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Medical Dreams, Doctors & Unionism

We all want free, accessible, high-quality care close to home. Patients want to choose doctors who provide great service and avoid those who do not.

For the most part, doctors want this too. The trouble comes with how to make it happen. It tangles our visions of ideal medical care, politics and doctors’ collective action into a massive challenge with a scary future.

There are 3 parts to the challenge.

Idealized visions stand at opposite ends of a care spectrum.
Politicians craft healthcare solutions along partisan lines.
Doctors collectively respond to the solutions.

Lets start with two visions of medical care:

Medical Dream #1

Salaried doctors with pensions and benefits.
Standardized visits.
Protocol-ized treatment.
Maximum decision support.
Quality by design.
Doctors as clinicians, not managers.
Doctors diagnose and treat.

Medical Dream #2

Doctors as small business owners.
Individualized patient visits.
Individualized treatment informed by evidence.
Quality by incentives, flexible design.
Doctors as professionals in the fullest sense, not solely clinicians.
Doctors diagnose, treat, lead, oversee and manage.

Of course, the dreams overlap and blur into dozens of options. Those who support vision 1 tend to believe we should fund it with higher taxes, lower fees for high billing doctors and lower incomes for MDs overall. Vision 1 requires greater government control.

Problems with #1

Doctors become clock-watchers attuned to breaks and quitting time.
Wait times soar.
Not sensitive to individual patient need.
Inflexible.
Docs see fewer patients; need more docs = higher costs/patient
Demoralizing to professionals.
Doctors stop thinking and just follow the rules.
Removing input makes physicians ignore system issues. Why bother?

Problems with #2

What patients want is not always the same as medical need.
Many doctors hate business.
Might reward cutting corners.
Busy doctors earning high incomes inflames public envy.
Individualized therapy costs more than guideline-based treatment.

Canadian Compromise

Faced with different medical dreams, politicians work to blend the best of both approaches, slanted toward their political ideal, all in a socialized setting. This compromise works okay when times are good but falls apart under pressure.

Picture a 250 lb. football player and a 100 lb. ballerina as a team in a three-legged race. Inevitably, the brute throws a sweaty arm around his partner to carry or drag her to victory.

As government runs out of money, politicians swing doctors into their bureaucratic axillae to get things done.

As Good as It Got

In many ways, we have lived through healthcare utopia. Medicare used to let doctors work like local grocery store owners, while bureaucrats coordinated supplies and infrastructure. The College of Physicians and Surgeons contented itself with catching the really bad guys and leaving grocers to their vegetables.

Times have changed. Government now wants to run the grocery stores, and the College wants to go through the grocers’ laundry. Brazen reporters demand politicians do their bidding. Politicians click their heels and obey to avoid a drop in public opinion polls.

A Brute of Our Own

In the face of power imbalance, eventually, someone fights back. The ballerinas of the world find their own brutes to team up with the footballers. Ontario’s doctors will do the same.

Police, nurses and teachers’ unions win consistent raises while doctors get 5 years of cuts. Despite tyranny, inefficiency, and entitled greed of some union bosses, many doctors want a bossy, greedy, mercenary union to fight for them. They would love to have union reps fight every little workplace grievance. Doctors want a gorilla to fight all the other (unionized) stakeholders in the system.

Unionism

Public sector unionization rises above 74% in Canada. Political campaign managers estimate 30% of voters are union members. As dependancy ratios continue to creep up, voters will support parties that promise handouts.

A big, fat Ontario Medial Association Union is almost inevitable in this environment. It will flex and bloat and crush everything. It will support governments that wink at big labour with higher taxes. It will shape Ontario’s future, not just for healthcare.

A well-funded union of 35,000 physicians will ensure all change swerves left towards bigger government and more control. Political parties will only win if they kiss big labour. It’s unclear whether this will help healthcare, but maybe it’s what Premier Wynne planned all along?

photo credit: GP Contract Changes May Hit Services, Says Doctors’ Union TheGuardian.com

Non-Profit Healthcare: Myth or Reality?

As one NHS manager put it, without business there would be no buildings, no drugs, no machinery, no beds, no scrubs – just a lot of doctors and nurses in a field in their underwear.

— God Bless the NHS by Roger Taylor

Healthcare profit is like sex in Victorian times. We pretend it rarely occurs, and we’d be better without it.

