by the inadequacies of the system that they are working in…their punishments seem very severe and hold them fully responsible for those mistakes while letting the system off the hook.
I am an OMA Board member. You, Shawn, have been an OMA Board member. Most physicians on Boards and Councils have day jobs…you know, where they are physicians who look after patients in very busy practices. A lot of the initiatives in the OMA come from the staff who have a full time job at the OMA. The same thing happens at the CPSO. Program planning comes from the staff. If the staff have been longstanding, do not like physicians for whatever reason and have been trained/worked in a culture that views physicians as lacking and wanting in so many ways, the programs that are planned that lead to new forays in controlling physicians will come from that lens.
If the new registrar is so committed to changing the way the CPSO behaves toward physicians, it will take time to learn all of the history that has led to the demonizing of physicians. It will take time to change the culture to one of collaboration with physicians rather than persecution. And it will take time to move out the staff who do not buy into the culture change and bring in new staff who can be trained to behave toward physician in a different manner.
I, for one, will hold off my applause for now and continue to watch the CPSO with a very jaundiced and skeptical eye…
Oh Paul. So well said!
Thank you for giving me a slap in the face, a shake by the lapels, a glass of cold water in the face — all of them at the same time. 🙂
Of course, you are right. It takes more than a few gentle, cautious updates to make meaningful change. If we wanted to use your jaundiced eye, we might say that this new process seems more gentle during steps 1 and 2. But just wait for steps 3-10! (or whatever). Also, the cost of this regulation has gone up by at least 10 times, for me, and decreased by probably 20 times for the college. An automatic, electronic process can be built and run without further cost.
And culture is everything. A culture built on disdain for doctors will continue to denigrate and hold doctors in contempt.
However, I remain firmly and cautiously optimistic. I have both fingers crossed. I reached out to a former president of the CPSO with my thoughts also. If I am wrong, it will make the disillusionment more painful. This is good. Pain does wonders for inspiring a passion to write and rant. 🙂 And as you mentioned, this does not fix all the other micromanagement.
Great to hear from you, as always. I can’t imagine what this shutdown has done to your fee-for-service practice. Decimation comes to mind. I hope I am wrong.
Be well!
Cheers
The nightmares are piling up on the younger generation…matching nightmares…student debt nightmares …CPSO nightmares…Hunan COVID19 nightmares…income nightmares…living and professional expense nightmares…being overseen by ideologically driven political and bureaucratic incompetents nightmares with Inevitable consequent social upheaval nightmares….neverendumnightmares piling on top of each other with dreams shattered.
Although rather depressing, I fear you speak truth, as usual.
As I read more history, it seems to me that people define difficulties relative to what they see to be normal. Each new generation gets further from any sense of what free enterprise means in medicine. More and more people see central control as normal, good, and so much safer than scary visions about freedom or diversity.
Anyhow, great to hear from you! Thanks for posting.
Cheers
For a long time I thought I was the only one who had that nightmare about inadequacy:
“Missing a diagnosis, Ignorance about a treatment that everyone else seems to know, Harming a
patient.”
Since my first interaction with the CPSO I have said that I would give up self-regulation in a nanosecond for the same rights that Canadians have in a court of law.
Hi Shawn,
Although I have no issue with anything you say in this post, it somehow falls short of your previous explanation. Yes, a doctor-hating staff will continue to keep the CPSO doing anti-doctor things, notwithstanding the breath of fresh air of the new administration. But even without doctor-hating staff, the CPSO makes the law, arrests the doctors, tries them, judges them, and assigns the punishment. Where else do we have such a process? Even in the most autocratic regimes such as North Korea and China, there’s a pretense that the police, the judges, and the executioners are not in cahoots. No such window-dressing at the CPSO. Until this is changed, the way the CPSO is set up will deliver the inevitable results, notwithstanding the best intentions of its staff and administration–even if they were all the nicest, most doctor-loving people, it would still work this way. (And Shawn, this is what you said in a previous post, so I can’t take credit for the thought).
