shawn whatley md

Free Speech in Hospitals?

The terror in Paris settled quickly but will flare again. Some people hate freedom and democracy. Some people believe they have a duty to punish those who say things they do not like.

Just as talk shows ran out of content, another hostage crisis erupted. Pundits comment and debate the slaughter. One theme focuses on freedom and the limits of expression in a free society.

Hospital workers also wrestle with free speech. What can they say without getting into trouble? Do they have a duty to report? Will they be protected if they hold an unpopular opinion?

In a time of universal deceit, telling the truth is a revolutionary act. George Orwell

Free Speech in Hospitals

In healthcare, ‘speaking up’ usually focuses on whistleblowing:

But can healthcare providers speak out on anything else? Should they?

Currying Favour with Politicians

Just after training, I wrote a letter to the editor about overcrowding in emergency departments. I asked the Minister of Health if he really knew what he was talking about. I invited him into our ED at “—Blank— Hospital” to see overcrowding for himself, to experience it firsthand.

My CEO blew up. He sicced the Chief of Staff on me. Then the President of the Medical Staff Association preached, “Never, ever, ever mention the name of the hospital in the media.”

My department chief said he agreed with my letter, thanked me for writing it and asked me to never do it again, ever.

Hospitals fight over one pot of tax dollars in Medicare. Thus, hospitals must never embarrass their political benefactors. Hospitals can lose project funding because one politician got their image tarnished. Image determines re-election, the most important political concern.

The public pays for hospital administrators to spend hours and hours in dozens of meetings worrying about “the media” or “the union bus getting parked outside” or a letter of complaint copied to the local MPP and hospital CEO. Dozens of meetings! In a way, administrators care about public image just as much as politicians.

Free Speech Fallacy

Those who know cannot speak.

Those at the coal face often know frontline problems better than CEOs, bureaucrats or journalists. But they cannot speak. If they do, they get in trouble, lose positions or promotions, and might get fired. Even worse, they might make work much harder for colleagues. Is this free speech?

Rules of “Free Speech”

Publish accolades and praise without fear. But if you have less than glowing comments, do not identify:

your organization.
an individual by name.
specifics of a bad outcome you report.

Never comment on

concerns about safety.
decisions made by organizations you work for.
details about religion, race, sex or any specific identifier even if central to an issue.

Some topics attract more pain and suffering than others. Avoid big labour, organizational movements and any hint of being politically incorrect. If you do, expect to be shouted down, punished and written off.

Is Free Speech in Hospitals Dead?

What if you’re an idealist? What if you can’t help but speak truth to power?

Go ahead; be an idealist. Talk about rates of this or that terrible thing; talk about ineffective efforts to improve X, Y or Z. (Yes, I’m too chicken to mention specifics!) Say it gently, kindly.

You might be in big trouble or out of work tomorrow. Another martyr for free speech.

photo credit: anonymousartofrevolution.com

Genomics, Not Cookbook Medicine?

Genomics promises the next wave of medical innovation. It will remake clinical care. At least that’s what the genomics researchers say.

Today, medications get tested on thousands of people. Hopefully, safety and efficacy in thousands of study patients means medication will work on each individual patient.

Can we do better?

Genomics

Imagine if we could match someone’s exact genetic coding with a perfectly suited treatment? Genomics promises to do that, soon.

Personalized medicine, pharmacogenomics, presupposes individuality. People respond uniquely to medication. Currently, we aim for similar targets in every patient on a particular pill but are not surprised that individuals respond uniquely.

It explains why, all things being equal, a patient needs more medication than her sister for the same condition.

Not Cookbook Medicine

Genomics undermines a powerful movement. Evidence based medicine (EBM) has preached standardization, clinical practice guidelines and ‘quality’ for decades. Evidence based medicine swelled on the imprimatur of statistical analysis.

Devotees believe the path to excellence and efficiency lies on the narrow road of crisply defined process.

Top-Down Control

Academics, central planners and politicians love EBM. They wield EBM to proscribe medical deviance. Clinical judgement takes the hindmost. Planners stand on giant studies and proclaim ideal treatment and best practices. Politicians lean on wayward physicians who allow too much patient choice in treatment, too much individuality.

Genomics delivers a new songbook. It sounds like old-fashioned pathophysiology that EBM discarded in the 1980s. Pathophysiology irritates statisticians and politicians. It encourages clinicians to think instead of memorizing clinical guidelines. Thinking is messy, hard to control.

Future

Genomics might become just another cookbook. It might dictate treatment based on computer analysis of patients’ genomes eliminating clinical judgment. Regardless, it will still ruin the one-size-fits-all approach clinicians get graded on now.

