Why Doctors Divide & How to Build Unity

Some board games almost guarantee war. 

Most families avoid conflict to maintain unity. But Risk, Taboo, and Twister after supper can turn the nicest people sour.

Most doctors avoid conflict. But given the right incentives and structures, doctors will attack each other, just like everyone else in society.

The Divide – Belong Paradox

People naturally divide. And people want to belong. In order to belong to one thing, we have to divide from something else. Our need for belonging fuels our desire to divide from those to whom we do not belong.

Focusing on differences creates tribalism, populism, activism, and identity politics.

We face a paradox. Tribes maintain unity by emphasizing how tribe members differ from outsiders. But if tribes turn their passion for difference onto those inside the tribe, it falls apart.

If we focus on tribes and division, we will remain divided and at odds with each other.

How can we foster unity in the midst of diversity?

How can we celebrate pluralism without becoming an indistinct mush?

How can doctors work together to make major decisions that impact specialities in different, unequal ways without causing war?

Representative Democracy

One well-worn solution is to erase groups. Destroy individual group identities:

Make all doctors wear scrubs and white coats.

Pay everyone the same salary.

Put everyone on the same schedule.

Dozens of countries have tried this experiment over the last 100 years. They all caused horrific human suffering.

The Greeks achieved unity in diversity with representative democracy. We all know the words, but we misuse the concept.

Churchill said, “Democracy is the worst form of government, except for all the others.” Churchill did not praise democracy. He praised representative democracy.

Democracy without representation is a terrible thing. Democracy interpreted as one-man/woman-one-vote on every issue is mob rule. It crushes minorities. Democracy without representation is evil.

Rep by Pop, Not Rep by Identity

Doctors demand democracy in medical politics, but we misunderstand representation. We think that representation means someone represents me and my group.

Western democracy runs on representation by population. A representative speaks for a diverse population that happens to share the same post office.

Representation does not mean representation by identity or interest. We do not elect members of parliament from the dairy, logging, and manufacturing industries. It would create chaos and division.

But many doctors want to base medical politics on clinical sections. It creates chaos and division.

In large centres, most doctors identify with their clinical section.

In small towns, doctors identify with their medical community. The local surgeon or psychiatrist might be the only one in town.

In larger centres, the surgeons and psychiatrists create groups of their own. Everyone belongs to a tribe. No one belongs to a community.

Most doctors only attend meetings with members of their clinical section. Hospital medical staff associations mix doctors together by geography. But most MSA meetings are more like conferences: long reports with rare debate.

Section Reps vs Population Reps

When identity groups or special interests elect representatives, they choose the most outspoken, aggressive individuals to lead. Of course, they want someone smart and well-spoken. But they also want a warrior, a champion to fight for their clinical tribe.

When a population of diverse people elects a representative, they choose the most balanced, thoughtful, and unselfish individual to lead. They want someone who will fight for everyone in the group, regardless of identity.

If we build and govern medical politics on clinical sections, we will fight and divide.

Sustained medical unity requires a renewed appreciation for representation by population. It forces elected representatives to think about their whole community. It forces communities to elect representatives who build bridges and win wide respect.

Should we abandon clinical sections? Of course not.

We need to strengthen clinical sections. Clinical groups should have more authority to shape policy that applies to their section.

It makes no sense to give primary authority over section issues to a group of 300 council members, 297 of whom are not part of that section.

Unity

Things improve for doctors when doctors work together.  

Every political party has attacked doctors at some point.  Ideally, doctors find ways to work with government. But in single payer healthcare, the single payer runs the show.

When medical politics rests on structural divisions between clinical sections, unity becomes rare, difficult, and short-lived.

Sticking together requires the right structures, not just the right people.

Do our current structures foster unity or division?

Is there a way to improve governance, strengthen sections, and build unity at the same time?

If we design a game to create division, we should not be surprised when some of the nicest people start to fight.

