One of the most popular skits from Monty Python and the Holy Grail is “I’m being repressed!”
It contains a powerful lesson on what’s wrong with healthcare and how to fix it.
The skit opens with King Arthur overtaking a young peasant man, Dennis, who Arthur mistakes for an old peasant woman.
Dennis is pulling a cart.
Dennis berates Arthur for exploiting the workers with “outdated imperialist dogma which perpetuates the economic and social differences in our society.”
A peasant woman calls out from the ditch at the side of the road, “Dennis! There’s some lovely filth down here…”
Both peasants then cross examine Arthur on his right to be King:
Peasant Woman: Well, how’d you become king, then?
[Angelic music plays…]
King Arthur: The Lady of the Lake, her arm clad in the purest shimmering samite, held aloft Excalibur from the bosom of the water, signifying by divine providence that I, Arthur, was to carry Excalibur. That is why I am your king.
Dennis: Listen. Strange women lying in ponds distributing swords is no basis for a system of government. Supreme executive power derives from a mandate from the masses, not from some farcical aquatic ceremony.
Arthur: Be quiet!
Dennis: You can’t expect to wield supreme executive power just ’cause some watery tart threw a sword at you!
Arthur: Shut up!
Dennis: I mean, if I went around saying I was an emperor just because some moistened bint had lobbed a scimitar at me, they’d put me away!
Arthur: [grabs Dennis] Shut up! Will you shut up?!
Dennis: Ah, now we see the violence inherent in the system!
Arthur: [shakes Dennis] Shut up!
Dennis: Oh! Come and see the violence inherent in the system! Help, help, I’m being repressed!
Arthur: Bloody Peasant!
Dennis: Ooh, what a giveaway! Did you hear that? Did you hear that, eh? That’s what I’m on about! Did you see him repressing me? You saw it, didn’t you?
Many doctors feel repressed by the “imperialist dogma” of government.
And many observers feel that doctors, like Dennis, bring the repression on themselves. In real life, comedy ends too soon.
Doctors and government have fought for fifty years, and patients have often suffered for it.
Sure, there are times of cooperation and relationship. But when resources run thin or when the system needs to change, each resents the other.
Doctors resent politicians and bureaucrats telling them how to provide care.
Politicians resent doctors who resist the latest government redesign.
Bureaucrats come up with grand, new ideas, because that is what each new government needs to prove its worth. The election cycle drives change. Change, for its own sake, drives doctors nuts.
Both doctors and those in government are mostly well-intentioned people. The rules of engagement in a nationalized industry inevitably pit each against the other.
Although Medicare started as an insurance program, government now believes it has a divine right to manage healthcare.
Most people respond like the Peasant Woman:
Peasant Woman: Didn’t know we had a king. I thought we were an autonomous collective.
Dennis: You’re fooling yourself. We’re living in a dictatorship! A self-perpetuating autocracy, in which the working classes…
Peasant Woman: Oh, there you go, bringing class into it again.
Dennis: Well, that’s what it’s all about! If only people would–
Governance in Healthcare
Government has three levers: legislation, programs and spending.
Government can write new laws, design new patient care programs and either increase or decrease spending. It often does all three at the same time.
Government intervention is usually rigid, definitive and slow.
Government studies something to death. Then it creates an inflexible law or process. And then it standardizes and quantifies everything: new managerialism at its best.
Since the start of Medicare, the number of medical laws, statutes and regulations has increased exponentially.
Layers of government red tape stick to thick policies and guidelines from the regulatory colleges.
These stack on top of hospital rules and regulations.
The depth of medical regulation makes Harrison’s Principles of Internal Medicine look svelte.
Dennis offers a governance option:
Dennis: I told you, we’re an anarcho-syndicalist commune. We take it in turns to act as sort of executive officer for the week…
King Arthur: Yes…
Dennis: …but all the decisions of that officer have to be ratified at a special bi-weekly meeting…
King Arthur: Yes I see…
Dennis: …by a simple majority in the case of purely internal affairs…
King Arthur: Be quiet!
