Doctors help create the health care system—for better and for worse


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13 comments

  1. Adam Venning

    The smartest article I have read on healthydebate.ca in a long time. Congratulations!

  2. Don Taylor

    What a refreshing perspective. Thank you. Sadly, healthcare practitioners blaming the “system” has a knock-on effect on patients, increasing their anxiety, and possibly despair, as to the quality of care they won’t receive because of the “system”. The worst case scenario: both practitioners and patients focussed on helplessness, rather than action.

  3. Wendy Ungar

    Excellent article and great to see these types of initiatives taking root. While we love our publicly financed health care system, one of the adverse consequences, unlike a private health system, is that there are no built-in incentives to improve efficiency in processes or lower costs by reducing consumption of unnecessary tests and physician visits. When I was at my eye doctor this week for a check-up he reviewed the results of an imaging exam he ordered that he admitted was completely useless for someone as near-sighted as me. When I suggested that we skip the exam next time and save the system some money, he thought I was being funny. If that physician could see the direct benefit of reduced test ordering to his own institution, that would help create the incentives to alter physician behaviour in the future. What’s needed is a cultural shift — one that that allows us to think about publicly financed healthcare resources as precious — resources that should not be squandered.

  4. Gerry Goldlist

    For decades physicians have watched our healthcare system deteriorate because of bureaucrats who think like this:

    “In the quest to provide the best care possible, physicians can become caught up with the patient in front of them.”

    • Gerry Goldlist

      To be clear, Melody, that was not meant to be a personal attack on you but just my observation about bureaucrats and health care consultants.

      • Steven Lewis

        I think you’re missing her point, which is precisely that excessive and unwarranted advocacy for and spending on an individual patient create problems for the system. If my physician knows that I do not in fact need an MRI, or that I do not in fact require urgent intervention, it is unethical for my physician to command the resources and engineer the privileged access on the pretext that there is an exclusive duty to me and the satisfaction of my preferences. In a finite system, every knowingly unwarranted diagnostic procedure or intervention is irresponsible grazing of the common. It is an abdication of responsible stewardship and distributive justice.

        It is the duty of public servants who oversee a publicly financed health care system to attend to distributive justice. As a citizen and patient I would prefer that this function be delegated to health care providers willing to assume joint responsibility for high quality care, sound resource stewardship, and fairness. But if physicians maintain that their exclusive duty is to the patient in front of them on any given day, and their own patients more generally, then they have ceded to others the role of ensuring that the system operates fairly and efficiently. If physicians wish to avoid the resulting tensions, they have only to demonstrate their commitment to all three dimensions of a functioning public system and their willingness to be good stewards. Own the problem and fix it and the public servants will be pleased to get out of the way and the consultants will be out of business. Otherwise be grateful that others are watching out for people whose greater needs are deemed irrelevant to how individual doctors practice medicine and requisition public resources. It may be your patient who is unfairly disadvantaged when other physicians game the system on behalf of theirs.

        • Gerry Goldlist

          Having had decades of experience with the Ontario Health Care System as a patient, a practising physician and from discussing the experiences of hundreds of physicians if not more, I can attest to the following.

          1. Front line physicians have been dealing with patients’ unrealistic demands for a long time. Most of us are too busy to do “unwarranted advocacy”: we are busy enough doing warranted advocacy for patients who need services that are in short supply.

          2. My first duty is to my patients. Unfortunately, I am always under the threat of the government or the CPSO punishing me for not following not only their edicts but their conflicting edicts.

          3. You may not know that the patients who get the worst ratings on RateMD are the ones who don’t do what their patients demand. I don’t care about RateMD but I do care when a patient is disgruntled that they didn’t get their demands met and so complains to the College about me. This puts me in the position of spending time and maybe money to deal with the College. The College has the power to discipline, fine and remove licenses.

          4. Notwithstanding what you think is unethical, it is unethical for a physician to not do what is best for the patient sitting in front of him. That is no pretext: that is reality.

          5. When I order tests, I balance the risk/benefit ratio. I don’t order *unwarranted* diagnostic procedure or interventions. I venture that very few physicians do. In veterinarian medicine, it is the payer not the patient that decides what is *worth* paying for. In Ontario healthcare the government is the payer.

          6. Doctors have been working on hospital committees, health advocacy groups, LHIN advisories, government advisories, OMA advisory committees to government etc. since before I was born. It is ludicrous to imply that we don’t and haven’t done these things. The power to ensure that the health care system runs fairly and efficiently was not ceded by physicians: it was taken away from us by government, bureaucrats and administrators.