 

Photo by Suzy Hazelwood on Pixels.com

22 thoughts on “Why Doctors Divide & How to Build Unity”

  1. The real graduation day for our med school class was Match Day. The differences became apparent about a month later as people were studying for The MCCQE exam — it was a bonus not just to study with your friends, but with people who had diverse interests to “cover all the bases” (I studied with ER, Rad Onc and Urology). And we noticed some people drifted apart, unless the relationship was very strong, they were in the same discipline, or in the same city for residency. The commonalities of our profession lead to our discipline colleagues first, especially as resident. An analogy would be the tribe building at the beginning of Survivor. It helps with a sense of identity when the hours and stress and demands become overwhelming in residency. Shared experience in the OR as a common thread, and the relatability of that experience, helps people achieve the best they can in their career, but it can lead to the Coats vs Scrubs mentality. Common things in residency are usually by discipline, rarely by year, or even more rarely the universality of being a medical trainee. Tribes usually trade with, or are hostile to other tribes. It often takes a great threat from outside to unify them (the TPSA, Hoskinus of MOHLTC, or the scrutiny of the public with adverse press). Can you preserve the benefits of the tribal mentality without the hostility of intersectional rivalry? Maybe. But a lot of work would have to be done on physician wellness, autonomy, and the stability of the health care system before it could reasonably be achieved.

    1. Solid comment, Graham.

      As you say, our whole training system inculcates a tribalist mentality. Having said that, I’ve seen small town practice environments overcome the training years. After 10 years in a small town, members of the medical community held more in common than not. I do not think that happens in medium to large centres. Mind you, an external threat has a wonderful way of pulling everyone together, too, as you mentioned.

      Thanks so much for reading and posting a comment!

      Cheers

  2. Excellent ideas Shawn!
    So how does tribalism fit in at an nnual meeting for Members?
    Is it right for tribes to push their agenda’s when members meet or should members be allowed to voice their own opinions?
    Do we create a tribe by paying them to speak only in the voice of the tribe?

    Have a Great Day!

    David

    1. Thanks David,

      I’m not sure how much I can respond here since I cannot remember how much of the conversation relates to something else…

      Regardless, direct democracy would have all/any member show and up to an AGM and voice his/her own opinion. Each owes no fealty to anyone, since no one sent them there. They represent no one other than themselves.

      If a person attends as a representative, then they have a responsibility to know the ideas held by the party(s) that sent them. They cannot just speak whatever they want. If they did, it would corrupt representative democracy.

      Ideally, elections should bring out those delegates who show the greatest potential for being able to speak for a wide swath of those they are supposed to represent.

      Thanks for reading and posting a comment!

      Cheers

  3. There are only two things that will turn docs on one another ….. patient care and money.
    Docs will always remain united in the interests of patient care and divided where money is concerned.
    Every doctor values the expertise,skill, patience,hours and sacrifice that different sectional members contribute … but aren’t willing/able to put a price tag on it.When they do,on a relative basis,based on varied opinions/data …. all hell breaks loose (OSA).
    There in lies the problem with single payer health care where the docs determine the fee schedule …. only the market/patient/agent(gov’t) can truly determine the value of a given service.Single payer models want to throw the meat into the middle of the room,and have the starving dogs fight over it….the system doesn’t care as long as the masters are served.
    Follow the money Shawn …..

    1. Great comments, as always, Ramunas.

      What you say is exacerbated when everyone in the room has been elected to represent their own sectional interests. I find the ‘starving dogs’ scenario feels less wild when delegates have been chosen by a diverse population of many different specialties. Common sense seems more likely to prevail.

      However, your comments about a fixed price system still stand.

      Thanks again!

  5. Over the decades, the medical leaderships allowed the atomization of our profession, encouraged by those who wished to control the profession with their divide and rule strategies…so here we are in the bowels of the statist slave galley trireme, chained to the oars, rowing to the beat of the governmental central planner drummer….those rowing on the upper row ( the thranoi,) feeling a sense of superiority over those rowing below them, the zygoi and both over those rowing at the bottom row, the thalamoi.

    The slave representatives being limited to the negotiation of the amount of gruel , the rationing of water, the thickness of the seating padding and the padding of their leg and wrist manacles…it seems that the thranoi of our profession are negotiating for an extra serving of stewed beans, which bodes badly for those rowing below them.

    The concept of professional freedom has faded over the decades and the slave mentality has become completely and utterly entrenched….our once proud profession got to this sorry state because of its naievity , ignorance, intellectual laziness and cowardice.

    Self defence is nature’s oldest law, our profession has to relearn the principles of self defence and doesn’t have to ask anyone for permission to regain its freedom.

    Paraphrasing William Blake “ We must create a better system or be enslaved by another man’s which has proven to have been an unmitigated disaster for all concerned in Canada”.

    1. Stimulating comments, Andris!

      I think you nailed it with, “The concept of professional freedom has faded over the decades and the slave mentality has become completely and utterly entrenched….our once proud profession got to this sorry state because of its naievity , ignorance, intellectual laziness and cowardice.”

