Canadian healthcare stands paralyzed in a Robert Frost poem:
Two roads diverged in a yellow wood,
And sorry I could not travel both
And be one traveller, long I stood
And looked down one as far as I could
To where it bent in the undergrowth;
– The Road Not Taken
Wooly-minded people pretend binary choices do not exist. They think we can choose both roads. Or they think one road will always be clearly wrong, as long as we use logic, facts and good will in choosing.
Doctors face two roads every day:
Do we do what’s best for the patient and prescribe an expensive treatment, or do we do what’s best for society and save the money for something else?
Until recently, doctors just prescribed what patients needed.
Doctors can do what’s best for individual patients, and society at large, most of the time. But as researchers invent more super-expensive treatments, governments balk at paying for care.
They want doctors to order fewer treatments and start being better stewards of the public purse, as though treatments were ordered by preference or whim.
Popular Debate
Andre Picard, at The Globe and Mail, wrote that stewardship is “one of the most popular buzzwords in health care today…”
“Traditionally, the only thing that matters for a physician is the patient in front of them: diagnose and treat…
Now, however, there are three parties in the room: the provider, the patient and the payer (who, in Canada, is ultimately the taxpayer). Treatments, and the cost of those treatments, must be considered within a larger social context. Do they provide value for money? Could those health dollars be better spent more wisely elsewhere?”
Stewardship raises two distinct issues: 1) Who comes first: individual patients or society? and 2) Who should count the costs of treatment: doctors or society?
Many people, often those with close ties to government, say “Both” to the first question on social media.
@shawn_whatley @NatriceR Both. We have concurrent accountability to individual patients and to society which grants us monopoly privileges
— Dennis Kendel (@DennisKendel) October 6, 2016
Practicing doctors do not find it so simple:
@picardonhealth @shawn_whatley When something is best for society but not best for indiv patient,or vice versa,how should MDs respond?
— Dr Lisa Habermehl (@NWOdoctor) October 6, 2016
@picardonhealth @shawn_whatley I face this dichotomy daily. Best available (expensive) equipment for today's operation vs. global OR budget.
— Trevor Bardell (@TrevorBardell) October 6, 2016
Furthermore, doctors are bound by law to their patients:
@shawn_whatley quoting a staff surgeon: I know of no law or ethical code that indemnifies me for doing what's best for the healthcare system
— Cale Zavitz (@calezavitz) October 7, 2016
…”at the expense of my patient” (second tweet).
This debate started soon after Medicare became law. Professor Hellman wrote a classic paper on it, 20 years ago in Nature, Medicine (gated): The Patient and the Public Good. He said, Put patients first. It is one of many other, newer articles like: Debating the Oncologist’s Role in Defining the Value of Cancer Care: Our Duty Is to Our Patients.
Bait and Switch: Waste and Stewardship
Champions of stewardship trick us into thinking that stewardship is just like avoiding waste.
Pro-stewardship advocates hijack the anti-waste movement. They promote popular campaigns, like Choosing Wisely, to gain the moral high ground.
That would be fine, if they stopped there. Instead, they leverage anti-waste thinking to promote their ideas about doctors as stewards of public spending on healthcare.
They take something good — being anti-waste — and use it to promote something anti-patient.
Asking doctors to control the cost of medical care, while caring for patients, is like asking firemen to control the cost of water, while hosing down a blaze.
No one defends firemen wasting water to make rainbows for crowds of children. And no one defends doctors choosing unwisely because attractive drug reps suggest new products.
Anti-waste is not the same as pro-stewardship. You can fight waste in healthcare and be either for, or against, system stewardship, at the same time.
But you cannot be pro-patient and pro-stewardship at the same time. At some point, the needs of individual patients will clash with the needs of the system to contain costs.
Who Should Decide?
All things being equal, doctors should choose the best treatments that cost the least. It makes no sense to pay for treatments that do nothing.
Doctors can make these decisions without compromising their commitment to patients. Problems come when there isn’t enough money to pay for all the best treatments.
Canadians decided to pay for medically necessary care using tax dollars, in the late 1960s. Fifty years later, medically necessary care costs much more.
Society can no longer afford all the care it wants. Canadians need to decide what they can fund.