Hard core, individualized science might make a comeback. It will change everything. And it won’t be cheap.

photo credit: telegraph.co.uk.com

Healthcare’s Only Hope (is NOT Government)

Healthcare loves new ideas that promise even a glimmer of improvement. Every new approach brings hope that maybe this will fix healthcare.

We believe that some one, or some thing, will put everything right.

Like Princess Leia, we believe our only hope exists but disagree on where to find it. (Video clip: “Help me Obi Wan Kanobi you’re my only hope.”)

We can organize fads or solutions by the level at which they promote their change.

Individuals

Some believe specific providers will deliver an ideal healthcare system. We just need nurse practitioner led clinics; more nurses, nursing assistants, more doctors…

All providers overlap in the services they provide. But healthcare’s far too diverse for us to believe one type of provider can be healthcare’s only hope.

Teams

‘Team care’ used to guarantee thoughtful nods from audiences. Specialized teams promised to solve everything from education to quality and efficiency. They help. But they don’t make individuals and organizations obsolete.

Organizations

Many pundits believe something like Kaiser Permanente offers healthcare’s only hope. Organizations and process solutions hold promise for operational efficiency. KP seems to deliver great patient service and holds collectivist values many find attractive in Canada. But they only serve select populations and have had to close down in some locations.

Social Institutions

Military?
Private business?
The free market?
Organized religion?
Unions?

Government

Should we place our only hope in government?

If so, which level of government?

Municipalities don’t get enough help from the province.
Provinces continually ask for help from the feds, so clearly they can’t provide healthcare by themselves either.

Maybe a national plan would solve everything, like the British NHS we copied in the 1960s?

John Roberts served as a Liberal cabinet minister in the Trudeau and Turner governments. In 2003, he wrote an essay in Searching for the New Liberalism: Essays in Renewal. He wrote that since the 1930s,

“…government departments multiplied and expanded, and a plethora, almost uncountable, of crown corporations was established.”

“Government was poor, however, at managing for a variety of reasons — the political processes of government militate against flexibility, decentralization and the delegation of responsibility; personnel management, an essential instrument of management, remains largely outside the hands of political direction; government does not have profit as a bottom line objective and therefore finds it difficult to apply as a means of bureaucratic control; the objectives of government are as mixed and as varied and as contradictory as the members of society. These amorphous purposes, the lack of precision in purposes, make public management cumbersome rather than streamlined.”

Roberts, a believer in big government, says government cannot manage because:

Government resists flexibility, decentralization or delegation
Government struggles with personnel management
It has no bottom line for bureaucratic control (unlike profit in business)
There are too many objectives
Purposes are amorphous and imprecise

Healthcare’s Only Hope?

Here are some steps we might consider instead of searching for Obi Wan:

1. Stop looking for healthcare’s only hope. It does not exist. Complexity requires complex solutions.

2. Empower providers. Explore how ALL PROVIDERS can work to the full scope of their expertise. Not just nurses and pharmacists (as the latest only hope for healthcare). Doctors could supervise other providers in large clinics much like dentists.

3. Liberate, don’t regulate. Instead of saying “You can’t do that” we should say, “Show me how well you can do it.” Let individuals, teams, organizations and social institutions prove their worth in the results they deliver.

4. Challenge veto power and special interests. We are immobilized in a system where every stakeholder can insist why everyone else cannot do something or change the way they currently work. Everyone has veto power. Everyone can say “No” – Regulatory colleges, unions, associations, hospitals, and special interests. No one allows anyone freedom to prove their worth.

5. Innovate, experiment and learn. Stop thinking healthcare is so concrete, so specialized. Most things do not have ONE obvious answer. Focusing on innovation, experimentation and outcomes could move us beyond our devotion to rigid ideas of evidence (logical positivism) without falling into postmodern relativity.

6. Challenge hegemony wherever it exists. Arbitrary governing authorities that regulate, legislate and manipulate healthcare according to their own vision of utopia guarantee stagnation.

7. Get government out of management. Only pride, power-lust or ignorance insists government manages best. Bureaucrats are not business leaders. Healthcare deserves the best leadership and management expertise available. Youthful poli-sci grads are great for many things, just don’t ask them to manage healthcare.

8. Empower Patients. They’re smart. For the most part, patients do not need, or want, to be passive, obedient recipients of healthcare largess. Patient empowerment and accountability offers a huge untapped opportunity to reform healthcare.

9. Diversify labour. Who, besides the unions, benefits from having 98% of the hospitals unionized in Ontario?

After we tackle these issues, we could examine hospital ownership, public health mandate, CCAC, LHINs, and much more, all within a national insurance plan like Medicare.

What to you think? Are we searching for healthcare’s only hope? Are we putting too much faith in government to save us? Are we hoping to find some other super-solution for all that ails healthcare?