Essays December 2008
Spare the Policy, Spoil the Profession
The jig is up: Canada's publicly financed healthcare system does not reliably deliver safe, high-quality, efficient care - and this after doubling spending in the past decade. Patient friendly it isn't; the convenience of providers comes first. Need primary care after 5:00 p.m.? Go to emergency. Got four complaints? Make four appointments. Every serious analysis comes to the same conclusion: the system needs a major refit to improve access, quality and value for money.
Yet, we remain a nation of demonstration projects, taking two steps backward for every step forward. Of the many obstacles to transformative change, one looms larger than all the others: organized medicine. For the better part of 40 years, organized medicine has more often than not stood in the way of efforts to re-engineer healthcare. It has pursued its own interests with brilliant success and passed them off as the public interest. It has secured more money, the right to saturate one jurisdiction or specialty with doctors and neglect others, largely autonomous and unaccountable practice, and separate and unequal access to the councils of state and the boardrooms of health organizations. Don't blame organized medicine for the way it behaves; blame us, meaning the citizenry and the governments we elect. We're the enablers.
Predictably, the system suffers: the documented shortcomings in safety, access and quality speak for themselves. More surprisingly, doctors are suffering too. Their own surveys unearth a litany of miseries, fantasies about leaving practice within a couple of years (they don't, even when they say they will), overwork, ennui. So, if it's not working for us, and it's not working for them, why does nothing change?
We owe the doctors of Canada a serious apology for spoiling a noble profession. By kowtowing to organized medicine, we end up with collective agreements and policies that entrench the status quo and keep Canadian healthcare in the dark ages. Doctors who have nothing to do with medical politics nonetheless bear the consequences of the positions taken by their representatives. The culture of self-centredness and privilege erodes idealism and produces generations of cynics who chafe under the rules of the game but lack the will to change them. Here are the main errors for which we need to atone:
First, we have erred in how we pay most doctors, and for letting medical politics determine what and who are worth more and worth less. Allowing organized medicine to divide up the pie has distorted care patterns, undercompensated many doctors, obscenely enriched others and pitted group against group. The doctors who use their hands out-earn those who use their brains. The ophthalmologist who does 20 cataract procedures in a day earns more than the one who figures out 20 complex eye disorders in a week. The dermatologist's pay leaves the rheumatologist's in the dust. We stand by in learned helplessness as the medical associations concoct a reward system that produces 10 times as many pediatricians as geriatricians, a steady abandonment of primary care and a generation of doctors practising at the low end of their capacities.
Second, we should apologize for letting doctors practice in the 21st century with the tools of Bob Cratchit. Governments sign collective agreements that condone quill pen medicine - we're at the bottom of the G7 pack in the adoption of the electronic medical record. Quality improvement (QI) tools and techniques are optional. There is no obligation to undergo practice profiling and recertification. Most doctors have no clue about the quality and effectiveness of what they deliver - and those who think they do are almost certainly wrong. The inevitable results: medical practice harms 10% of patients in hospitals; there is routine prescribing of dangerous dosages and drug combinations to the elderly; there is widespread failure to diagnose and effectively manage the most common and straightforward chronic diseases; primary healthcare patients get all of the evidence-based care they need only about half the time; and the list goes on.
Research shows that the longer doctors practice, the more they decline. We would never neglect the career development of our pilots, car mechanics or workers in fast-food restaurants the way we have neglected the professional competence of doctors. And instead of organized medicine imploring governments and health organizations to analyze patients' anonymized data, feed back the results and help doctors with QI, the Canadian Medical Association president makes ominous speeches about privacy.
Third, it's been a mistake to leave unchallenged the attribution of access problems to shortages of doctors and to inflate medical school enrolments by two thirds in response. Instead, we should have mandated strategies that could dramatically improve access right now, such as advanced access scheduling. Millions of Canadians can't get to see their family doctor the same week they call for an appointment, while everyone in England can and does in 48 hours. Do the process re-engineering, optimize the division of labour among the professions and then assess whether there are shortages - and if so, of what? And recognize that expanding enrolments in medical school won't solve the shortage of specialists in the disciplines that internal medical politics has consigned to the bottom of the income ladder.