Society cannot force doctors to make the decision for them. Doctors cannot protect socialized medicine by compromising the needs of individual patients.
Doctors serve patients, not because it makes sense, or because it is scientific. Doctors serve patients by swearing allegiance to an arbitrary moral absolute. “The Hippocratic Oath… represents not a triumph of science but a triumph of moral absolutism.” Goldberg – The Tyranny of Cliches
This bring us back to an offensive idea. The doctor-patient relationship is an exclusive, privileged, demanding, and sacrificial commitment that doctors and patients enter, to alleviate suffering.
This relationship – the core of medicine – offends modern progressives, who seek to replace privilege with equality and to promote collective solutions in favour of individualized care.
Appropriateness
We should debate appropriateness, not stewardship. The public needs to decide what tests and treatments it can appropriately fund.
No one wants to make this decision. No one wants to decide between gender reassignment surgery and bone marrow transplants. Doctors can help; we can offer advice. But society needs to make the final decision about spending. Doctors cannot make decisions at the bedside about who gets care.
Politicians avoid the issue by funding everything and then leaving patients on wait lists. This means that people, like 18-year old Laura Hillier, die without treatment, for curable cancers.
We cannot solve the healthcare crisis by turning doctors into bureaucrats. Society, not doctors, must decide what socialized medicine can afford. Canadians have come to a fork in the road, and they cannot stand still any longer.
Photo Credit: Wikimedia Commons, Jonathan Billinger
As always Shawn, well written and thoughtful.
Thanks, Elizabeth!
PS. I got your other message, too. All fixed. Thanks again! S
You’ve summarized my feelings very well but lets not let the politicians off so easily. We are faced with a budget crunch, a budget funded by taxes. Any honest politician would look at the system and say “let’s eliminate waste” but the liberals won’t even look at the most wasteful part of our system – the overwhelmingly redundant bureaucracy. If the politicians were honest they would eliminate waste and then realize that budgets are limited because of artificial notions about taxes. Honest politicians would say to the public, “if you want the services you have to pay for them”, instead they hide the problems in waiting lists and artificial limitations on medications. Our current politicians are focused on the next election. They want to be seen as doing something even if the something is the worst thing they could do because the catastrophe they are brewing in Bill 41 wont be evident until after the next election. What we have is the opposite of the honest politician we just an ordinary politician
Wow. Brilliant comments, Ernest!
I agree. We let the politicians off the hook, for the most part, in this post. We would not be here, if they behaved differently. As long as elected office offers a sweet position with fringe benefits, people will fight to the death to stay in office. If more people ran for office at the expense of their day jobs, instead of running to get a better job, we would have very different governments. I guess Maistre is proved right again: Every nation gets the government it deserves.
Thanks so much for reading and sharing your thoughts!
Best regards,
Shawn
A is A
Thanks Shawn for another great, thought provoking post!
Ayn Rand wrote in Atlas Shrugged that A is A, meaning that what we see is absolute. This implies that we have a choice: we can either accept that A is A, or we can insist that A is not A. To Rand, the idea that we can subscribe to the notion that A is both A, and not A, at the same time is not only impossible, but morally reprehensible. I would say that it is worse than that. I would say that it is dehumanizing. By subscribing to a notion that nothing is absolute, we abrogate responsibility for the choices we make, and for the need to stand by them. That is the nature of health care bureaucracy.
Bureaucracy and politicians are removed from the experience of patients and front line health providers. They don’t understand that being a patient isn’t about being a “client” consumer, it is about being afraid and in pain. Bureaucracy functions with ruthless, unfeeling efficiency because it doesn’t have to see that fear in a patient’s eyes, or hear that scream of pain. Patients are no longer seen as individuals, they are a collective. The collective is a formless construct with no inherent value. It is therefore easier to say that A is whatever you wish it to be, and so removed, one can commit atrocities and convince themselves that they are doing good. This is part of “The Horror of Medicine”.
What an amazing comment, Coryn!
I hope readers get a chance to read through and see it. You pull us back to the reason healthcare exists in the first place: to serve people who are afraid and in pain.
Thank you SO much for taking time to read and share such a thoughtful comment!
Best regards,
Shawn
As you elected to cite my response to one of your tweets, I will respond to your blog. I’ve elected to respond specifically to the sections of your blog entitled “appropriateness”.