But,

Doctors, nurses, techs, clerks, administrators all get paid; they work for profit.
Paid bureaucrats profit from running Medicare.
Even politicians politicate on healthcare to keep their jobs; they profit.

Furthermore, healthcare cannot run without business providing almost everything needed for care. All the technology, medical wonders, and super drugs come from businesses driving innovation. Pharmaceutical company TKM hopes to have an Ebola treatment out soon. Businesses research and develop new products to help patients and to build profits. Patients benefit from businesses that profit.

Medicare is not a charity.

Can Medicare Ever Fail?

Business owners expect a return for their investment in business. Failing companies close. If they cannot serve customers, they go out of business. Owners hopefully salvage some of their investment.

Public organizations spend all their money. They never decrease spending voluntarily. In fact, they put operational savings into more staff or new buildings, even if service doesn’t change. When publicly run organizations fail to serve customers, they do not close. Instead, the state spends more to prop them up.

Only Non-profit Healthcare Cares

Fundamentalists insist that only non-profit healthcare values patients more than money. Only public organizations put patient interests first. They insist that only state run medicine can truly care, having had its motives purified with other people’s money. They imply that Dentists, Orthodontists, Pharmacists and everyone else not covered under Medicare cannot genuinely care about patients.

But in publicly run Medicare:

Patients wait for urgent surgery. The state rations operating room time to save money.

Patients wait for imaging (MRIs etc.). The state turns machines off at 5 pm to save money.

‘Non-profit’ medicine cares about money just as much as ‘for-profit’ healthcare. Non-profit care cuts services to save money. It cannot incentivize productivity or increase budgets by serving more patients. It can only cut, or raise taxes.

Who Cares Most About Patient Service?

The key difference between non-profit and private healthcare is the value each system places on patient service. Non-profit medicine cares comparatively little about service. Without incentive to pursue excellence, it aims for average.

Private healthcare must put patients first or risk insolvency.

Profit prudes impugn those who question ‘non-profit’ healthcare. It’s time to expose the myth. Non-profit zealots enjoy huge profits as healthcare burns up 50% of provincial budgets. Non-profit healthcare would have nothing to offer patients without the proceeds of business endeavours.

Non-profit chauvinists denigrate any care other than their own. It is hypocritical moral supremacy.

Put Patients First – What Does It Mean & How Can We Do It?

“Then you should say what you mean,” the March Hare went on.   

“I do,” Alice hastily replied; “at least–at least I mean what I say–that’s the same thing, you know.”   

“Not the same thing a bit!” said the Hatter. “You might just as well say that “I see what I eat” is the same thing as “I eat what I see”!”

Great healthcare systems put patients first; patients hold top priority. How we view patients impacts treatment. What then does “put patients first” mean?

Do we envision product placement, like ‘put magazines in front of customers’?
Or do we mean a ceremonial nod to a notion that germinated Medicare?
Or do we mean something like, “Go Blue Jays!”?

Individuals versus Herds

A system cannot put patients first. A health care system cannot function by considering patients as individuals. To design a service that cares for 11 million people, we ignore individuals and focus on herds. We step away from the bedside and envision patients as discrete atomic units or numbers.

Furthermore, systems are impersonal. Only people put patients first. Systems grow out of complex relationships between organizations, providers, suppliers, regulatory authorities, governments and a crowd of others. Systems cannot put patients first without intent and effort.

Medicine is ineradicably individualistic. The doctor-patient relationship defines medicine. Unless a healthcare system intentionally measures its policies by whether or not it puts patients first, patients will get treated as members of a herd.

Put Patients First

It means we assign or attribute value to patients above innovation, budgets, quality, regulation, efficiency or any other important issue that systems tackle. Patients must be seen as individuals with unique perspectives, genetic make-up and experience of disease and health; as units of social groups, communities and families; as members of society with complex roles to play in other patients’ lives.

It relates to how we consider patients when we think about healthcare systems and design. It implies that our thoughts about process and efficiency place patients’ needs and unique expectations before system policy, budgets and regulatory restraints.

A vision for healthcare must start by adopting an intentional, arbitrary standard of putting patients first. ‘Intentional’ because systems can function efficiently without considering patients. ‘Arbitrary’ because systems can choose to not put patients first. Next time we see heads nodding when you talk about putting patients first, make sure we say what we mean.