That’s why to me the truest comment above is Goldlist’s: “I would give up self-regulation in a nanosecond for the same rights that Canadians have in a court of law.”
Brilliant comment, Anonymous.
I still stand by the need to separate the authorities. To be clear, I was only honing in on this one element of the CPSO — the revamped alternative to peer review. However, all the other problems remain, as you say.
We should continue to highlight the fact that, “the CPSO makes the law, arrests the doctors, tries them, judges them, and assigns the punishment.” This is autocratic by design, and it risks tyranny without any way to prevent it.
Thanks again for pulling this idea into the discussion!
Cheers
Doctors really have no meaningful way to measure their ongoing performance. We spend at least ten years of our lives scrambling for grades or reference letters or to pass exams and then poof all the opportunities to evaluate ones performance evaporate. Don’t get me wrong I don’t want us to have to take exams every ten years to prove we knew medical facts that are often outdated or irrelevant to daily patient care. But I don’t like what we have now.
You practise, you work hard for your patients, you truly and meaningfully care for your patients but you still live in a constant fear that you aren’t doing enough. That you don’t know how to be a doctor. You do CME/CPD but most of it doesn’t have much true evaluation and most of us take CME/CPD that conforms to what we feel we already know the best (it’s a type of cognitive biasing but I can’t recall it’s formal name and I’m too tired to google it). The only real evaluation we have is from the college. So either your “random” assessments or a complaint. Fear filled, potentially punitive processes. Unlikely to truly improve anyone’s practice and certainly not keeping the public safer.
So we want self regulation (although as some have said maybe we don’t but I actually don’t really relish the idea giving that up just yet unless someone can propose a better option than the courts as they have a completely different purpose). How do you assure a safer profession? We need a real way to engage in ongoing evaluation of our own practices in a constructive way. Peer audits locally within our clinics or hospitals, Return to things like M and M rounds at hospitals, locally lead CME that deals with real local practice issues, a willingness (and mechanism) to at a local practice level say to a colleague “Your having trouble, what can we as a group do to fix it”. We get pissed off when anyone tells us what to do, yet we don’t show a willingness to put on our big boy pants and take the responsibility that this job requires (many of the fine posters here exempted as I know many of you have stood up and said “No, the buck stops here” on a variety of things).
Are we too tired? Too scare? To jaded and calloused? We don’t want the Ivory tower in Toronto to tell us how to be doctors. I agree. But we have to prove we deserve to not be told how to be doctors. The regulation starts locally. First you give me tools as a physician to do real reflective practice and a way to measure and receive feedback on that reflection. If I can’t be trusted to do that, my local colleagues (see same root word as College, neat how that works, eh) step in and have a chat with me. Offer me suggestions, show me their evaluations of my work, ask me if my home life is ok because I’m sleeping in my office again, etc. If I tell them to bug off then my local colleagues can take it to the next level and involve the college. Who starts with a presumption of productive improvement (unless of course gross negligence or abuse of any kind against patients). Ask the same questions as the local colleagues but with a bit more on the line but also more resources to help (automatic involvement of physician health program from OMA for example, better integration with med school remediation programs without such a punitive intent). If and only if this fails do we go to “trial”. But the rank and file physician in general doesn’t want to be part of such an elaborate process but yet still want to maintain the right to complain if they get caught in the flawed current process.
I don’t know how to get our colleagues reengaged. I feel like I’ve tried in my own small way locally but it has bit me in the butt in a way that makes me skeptical that it can be done. I keep trying. Which I think is perhaps the true definition of insane. But what else can you do. Giving up seems to suck even more.
Great comments, Dan. And very thoughtful and thorough, as always.
I cannot start to engage without engaging with everything…seriously, you raise SO many important issues here. As such, I will simply offer a shout-out for readers to make sure they spend some time with them.
Thanks again!