      Thanks for posting a comment…I know the readers love them!

      Cheers

      PS I loved your information about the slaves. I didn’t know that.

    2. Beans!

      BPE… Best Post Ever.

      Rich writing and a perfect analogy. Visual, and potentially auditory and olfactory. Suffice to say memorable.

  6. When groups try to actively take money from other groups, it should be obvious what will ensue.

    It’s ridiculous that the OMA was dumb enough to even consider it, let along vote for it. When I say the OMA, I mean specifically council for voting in favour initially, and the board for allowing it to get even that far.

    I could care less about the ‘OSA’ or ‘OMA’, except I hope that I can leave the OMA permanently at some point. Waste of money.

    1. Fair points, Kiltin.

      I agree, the board should have seen what was going to happen. As you know, the board apologized and helped set things back on track. But this, plus a bunch of other things, added to a snowball of dissension.

      I hope we can align once more. I used to share your thoughts about the OMA being a waste of money. That’s why I got involved. I was angry with the OMA. I still think the OMA can drive more value for money. Dues haven’t gone up for years, and the OMA is undergoing a massive transformation. Organizations take a few years to change, just like children. I hope you will be happier with the OMA on the other side.

      As for the OSA, I completely understand why people find it attractive. The OSA has focus and purpose. It has trimmed its vision. However, like any new project, things look great and utopian until you get to work. Anything built with people soon becomes complex and less pure and focussed than it promised at the start.

      The OSA has made a solid point. Medical associations should not cannibalize minority interests. That’s why we need true representative democracy. Representation by interest will always leave the minority interests at risk.

      Thanks for posting a comment!

    1. Good question, Brian.

      80% of BC residents would support private care options if the waits in the public system were too long (Ipsos Reid). 70% in Quebec feel the same (Montreal Economic Institute).

      I do not have a poll for physicians. No matter how bad things are in medicare, it works out to be a great deal for doctors as long as the funding flows fast. I think most doctors realize that there isn’t enough of other people’s money to fund it like we did in the 1970s.

      1. Interesting. I speak from the point of view of an end user and end user experience should have as much weight in the debate as people with in the system. My issue is with the listed services that medicare covers but more importantly the services that are not covered. Everything that has produced result (the only metric that counts) for Pat has been outside medicare and out of our pocket. A big improvement to medicare would be an opt out clause because we don’t use it and we could use the money that we pay to fund the system to fund the care that we are funding now out of our bank account. The name of my blog is provocative and it is meant to our experience with Pat being a 25 year veteran as a physician and then becoming a patient of the same system is an account that everyone should hear about.

        1. Thanks so much for sharing this, Brian. I’d encourage readers to check out your blog/story.

          I agree. Patients should have much more control/choice/options/input into their own medical care options. Many look down on patients. Dr. Charles Wright, formerly of the Health Council of Canada and former VP of Vancouver General Hospital, said,

          “Administrators maintain waiting lists on purpose, the way airlines overbook. As for urgent patients on the list who are in pain, the public system will decide when their pain requires care. These are societal decisions. The individual is not able to decide rationally.”

          Thanks again for reading and posting. I hope things improve for you and your wife!

          Best,

  8. Thank you, Shawn, for an excellent, thought-provoking article. The comments reflect the entrenchment of some physicians on the dastardly deeds of government.
    I agree with you that to achieve unity requires looking at the common goals for a better physician life for all rather than the tribalist approach which has destroyed nations and can destroy our profession.
    A unified profession can offer a significant barrier to the one payer system.

    1. Good points, Don.

      When government doubled its efforts to attack, cut, slander, and ignore docs in drafting legislation around 2012 and following, I kept saying that it was creating a new generation of doctors who will have great difficulty trusting any government. Bad decisions flowing from the concentration of power in the hands of a few elite decision makers leaves a permanent scar.

      Good point about unity being a problem for central control. It an adversarial relationship, it is definitely in government’s best interest to divide their opponent. However, all governments struggle with implementation. They need partners to implement change. As such, war with doctors — or any labour group — never turns out well.

      Thanks for reading and posting!

  9. I am impressed with the movement of the Drs of B.C. to set up divisions around the province in each community that includes specialists and GPS. The divisions seem to have nurtured that community networking seem in small communities even in larger centres as well as connecting the MD community with the wider community. Now there is a Dr. Tribe in each community. 👩🏼‍🔬👨🏽‍🔬👩🏼‍🔬

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