You state that “we should debate appropriateness not stewardship. The public needs to decide what tests and treatments it can appropriately fund”.
At its core, the current focus on “appropriateness” is not on the inclusion or exclusion of rare medical interventions like gender reassignment surgery on the list of medically necessary services. Rather, it is focused on sound shared decision-making between physicians and patients about well established medical interventions like lab and diagnostic imaging, pharmacotherapy, and some common surgical procedures.
The concept of physician-led resource stewardship applies mostly to our prudent use of these routine medical interventions. The reality is that we squander a lot of resources by electing to recommend and/or initiate some of these interventions in circumstances in which they offer little value.
It’s may be easy for you discount my perspectives since I currently serve in non-clinical leadership roles. However I would encourage you to consider the perspectives of practicing physician leaders like Dr. Carl Nohr, a general surgeon in Alberta and Dr. Intheran Pillay, a family doctor in a very small rural Saskatchewan community. Carl is the immediate Past-President of the AMA while Intheran is the current President of the SMA.
My perspectives on both appropriateness and medical resource stewardship have been shaped mostly by visionary colleagues like Carl and Intheran and not by any government. Indeed, my perspectives on appropriateness and medical resource stewardship are well aligned with the views of the entire SMA Board which includes colleagues from a very wide spectrum medical disciples. I am a very proud and committed member of the SMA as I perceive that the SMA is taking a very enlightened and progressive approach to these important issues.
Thanks so much for taking time to read and comment, Dr. Kendel!
Your service and wisdom have helped patients and physicians on a provincial and national level for years. Your example of service stands as an inspiration for all of us. If I did not think so highly of all the work you do, I would not have bothered to push back on a dangerous concept that I see being promoted by a number of respected leaders, in a number of medical associations, as you mention.
As I said, all things being equal, doctors should advocate for the least expensive option that meet a patient’s needs. What worries me is when we start to talk about an ‘intervention’ that has ‘little value’ divorced of the patients for whom the intervention was intended. Assessments of ‘value’ have very different meanings depending on which side of the treatment you view them from. If we use a utilitarian, maximizing benefit for the greatest number, approach, we will have to re-label most of what we do for the weakest, oldest members of society as being of ‘little value’.
I am not suggesting that doctors do everything possible, in every clinical scenario, regardless of cost. Rather, I am suggesting that society needs to have this discussion. Doctors can support the conversation and inform it. But doctors must not be shouldered with the job of making decisions about who warrants care, in the name of stewardship or social contracts.
I welcome debate on the issue. I worry that too few see the need for debate and assume that lofty fads like stewardship will somehow rescue Canadian healthcare from the mess it is in.
Again, thank you SO much for reading, writing and being active in the discussion!
Best,
Shawn
Hi Shawn,
I am happy to have finally found the time to read this post. I don’t think I have seen such a clear description of the pitfalls of the stewardship movement. We must be vigilant about the offloading of “difficult conversations” about what our system can and cannot afford by bureaucrats and politicians. We have a current situation in my region where Personal Support Services to palliative care patients are being restricted due to budget issues. Special bureaucratic approvals are needed before any of these services are provided. No one asked our advice about this “stewardship” and yet we front line palliative care providers, physicians and nurses, are the ones who have to tell our patients and families that we do not have the resources available to give our most vulnerable patients a bath, or to assist with their personal hygiene. That it is not possible to provide assistance for the person who wants to feel a bit “normal” by getting dressed in the morning but is too weak to do so.
To some, dressing someone who is “not going anywhere and not doing anything” would be considered to have “little value”. They might consider that the funds spent on this would be better spent on curative treatment or medications for another patient. Others would have much more difficulty deciding how to assign a value to dignity, or the feeling of being bathed, or the ability to sit in a chair.
Shawn you are absolutely correct that our society needs to have an adult conversation about the choices we want to have available. Only then can physicians help decide which of these available choices are most appropriate for each patient.
Thank you, Paul, for taking time to share this. Your example shows exactly what I am worrying about, and I’m sure there are many others that people could offer.