Dennis: …but by a two thirds majority in the case of more…
King Arthur: Be quiet! I order you to be quiet!
Peasant Woman: “Order”, eh? Who does he think he is?
Clinics cannot “order”, pass laws or arbitrarily increase spending. Clinics must manage people to succeed.
Successful clinics fund winners and cull failing programs. Government does the opposite.
Are Doctors Repressed?
Medicare is so cluttered with pilot projects, personalities and campaign promises: We need a Monty Python to save us.
Comedy might make us laugh at ourselves and figure out how to embrace new thinking. Patients might get better care with Dennis’ system over Arthur’s.
So, are doctors being repressed? Yes, but it’s not government’s fault any more than it was Arthur’s fault to be King.
Fault lies with the healthcare monarchy. That’s what needs to change.
Hello there,
This is a fine overview of a key issue. As a hospital CEO for years it became clear to me that we have a this exact problem. Through in multiple other stakeholders each with their own pressure points on government and the system fails to focus on its service mandate. How to get universal single pay without government? Hmm, insurance reciprocal anyone?
Hello Colin,
Thanks so much for taking time to share a comment! You open an excellent line of discussion. We most definitely can achieve universal care without the system we have now. We could also have much more patient-controlled funding, or at least patient-based funding, within a single payer system. There are plenty of universal systems that offer great care to all citizens which are not single payer.
Regardless of what approach we want to explore, the current system does not work as well as it could.
Thanks again for taking time to read and share a comment!
Cheers
Shawn
The only way to get balance,innovation,and motivation in our health care system is to develop a parallel private system for medically necessary services.Competition will help both systems thrive,improve access and service,as well as solving the relativity problem.Even Tommy Douglas never envisioned cradle to grave all inclusive services …. it is unsustainable and the reason no other country in the world has copied our (non) system.
It will come …. but I won’t see it in my career.
I hear you, Ramunas. I worry that you might be correct. I guess I’m hoping that we can improve the current system while we wait for the major change you describe. The oldest Baby Boomers are only in their early 70s. Once the majority of the Boomers are in their late 70s and early 80s, I think we will see massive change. That will take another 15-20 years.
Thanks for sharing a comment!
Cheers
Hi Shawn,
I’m a HUGE Monty Python fan, have used clips for years to make a point for students and in presentations.
I’d thought of using this same example to describe Paramedic Hallway Waits in the Hospital ER until May 17 when EMS Chief Anthony De Monte said to an Ottawa Citizen reporter:
“It’s time for (hospitals) to resolve this fundamental issue of holding our Medics hostage so we can return to the community to respond to the needs of citizens.” He said, “HOSTAGE”!! Wow. I almost fell out of the Ambulance. It’s describes what’s happening perfectly.
So now I’m thinking of using clips from the first ‘Die Hard’ Movie. There are so many… “Yippee Ki Yay, (I really don’t like the word he uses here)”, and “Welcome to the Party, Pal!”.
But I think in this case I’m going to go with the quote from Sgt Al Powell at the end of the movie , after all of the hostages have been freed and Hans Gruber’s famous fall from Nakatomi Tower (the Hospital in this analogy) is complete.
It’s when John McClane (the Paramedic in this analogy) asks, “Is the building destroyed?” Al looks up at the building and then turns to John and says, “No, but it’s going to need a new paint job and a shit-load of screen doors.” Hahaha!! I don’t think it will come to that, but it scene really resonates with me.
I personally think, after many years of being told, “There’s no Beds” and “Hospital Patients are more important than Patients out in the Community waiting for EMS to arrive”, that somewhere we can still find sober, thoughtful Healthcare Leadership who understand it’s absolutely unethical to hold Paramedics hostage in the ER hallway.
