Essays February 2013

Want Improved Healthcare Performance? Treat Canadian Doctors Like Finnish Teachers

Steven Lewis


On February 17, 2013, CBC Radio Sunday Edition host Michael Enright interviewed Pasi Sahlberg, author of Finnish Lessons: What Can the Educational World Learn from Educational Change in Finland? Finland routinely scores in the top three among OECD countries, largely because it has rejected just about every North American shibboleth about how to improve education. Students start school at seven (though most enrol in the voluntary pre-school programs). Schools do not grade, rank, or stream students in the first six years. There is a single standardized test taken at age 16. Students get 75 minutes of recess a day. Schools set their own curricula based on very broad national guidelines. Teachers spend 4 hours a day in the classroom. No tough love, no back to the basics, no two hundred fifty day school years. No school sports teams and jock envy (want to play? Join an after school sports group). Yet somehow, at age fifteen, the kids who take the international standardized tests kick our butts (but neither they nor their schools learn the individual results).

Damn. What’s up with the Finns?

Like every other large-scale social triumph, the explanation lies not in dazzling feats of genius, but the application of evidence-informed common sense. Teachers are elite professionals in Finland, equipped with master’s degrees in a substantive discipline supplemented by training in how to teach students ranging from gifted to disabled. Teacher salaries are unremarkable – about the middle of the OECD pack no matter how you calculate it. Teachers with 15 years of experience do get paid 102% of the salary of the average college graduate, compared to 62% in the US.

There are 10 applicants for every one accepted into teacher training programs. It is not a fallback occupation for those unable to get into law school; it is a prestigious choice. The citizens and the state trust them to meet students’ needs. Many schools are architectural marvels, designed to foster calmness, openness, and delight in one’s surroundings. The result is a culture of excellence. The system is 100% publicly funded and there are no private schools. Despite the autonomy, there is little inter-school variation in quality. It is working smarter incarnate.

There’s nothing different about Finns' DNA, and the country’s educational achievements cannot be traced to cultural memes transmitted over the centuries. It is simply cashing in on wise public policy decisions taken a few decades ago. The fundamental assumption is that if you treat kids as individuals, free them from anxiety-producing competitive pressures, and give them the freedom to explore their talents, they’ll thrive. And oh yeah, they’ll master math and science and languages along the way.

Highly selective admissions criteria; rigorous training; great public respect; considerable autonomy; a deeply held sense of professional obligation; evidence-based practice; terrific outcomes. Isn't that what medicine is supposed to be in this country? Unfortunately, we stop at the first four. The remainder are aspirations, not across-the-board realities. Why do Finnish teachers outperform Canadian doctors who are just as smart and paid three or four times as much?

The explanation involves both structure and culture. Finnish teachers are not independent contractors to the school system. They are the school system. They own and solve their students’ problems. They get to practice with considerable autonomy not because they have negotiated a privileged exemption from reasonable scrutiny, but because they have successfully fused autonomy with responsibility. The bargain is that if you let them pursue their vocation as they see fit, they will collectively deliver the goods.

The cultural factor is that Finnish teachers evidently care more about the joy of work and societal respect than money. There has not been a labour dispute with teachers in at least thirty years. It seems that teaching in a calm and happy environment of well-adjusted, curious learners is its own reward. According to Sahlberg, the teachers would walk off the job if their pay was tied to their students’ performance on standardized tests because such arbitrary and reductionist measures violate the fundamental ethos of what they are trying to achieve.

Healthcare is not exactly like education; some episodes are short and intense, and the stakes are often life and death. Still, most healthcare is chronic disease management, and primary care based on relationships that extend over time. Patient-centred care is conceptually similar to student-centred education. Applying evidence to practice and responding to individual needs are essential to high performance in any discipline or sector.  

How is it that a high degree of decentralization and professional autonomy have produced world-beating excellence across the board in Finnish education, and so-so performance beset by wide variations in Canadian healthcare? Surely a critical factor is that doctors for the most part are not fully integrated into the system, a compromise based on doctors' extreme aversion to becoming civil servants or hired help at the dawn of medicare. This distancing exempts them from both mutual and external responsibilities; the consequence is eroding trust and compromised performance. It serves neither them nor us.

As the quality and safety movement gathers steam, there are calls for more measurement, public reporting, practice profiling, and accountability. I sing in that choir. But I realize that they will accomplish only so much if they are mere overlays on an unyielding professional culture. We have a long way to go, still mired in a non-system populated by demoralized doctors who work in relative isolation from each other and other professions, unaware of their own practice idiosyncrasies and oblivious to the harms they may cause. In this context it is only natural to want to arm the public with granular and forthright performance reports so that some of them will exercise their right to make informed choices about their care. But it would be far better were such choices unnecessary, as is the case with Finnish schools, which are uniformly good.

So here's a toast to those few Canadian doctors who think and act like Finnish teachers. For that to be the norm, we the public will have to choose them wisely, educate them rigorously, expect much from them, provide them with superb working conditions, trust them, and celebrate their achievements. Above all we must quit treating them like mercenaries who will underperform unless we stuff their pockets with gold. And we must also stand up to their negotiators when they do act like mercenaries.

For their part, doctors will have to fully join the system, embrace data-driven, patient-centred care, abandon payment methods that wring the creativity and empathy out of their practices, and organize their work to be joyous, collegial, and effective. Cultural transformation is hard work, but deserves a fight to the Finnish. 

About the Author

Steven Lewis is a Saskatoon-based health policy consultant and part-time academic who thinks the healthcare system needs to get a lot better a lot faster.
Contact him at:



Karim Keshavjee wrote:

Posted 2013/02/22 at 02:35 AM EST

Excellent essay Steven. You're asking for a massive cultural change in a system with multiple vested interests in maintaining the status quo.

It will take significant political will (which will be vigorously opposed and perhaps even challenged in court) to make the changes required. I don't see any politician in Canada willing to take this step. Perhaps in Quebec? But they are unlikely to be paragons for the rest of the country, even if they do.

How do you expect doctors to be data driven when the technology they use is designed to make data difficult to extract and analyze? They also don't have the ability nor the time to massage the data to be data driven. When hospitals (which have large numbers of IS professionals working for them) have a hard time using data, how do you expect primary care physicians (who have no IS professionals working for them) to be able to do better?

We do need a change, but it will require a grassroots effort led by rank and file physicians. I hope we can do it.


Anton Hart wrote:

Posted 2013/02/23 at 11:30 PM EST

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