I really appreciate you taking time to share this. For now, the pro-stewardship utilitarians have an unchallenged pulpit. Their message seems so reasonable, especially when no one asks questions or offers any debate. The stewardship discussion seems so reasonable, and scary. We need people outside of medicine to discuss this and understand the full implications a stewardship approach would have to to patient service and the nature of the doctor-patient relationship.
Thanks so much for taking time to share!
Warm regards,
Shawn
Shawn,
Wow!Excellent piece and comments.I wish those who choose to dismiss Canadian Health Care dilemmas and the role of physicians would consider these pieces. Maybe it would give them pause for thought before they issue their next derogatory “sound bite” Thank you Shawn for continuing to talk sense to nonsense. Helen
Thank you, Helen! Every reader and every comment adds a little more support to idea that ‘stewardship’ might not be the unassailable solution that so many people believe. While reasoned challenges should be enough to make system planners pause, politicians, of all stripes, respond to numbers and volume more than reason and thoughtfulness. If they think that they have majority support, reason, ethics and even patients be damned.
Warm regards,
Shawn
Amazing, thoughtful blog, Shawn. Thank you for putting it out there. The questions you pose are tough: how do we weigh the needs of the many vs the needs of the individual? Who decides? Should it be the bureaucrat in an office who is not privy to what an individual patient suffers (but likely knows someone or someone themselves who rely on the system)? Should it be the doctor, nurse, nurse practitioner sitting who has to look that patient in the eye? Should it be an intermediary like a LHIN? Should it be the patient themselves?
So far this government has taken a top-down approach to this question. They choose, usually unilaterally, how much and what they will fund, leaving front-line docs and nurses and patients to patch together something that resembles “comprehensive care”. This model is clearly not working. So what will? Provinces like Alberta have decided to get docs as medical experts involved in system stewardship.
I wonder though if there should be an even more bottoms-up approach: ask the patients. They pay hard-earned money in health taxes. They should share in the decision-making. Have an open referendum. We will never find an answer if we never ask the question. And arguably, we’re at the point where we need an answer and soon: we’re already rationing care and patients are suffering in a system that doesnt’ serve them well and is broken.
Great comments, Nadia. I like your call for more patient involvement. We need the right patients, too. Those who’ve experienced rationing and waits need a way to influence change in the system.
I worry about this latest horah to patch together healthcare. Cuts are cuts. Asking doctors to make the cuts in the name of stewardship does not ake the cuts less painful.
I sure appreciate you taking time to share a comment!
Warm regards
Shawn
Shawn, thank you for this thought provoking piece. What troubles me on a daily basis, is the current government’s ill thought out priorities. It takes time during an unhurried doctor-patient visit to explain the reasons why “routine testing” is unnecessary and may at times cause more harm than good. Such concepts as NNT/NNH are challenging to properly explain. In an age of information overload, patients deserve our help in understanding the science and the statistical significance of the data. We cannot dismiss their search engine results with a wave of our hand, because we know best. Patients expect and deserve a proper explanation of why a given diagnosis, investigation or treatment is not up for consideration. To that end, if I had to work as a FFS physician, I would never have time for patient education in the 15 minute appointments that I used to schedule. As a FHO physician, I can take more time to educate my patients. Just when we need more time with each patient who attends our clinics with complex medical conditions, aging in place concerns and the myriad issues around polypharmacy and choosing wisely; the government is severely restricting such rostered payment models. This makes no sense to primary care providers, but we know it makes “sense” to the bean counters. Once Bill 41 passes and I have to provide more accountability metrics to my LHIN, I will have even less time for patient care. Let doctors take care of their individual patients and recommend what are best practices in their communities. Let society decide how much care is to be publicly funded and which services are deemed necessary. Then let us finally have the difficult conversation about private health care as a choice. We need to read the writing on the wall and stop kidding ourselves. There is no increase to our tax base coming anytime soon, and no appetite to increase personal taxes. Medical advances help us to live longer but they come at a price. The buck stops somewhere. We have reached that fork in the road.
Well said, Audrey!
Sorry for not responding sooner. You said it well: care requires even more time now that patients have more information, than in the past. We cannot keep spending more and more time with patients without costs going up. Even if docs don’t earn one penny more, if we spend longer with each patient, the system needs more doctors. More doctors cost society more.
Thanks so much for taking time to read and share a comment!
Best regards,
Shawn