Perhaps not. Maybe I’ll eventually do a #BadLipReading overdub on this early scene from ‘Die Hard’.
Dr. Gruber: Mr. Paramedic? Are you still in the Hospital Hallway?
John McClane: Yeah, I’m still here. Unless you wanna let me get in my Ambulance and go back to doing my own job.
Dr. Gruber: Uh, no, I’m afraid not. But, you have me at a loss. You know my name but who are you? Just another Paramedic who saw too many movies as a child? Another orphan of a bankrupt EMS culture who thinks he’s John Wayne? Rambo? Marshal Dillon?
John McClane: Was always kinda partial to Roy Rogers actually. I really like those sequined shirts.
Hans Gruber: Do you really think you have a chance against us, Mr. Cowboy?
John McClane: Yippee-ki-yay, motherfucker.
Don, you are WAY too creative!
I agree. We hold EMS hostage by refusing to offload patients. It is crazy that our sickest patients wait on ambulance stretchers, then get put in an offload area, then maybe they will get a room for assessment in the ED, then they get admitted to a hallway in the ED, then to a hallway (or bathroom!) upstairs, then finally when they are almost better they might get into a hospital room of their own. So the healthiest patients get the best rooms. Insane.
Thanks so much for sharing such a creative, thoughtful comment!
Cheers
Love the Monty Python reference. So true, unfortunately! I am relatively new to OHIP (ex-Forces, where I was salaried), and am amazed at how this system is designed to reward quick care, which will sometimes result in far more visits long-term and mediocre health, and prevention is preached but the fee schedule demonstrates that there isn’t much respect for disease prevention or reversal. It would be a good starting point if the system was poorly designed, poorly remunerated physicians but at least was improving health care across the province, or if physicians were better remunerated but health care was not overly improving across the province. We’re not even there, it seems. Instead we seem to have a very reactive, very outdated system that does not reflect the reality of today’s chronic disease prevalence, that does not provide optimum care for patients and fails to respond to the basic needs of clinicians, especially physicians. I do feel like I’m in a Monty Python movie at times….
Great comments, Jennifer.
We finally got primary care redesigned in the early 2000s to incentivize doctors to try to avoid bringing patients back to clinic over and over. We were supposed to do more telephone followups and virtual care. Now the government is upset that we aren’t seeing enough patients face to face! Fee for service is wonderful for driving activity and improving access, but the government cannot afford to fund it.
I think we need to build a system based on patients needs; including felt needs. We should want to serve them, want to see them. Only then will patients feel like they are getting great service. I know this requires change on the patient side of things, too. Too many people see Medicare as a free entitlement, so they don’t value appointments and skip them without notice.
I’m starting to ramble…
Thanks again for taking time to read and share your thoughts!
Cheers
I was OHIP’s lawyer. If there is an NDP Government in Ontario, I expect that many Ontario physicians will withdraw services in 2019 when the NDP Government refuses to implement the substantial arbitration award that I expect physicians will be awarded.
Wow. Powerful comment, Perry!
Thanks so much for sharing it. Very interesting perspective from someone with your experience. It’s interesting how the NDP haven’t said much about doctors during their campaign.
Thanks so much for taking time to share!
Cheers
I really enjoyed Don and Shawn’s movie allusions.
Thanks Gerry. Always great to know that you dropped by!
My father had supranuclear palsy and his health had significantly deteriorated. He ended up having a stroke, when we brought him in ER, the ED doc and the geriatrician said, that we need to let him go as his body is failing. Me and my family refused to accept that, we forced the providers to admit him and even do an MRI on him , as we didnt want to leave any stone unturn. We got him a food pipe surgically inserted, as his mouth was shut due to the stroke. He spent 3 weeks in the hospital
1 month after discharge he passed away. I reflect back and realize that if I had to pay for the additional MRI and the additional hospital time, I would have listen to the doctor and opted for comfort care sooner.