          8.re: “Public servants will be pleased to get out of the way and the consultants will be out of business.”

          LOL – The public servants’ jobs and income depend on this business. The prime directive of a bureaucracy is to perpetuate its own existence by expanding its roles and never to decrease its role.

          9. And finally, this was written in 1986 by an Ontario physician. As our health care system continues to implode, it is even more relevant today.

          The duly elected representatives of the patients created this health care system. We are not responsible for it, but just doing the best we can

          • Steven Lewis

            Well, you can’t have it both ways. You assert that physicians have been battling to secure access to services in short supply, the implication being that they are cruelly rationed by an uncaring government. Yet it is physicians – not others – who have identified the massive overuse of literally hundreds of tests and procedures, which has led to the Choosing Wisely campaign. Despite the best efforts of physician leaders, little has come of it. There is enormous resistance to physician-generated practice guidelines and care pathways by their physician colleagues. High-performing health care systems embrace physician-led and peer-developed efforts to standardize practice on the basis of the best available evidence. Costs and utilization tend to go down in systems that take quality improvement seriously.

            It is hardly surprising that physicians believe that their practices are evidence-based, their resource stewardship is impeccable, they never order a test or prescribe an antibiotic to shorten a visit or placate a patient, and that the reward for their excellence and courage is an inquisition by the brutish regulatory authority of their peers. All of them cannot be right given the massive evidence of unwarranted variations in care and resource consumption, and the unhappy position of Canada at or near the bottom of the Commonwealth Fund rankings of health care systems in rich countries. Assertions of one’s own excellence and the imputation of the systems flaws to everyone except the people at the centre of it – the point of the soon-to-be Dr. Ng’s article – prove nothing except a remarkable capacity for self-absolution.

            A simple example is waiting lists. Common sense would suggest that if you want people to be served in order of need, and all to be served without undue waits, pool the wait lists and assign OR time on the basis of patient needs. Yet many physicians fiercely resist this measure because a long wait list secures access to more OR time and more income, the consequences for patients be damned. (And no, a pooled list does not mean patients can’t choose their surgeons. It may mean that if you insist on surgeon X, you are voluntarily deciding to wait longer.) The response to practice variation is “my patients are different,” or “my patients are happy,” and there is little interest in collectively addressing these worrisome anomalies to come to a common understanding of how to resolve them.

            It is interesting how thin-skinned many physicians are when gingerly challenged to take some responsibility for the system’s imperfections while at the same time demonizing others. Public servants are assumed to be interested only in the preservation and expansion of their meddlesome sinecures. The overuse of services is attributed to insatiable patient demand, as if our expectations and preferences are entirely our own, unmediated by and impervious to the counsel of our physicians. If there is to be progress there has to be respect, and respect is bi-directional. No one is demonizing doctors; there is an open invitation to co-design a better future.

            Physician leaders are stepping up and speaking truth both to power and to themselves. This is an admirable development. Ms. Ng has decided not to be a victim, not to take comfort in false dichotomies, and not to oversimplify the ethics of patient-centredness. If she is representative of the coming generation of doctors, the system will be in good hands.

            • Gerald I Goldlist

              Services to health care IS being rationed. I didn’t say that govt is uncaring but it is their policies that have allowed the rationing to get worse and worse while trying to shift the blame to doctors who are juggling the impossible.

              “Yet it is physicians – not others – who have identified the massive overuse of literally hundreds of tests and procedures, which has led to the Choosing Wisely campaign. Despite the best efforts of physician leaders, little has come of it.”

              Do you have any PROOF of what you have said?

              “There is enormous resistance to physician-generated practice guidelines and care pathways by their physician colleagues.”

              Do you have any PROOF of that?

              “High-performing health care systems embrace physician-led and peer-developed efforts to standardize practice on the basis of the best available evidence.”

              Are you implying that those in frontline medicine don’t do continuing medical education to learn best practices?

              “The unhappy position of Canada at or near the bottom of the Commonwealth Fund rankings of health care systems in rich countries. Assertions of one’s own excellence and the imputation of the systems flaws to everyone except the people at the centre of it – the point of the soon-to-be Dr. Ng’s article – prove nothing except a remarkable capacity for self-absolution.”

              After being blamed for the ~33rd best health care system as ranked by World Health Organziation,, we are not going to take this anymore. The control of the health care system has been taken away from physicians by government legislation and bureaucratic rules. We have fought them for years and physicians have lost the battle.