Fourth, we have erred in adopting organized medicine's view that all doctors' problems, dissatisfactions and anxieties are soluble in cash. When doctors tell us they can't be on call 24/7, 365 days a year in rural areas, we empathize and come to the table to help find a solution. Nurse practitioners? No thanks. Group-based practice? Can't sell it to the members. How about a hundred thousand bucks extra? Sounds good! So we inflate doctors' incomes to do the same things that sap their energy, ruin their home life and keep them on a treadmill to depression, substance abuse and burnout. Shame on us.
Fifth, we've blundered in letting medicine dwell in splendid isolation atop the heap of the health professions. We allow the guild to keep competent others out of the sandbox: nurse practitioners are threatening; let's go for physician assistants. The pharmacist who knows more than the doctor about pharmacotherapy remains a diffident subordinate instead of a true partner. The other guilds follow medicine's lead, and we wonder why interprofessional collaborative practice goes nowhere. If being separate and unequal made doctors happy and the system better, fine. But the job satisfaction survey data show the unhappy consequences of letting organized medicine get in the way of its own members' well-being.
Sixth, we owe a mea culpa for letting organized medicine's media grandstanding, government baiting, hyperbole and fear mongering go unchallenged. Because we do not hold organized medicine to a higher standard of discourse and accountability, its rhetoric becomes bolder and it comes to believe its own propaganda, that every misdeed or wait list is everyone's fault but doctors'. We've turned organized medicine into expert blackmailers: more money, more machinery, a bonus here, a new medical school there. Attend a committee meeting? Pay us. Become true partners in the hard job of running the system? Nah, we like being independent contractors, not integrated team players. Staff the emergency room? Pay us fee-for-service, an hourly rate on top of that, a shift bonus on top of that. Set up shop in the poor part of town where the need is greatest and unmet? Charter of Rights! Freedom! We fed the beast and stood by as medical altruism and decency became entombed in a hard shell of self-serving cynicism. No one wins.
Our biggest mistake is failing to demand more of both organized medicine and individual doctors. We admit only superior students into medical school. We put them through intensive training (but not much education in citizenship and how systems work). We then turn a blind eye to huge variations in practice and never evaluate them seriously. And because this is a proven recipe for substandard quality, we let organized medicine persuade us that the remedy is to pay extra for mere competence - participating in chronic disease management collaboratives and following the occasional clinical practice guideline. This is our fault and our folly.
Lord Acton would have expected as much: power corrupts, and we have given organized medicine too much power. The dysfunction is intergenerational: we have not sufficiently protected and nurtured opportunities for new generations to chart a different path. We have given medicine autonomy without accountability and increased its allowance while its grades declined and it acted out at the table. Small wonder that practice is anarchic and error abounds. We didn't bring organized medicine up right, and we have only ourselves to blame for its values and behaviour.
Apology is a precursor to reconciliation and recovery. We need to recognize our mistakes and become the partners organized medicine deserves to restore its dignity as a profession that advances the public interest and justice for its members. Collectively, physicians are worse than the sum of their parts, and that harms all of them, and us. Our mistake has been to give organized medicine what it wants. It is time to give it what it needs, and to help it understand the difference.
About the Author
Steven Lewis is a Saskatoon-based health policy consultant and part-time academic who thinks the health care system needs to get a lot better a lot faster.
Josephine McMurray wrote:
Posted 2010/08/17 at 10:51 AM EDT
Jonny Konig wrote:
Posted 2010/08/17 at 12:31 PM EDT
Melodie Zarzeczny wrote:
Posted 2010/08/19 at 08:23 PM EDT
Wonderful article, but so discouraging.We'll probably read it again in 2012 and it will still be relevant.
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