A Man for All Sections: Physicians, Heed Thy Hobbes

Steven Lewis

I dunno, maybe it's the season, but I feel especially moved by the plight of doctors at the bottom of the medical politics food chain. Ontario emergency room docs are just the latest in a long line of disgruntled groups crying foul over the agreement negotiated by their medical association. That agreement got the support of 79% of Ontario doctors, but most ER docs said no. Now they're mobilizing to pursue distributive justice by other means.

Unfairness in the relative income distribution of physicians is not an occasional aberration, a minor side effect of an otherwise exemplary allocation process. It is the inevitable outcome of a fierce competition within a guild that does most of its bare-knuckled work behind closed doors. Fee schedules are complex and no well-intentioned amateurs - the kinds who sit at the table on behalf of their peers - can possibly master the game with equal panache. Over time, power shifts and accretes, some groups gain the upper hand, and income disparities proliferate. There are winners and losers - all relative of course, since every full-time physician's income is at least upper-middle class. Provincial medical associations are the certified bargaining agents for all doctors - even for doctors who choose not to join. In general, the association and the government negotiate a total amount of money for physician compensation, and most of the details get worked out by the doctors themselves. Sometimes the government targets a top-up here, a fee code adjustment there, but overall, the physician categories - called sections - duke it out for shares of the booty. The mystery is not the injustices that follow, but why habitually shafted specialties, from primary care to rheumatology to geriatrics, stay with the medical herd. We outsiders don't really know - the doctors don't air their reasoning to outsiders - but we can speculate. First, they are a profession, and professions love nothing more than self-regulation and self-management। They might prefer the irritations of internal decisions to the prospect of subjecting the guild to external scrutiny and meddlesome guidance. Who ya gonna trust: your peers, or the bureaucrats? We are a band of brothers (and sisters), are we not? We look after our own - imperfectly, but we get you. Stay with us, and we'll harder for you next time. To continue reading please click here.

Spare the Policy, Spoil the Profession

Steven Lewis

The jig is up: Canada's publicly financed health care 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 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 health care. 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 health care 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-centeredness 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 outearn 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 ten times as many paediatricians as geriatricians, a steady abandonment of primary care, and a generation of doctors practicing 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 adoption of the electronic medical record. Quality improvement 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 that think they do are almost certainly wrong. The inevitable result: 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 health care 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 CMA 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 inflate medical school enrolments by two-thirds in re-sponse. 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 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' prob-lems, dissatisfactions, and anxieties are soluble in cash. When doctors tell us they can't be on call 24/7/365 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 sand box: 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. Fifth, we owe a mea culpa for letting organized medicine's media grandstanding, government-baiting, hyperbole, and fearmongering 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 ER? 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, 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 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.

Show Me the Way to Stay Home

Nursing Leadership (CJNL), 21(4) 2008: 29-32 Show Me the Way to Stay Home Lynn M. Nagle

As the health system continues to evolve through the implementation of the electronic health record and other information technology initiatives, it is imperative that governments undergo a paradigm shift and recognize the need for strategic investment in home care (CHCA 2008a:7). Among my closest baby boomer contemporaries, recent life experiences have revealed an increasingly pervasive challenge - maintaining the independence of aging parents. As one of the major issues facing middle-aged Canadians today, the provision of emotional, material, and physical support and care to this cohort takes a toll on family caregivers. The lay caregivers of Canada save taxpayers millions annually by avoiding the cost of institutional care. Although given comparatively less airplay these days, there is also tremendous cost avoidance afforded to the healthcare system because of home-based, family-delivered care for chronically ill children and young adults. A significant number of Canadians are doing their bit to supplement the gaps in service: family and friend caregivers constitute up to 80% of the care delivered in the home (Canadian Home Care Association [CHCA] 2008b). More than 10 years ago, it was estimated that 2.85 million Canadians were caring for a family member with long-term illness (Cranswick 1997), equating to more than $5 billion of unpaid labour annually (Fast et al. 2002). Given the country's demographic trends, one can only surmise what those figures might be in 2008. 'Twas ever thus that a majority of families assume responsibility for certain aspects of care for their loved ones, but limited attention is afforded these contributions.