              “Undue waits?” Waiting lists are a result of lack of OR time and resources and has nothing to do with the order we do them. Almost every surgical specialty in Ontario has absurdly long wait lists that are often beyond the standards set by government and physicians. These are not within our control: government controls the purse strings and funds hospitals. Hospitals are not allowed to go over budget and so are forced to close OR’s for up to months at a time at fiscal year end. You cannot create more OR time by centralized booking.

              “My patients are different.”

              No! My patients are individuals. They are human beings. No number cruncher can see the actuall suffering of patients: the inability to enjoy grandchildren, the inability to exercise and the inability to work.

              “There is little interest in collectively addressing these worrisome anomalies to come to a common understanding of how to resolve them.”

              Actually there is a lot of interest by physicians.

              “Gingerly challenged” & “No one is demonizing doctors.”
              Walk a mile in our shoes. From our point of view, that is false. We constantly feel demonized by Health Ministers, newspaper columnists and even some patients.

              • Steven Lewis

                Since you posed a number of questions I will answer them. My responses are in CAPS to distinguish them from your post, reproduced here.

                Services to health care IS being rationed. I didn’t say that govt is uncaring but it is their policies that have allowed the rationing to get worse and worse while trying to shift the blame to doctors who are juggling the impossible.
                ARE YOU THEREFORE DENYING THAT THERE IS WIDESPREAD OVERUSE OF DIAGNOSTIC TESTING, AND THAT THERE ARE INEFFECTIVE SURGICAL PROCEDURES (E.G., MUCH BACK SURGERY, SOME CATARACT SURGERY, ALL DOCUMENTED IN THE LITERATURE IF YOU’D CARE TO LOOK)? GOVERNMENTS DOUBLED, IN REAL TERMS, HEALTH SPENDING FROM 1997 TO 2010. DID THAT FIX EVERYTHING? ANYTHING? NOT EVERY PROBLEM IS A RESOURCE PROBLEM. SOMETIMES ABUNDANCE CREATES AS MUCH MISCHIEF AS SCARCITY. “DOCTORS ARE JUGGLING THE IMPOSSIBLE.” NO, MSF DOCTORS AND CUBAN DOCTORS ARE JUGGLING THE IMPOSSIBLE.

                “Yet it is physicians – not others – who have identified the massive overuse of literally hundreds of tests and procedures, which has led to the Choosing Wisely campaign. Despite the best efforts of physician leaders, little has come of it.”

                Do you have any PROOF of what you have said?
                READ THE LITERATURE UNDERLYING CHOOSING WISELY AND THE EVALUATIVE LITERATURE ON UPTAKE. TALK TO THE PHYSICIAN LEADERS WHO HAVE DECIDED NOT TO BE OSTRICHES AND WHO RECOGNIZE THAT OVERUSE IS AS HARMFUL AS UNDERUSE.

                “There is enormous resistance to physician-generated practice guidelines and care pathways by their physician colleagues.”

                Do you have any PROOF of that?
                THERE IS A HUGE LITERATURE ON THE GENERAL INDIFFERENCE TO PHYSICIAN-PRODUCED CPGs.

                “High-performing health care systems embrace physician-led and peer-developed efforts to standardize practice on the basis of the best available evidence.”

                Are you implying that those in frontline medicine don’t do continuing medical education to learn best practices?
                I AM ASSERTING THAT THERE CONTINUES TO BE ENORMOUS PRACTICE VARIATION FOR WHICH THERE IS NO CLINICAL JUSTIFICATION. CLINICIANS DO CME. IT CANNOT BE THE CASE THAT THEY ALL LEARN AND ADOPT BEST PRACTICE AND YET PRACTICE SO DIFFERENTLY FROM EACH OTHER. THE HALLMARK OF QUALITY IS DOING THE SAME THINGS IN THE SAME CIRCUMSTANCES WHERE THERE IS GOOD EVIDENCE OF WHAT WORKS AND WHAT DOESN’T.

                “The unhappy position of Canada at or near the bottom of the Commonwealth Fund rankings of health care systems in rich countries. Assertions of one’s own excellence and the imputation of the systems flaws to everyone except the people at the centre of it – the point of the soon-to-be Dr. Ng’s article – prove nothing except a remarkable capacity for self-absolution.”