I share this because I believe citizens are also using healthcare services like its a free for all, we have this notion that free universal care, but it isnt . We need to fix the economics of the health system. Health care is a service, and patient should consider the cost implications before using a service. Physicians should consider the same before prescribing. or if the physician was paid by the patient not the government, the physician workflow will completely change, he will have to provide me with the best service, he would have to be accountable , otherwise i as a patient will find another doctor to go to. Administrators get these block fundings and they are not incentivized to save, because the next year they will get less funding. If there was competitive economics, and negative billing , administrators would have to get their act together.
Shawn, having worked in BC, Ontario and now Alberta, realistically speaking the time for marginal changes is gone. I think shifting the problem only to government is also scapegoating. When we use the word ‘system’ its a nebulous term that dilutes the issue, because we all know where the key problem areas lie.
Politicians, CMA , health authorities are all trying to maintain a status quo, and only committed to marginal changes as they dont want to rock the boat too much for their self-interest.
The change we all are asking for will come at a price and would entail that everyone will lose something, meaning everyone will be unhappy. Everyone will have to compromise, including doctors, government, public, administrators. Why? because the thing about change is that, no one really likes it! but once you weather the storm, there is always rays of sunshine!
If we want to change the system, the LAST and ONLY option we have is the public. Nobody from the public is advocating for better healthcare. We need citizens to unite across provinces, and drive change. We need a social movement that is focused on demanding specific changes in the Health Care Act to start the seismic shift.
I have faith in the public, I have faith in the democracy and in the good will of people to put their self-interests aside and work towards making our Canadian healthcare better! I have a dream….
Wow. Ali, what a moving story. I am so sorry to hear about your Dad….and so impressed with how you’ve used it to fuel your ideas about healthcare!
I agree. We all learn to maximize our situation given the current ‘system’. Doctors, nurses, hospitals, medical association….we all do what we can to get ahead inside the current set of rules. Changing the rules creates uncertainty. So we all fight to hang on to what we have instead of risking the chance we might lose if the rules change. In the meantime, patients wait and suffer.
I also believe that the public has the power to demand change. As I said above, I think the Baby Boomers are going to lead the charge. There’s no way they will tolerate what members of “The Greatest Generation” have endured.
Again, thank you so much for posting such a moving, powerful, thoughtful comment. You DO have a dream!
Cheers
“I reflect back and realize that if I had to pay for the additional MRI and the additional hospital time, I would have listen to the doctor and opted for comfort care sooner.” Wow Ali, what a powerful and insightful comment. It also made me a little bit sad. I’m sorry for your loss. Please be kind to yourself. You made the decisions you needed to make at the time. The retrospectoscope is 20/20 and is not very kind to the person looking into it. I think you’re right, the system and our attitude towards it skews how me make decisions within it.
What a brave thing to say: “I reflect back and realize that if I had to pay for the additional MRI and the additional hospital time, I would have listen to the doctor and opted for comfort care sooner.”
Hear. Hear!
Just like the character in another skit, Health care as it currently exists is trying to speak out: “but I’m not dead yet..” Really, “I’m getting better..”
At the end of the day though, the reality is different. Both for the character and for health care.. The sooner we realize the unsustainability of the situation, the quicker we can take definitive action to correct it.
Unfortunately our politicians are too busy figuring out how to tax the sparrows flying in coconuts for everyone to worry about the sustainable of coconut imports..
Cant worry about it.. Too busy dealing with my own killer rabbits…
Rob, Brilliant!
“Bring out your dead” – another great skit!
I agree. While politicians ponder whether two sparrows might be able to manage the journey, if they grasp the husk of the coconut together…healthcare crumbles. I say we need to ask all Ministers of Health three questions, “WHAT is your name? WHAT is you favourite colour? WHAT is the solution to patient wait times, the long-term care crisis, the opioid crisis, hallway medicine….” I’d love to see that!
Thanks again for mixing wisdom with wit!
Cheers