Approximately 900,000 Canadians access home care on a regular basis (CHCA 2008a). Home care is the fastest-growing sector in healthcare, and it is predicted that between 1996 and 2046 the number of people needing it will double (Home Care Sector Study Corporation 2003). It has long been a cornerstone of Canadian healthcare, but sadly, home care gets short shrift when it comes to public funding. In a study of the long-term care systems of 19 OECD countries, Canada was found to invest 0.17% of its GDP in such systems compared with the overall average of 0.35% (Organisation for Economic Co-operation and Development [OECD] 2005). Why is there not greater equity with other sectors in the funding of home- and community-based care? It seems obvious there are some potentially significant financial benefits to be derived by investing in community and home care services that keep Canadians out of high-cost institutions. With shorter hospital lengths of stay and higher discharge acuities than ever before in our history, where is the infrastructure to support recovery at home? Interestingly enough, a tremendous amount of rhetoric is directed to the need to focus on primary care, chronic disease management and aging at home. How can any jurisdiction effectively deliver on these agendas without some concomitant investment in community-based supportive technologies? We certainly do not have an endless supply of health human resources to deliver on the services needed to support same. Is it realistic for any jurisdiction to expect that without information and communication technology (ICT) investments, effective home and community support can be achieved? Assistive technologies to support individuals and family caregivers exist (e.g., remote monitoring of chronic disease and smart devices for those with dementias and sensory impairments), but are they widely utilized? Surely the cost of such supportive technologies would significantly offset the costs associated with short-term hospitalization or long-term institutionalization. Grim forecasts of pending shortages of health professionals, particularly nurses, should provide compelling enough reason to consider technology solutions to optimize efficiency and effective use of resources in every sector. Equipped with point-of-care technologies, nurses in the community could access client data and information from other providers and settings, collaborate with other members of the healthcare team on-line and ultimately contribute to improved clinical outcomes. Estimates suggest that access to remote technologies could extend nurses' capacity to visit more clients (up to 3-4 times more) and maximize access to this increasingly scarce commodity (Thobaben 2000). As the nursing profession is also aging, it behoves jurisdictions to consider deploying solutions to further support nurses in the delivery of home and community care. A recent publication by the CHCA (2008a) included several recommendations directed to investment in ICTs and other technologies to support the delivery of community-based care for lay and professional caregivers alike. In particular, the need to link community care, including primary healthcare teams and home care, to other sectors is highlighted as essential to enable "improved integration, communication and collaboration" (CHCA 2008a). Financial investments in ICTs to support the provision of home and community services remain relatively insignificant when compared with those being directed to other sectors. While infrastructure supporting the advancement of electronic health records in institutions has been emerging as a priority in every Canadian jurisdiction, few have recognized the need to move beyond institutional brick and mortar to the communities where the greatest amount of care is delivered by professionals and family caregivers. In our technology-obsessed society, one cannot help but wonder why more solutions are not being deployed to support and sustain the unsung heroes of home- and community-based care delivery. The current delivery of community-based care is undervalued and not integrated with the rest of the healthcare system, yet it is on the verge of becoming the single most important point of service delivery. The recent launch of the Canada Health Infoway-funded "VON Caregiver Portal" ( www.caring-connect.ca) is an excellent demonstration of the capacity to lend support to hundreds of thousands of Canadians seeking information and solace from others in comparable circumstances. As all providers of care (read "my generation") are also aging, relying entirely on families and communities to keep citizens out of hospitals will not be sufficient. The demographics, the statistics and the trends tell a clear story - community- and home-based care, while not a panacea, can go much further still in offsetting the continuing escalation of healthcare costs. I look forward to an acknowledgement by "the system" that there is merit in extending the reach of supportive ICTs. That acknowledgement will be clear when there is an increase in public funding for supportive infrastructures and technologies. If given the choice, I want to age "at home" rather than "in the home." How about you? About the Author Lynn M. Nagle, RN, PhD Assistant Professor, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto; Senior Nursing Advisor, Canada Health Infoway References Canadian Home Care Association (CHCA). 2004. Home Care: a National Health Priority (Position Statement). Ottawa, ON: Author. Retrieved October 17. 2008 < www.cdnhomecare.ca/media.php?mid=357 > . Canadian Home Care Association (CHCA). 2008a. Integration through Information Communication Technology for Home Care in Canada. Ottawa: ON: Author. Canadian Home Care Association (CHCA). 2008b. Portraits of Home Care in Canada. Ottawa, ON: Author. Cranswick, K. 1997. Canada's Caregivers. Canadian Social Trends Backgrounder, Ottawa, ON: Statistics Canada. Fast, J., L. Niehaus, J. Eales and N. Keating. 2002. A Profile of Canadian Chronic Care Providers, a Report Submitted to Human Resources and Development Canada. Alberta: University of Alberta, Research on Aging Policy and Practice. < www.ales2.ualberta.ca/hecol/rapp/ > . Home Care Sector Study Corporation. 2003. Canadian Home Care Human Resources Study - Technical Report. Ottawa, ON: The Home Care Sector Study Corporation. < www.cdnhomecare.ca/media.php?mid=1035 > . Keefe, J. and P. Fancey. 1998. Home Care in Canada: an Analysis of Emerging Human Resource Issues. Final Report. Halifax: Mount St. Vincent University. Organisation for Economic Co-operation and Development. 2005. Long-Term Care for Older People. Paris: Author. < http://oberon.sourceoecd.org.ezproxy. library.uvic.ca/vl=2717272/cl=17/nw=1/ rpsv/cgi-bin/fulltextew.pl?prpsv=/ij/ oecdthemes/99980142/v2005n11/s1/p1l.idx > . Thobaben, M. 2000. "Change and Growth in Home Care: Telehealth Care." Home Care Provider 5(2): 47.