                After being blamed for the ~33rd best health care system as ranked by World Health Organziation,, we are not going to take this anymore. The control of the health care system has been taken away from physicians by government legislation and bureaucratic rules. We have fought them for years and physicians have lost the battle.
                NO ONE BLAMES DOCTORS FOR THE RANKING OF OUR HEALTH CARE SYSTEM; IT IS A TEAM SPORT AND EVERYONE HAS CAUSE TO THINK ABOUT WHY WE DO SO POORLY AND TO RETHINK OUR VARIOUS ROLES. YOUR POSITION APPEARS TO BE THAT GOVERNMENTS IN CANADA ARE UNIQUE IN THE WORLD FOR HAVING INVADED THE EXAMINING ROOMS AND OPERATING THEATRES OF THE NATION AND OVERRIDDEN ALL OF THE CLINICAL DECISIONS OF HAPLESS PHYSICIANS. PLEASE POINT US TO THE LIBERTARIAN PARADISES WHERE UNIFORMLY EXCELLENT DOCTORS PROVIDE UNIFORMLY EFFECTIVE AND EFFICIENT CARE UNBURDENED BY THEIR GOVERNMENTS.

                “Undue waits?” Waiting lists are a result of lack of OR time and resources and has nothing to do with the order we do them. Almost every surgical specialty in Ontario has absurdly long wait lists that are often beyond the standards set by government and physicians. These are not within our control: government controls the purse strings and funds hospitals. Hospitals are not allowed to go over budget and so are forced to close OR’s for up to months at a time at fiscal year end. You cannot create more OR time by centralized booking.
                IT MIGHT SERVE YOU TO READ WAIT TIME INFORMATION AND THE PHYSICIAN-PRODUCED LITERATURE ON HOW TO OPTIMIZE WAIT LISTS. IN CANADA ALMOST NO ONE WAITS FOR URGENT SURGERY. FOR NON-URGENT SURGERY THERE CAN BE LONG WAITS FOR ORTHOPEDICS, DEPENDING ON LOCATION, AND OTHER SURGERIES FROM TIME TO TIME. THERE ARE INVARIABLY SOME PEOPLE WHO WAIT UNCONSCIONABLY LONG WHILE MEDIAN WAITS ARE ALMOST ALWAYS REASONABLY SHORT. THAT SUGGESTS AN ORGANIZATIONAL PROBLEM, NOT A SUPPLY PROBLEM. THE LONGEST WAITS IN CANADA ARE TO SEE SPECIALISTS, WHICH MAY BE A SUPPLY PROBLEM; IS ALMOST CERTAINLY A DISTRIBUTION PROBLEM (TOO MANY SPECIALISTS IN LARGE URBAN CENTRES, NOT ENOUGH ELSEWHERE); AND HAS BEEN SHOWN BY CANADIAN RESEARCH TO BE THE RESULT OF FAMILY DOCTORS REFERRING MORE QUICKLY.

                “My patients are different.”

                No! My patients are individuals. They are human beings. No number cruncher can see the actuall suffering of patients: the inability to enjoy grandchildren, the inability to exercise and the inability to work.
                NOT THE POINT. NUMBER CRUNCHERS ARE ALSO PATIENTS, ARE CONCERNED FOR THEIR FUNCTIONAL CAPACITY, AND SOME HAVE GRANDCHILDREN. NO ONE SAYS PATIENTS AREN’T INDIVIDUALS. THERE IS THIS ACTIVITY CALLED RESEARCH, THAT EXAMINES CLINICAL POPULATIONS, AND FINDS PATTERNS IN THE RELATIONSHIP BETWEEN PATIENTS’ NEEDS, THE SERVICES PROVIDED, AND THE OUTCOMES, WHICH INFORMS WHAT TO DO IN WHICH CIRCUMSTANCES. THAT’S HOW IMPROVEMENT OCCURS.

                “There is little interest in collectively addressing these worrisome anomalies to come to a common understanding of how to resolve them.”

                Actually there is a lot of interest by physicians.
                GREAT. SO WHY DO MAJOR VARIATIONS PERSIST THEN? DO PHYSICIANS ROUTINELY GET TOGETHER WITH THEIR COLLEAGUES TO REVIEW THEIR DATA, IDENTIFY VARIATIONS, DISCUSS THE IMPLICATIONS, AND RESOLVE THEM? IF PHYSICIAN X ORDERS 3 TIMES AS MANY CT SCANS AS PHYSICIAN WAY FOR A SIMILAR PRACTICE POPULATION, IS THERE ANY REQUIREMENT TO GET TO THE BOTTOM OF THE VARIATION AND CHANGE PRACTICE? WE BOTH KNOW THE ANSWER TO THAT QUESTION.

                “Gingerly challenged” & “No one is demonizing doctors.”
                Walk a mile in our shoes. From our point of view, that is false. We constantly feel demonized by Health Ministers, newspaper columnists and even some patients.
                I CAN’T DISPUTE YOUR FEELINGS. IT IS TRUE THAT AT TIMES, ORGANIZED MEDICINE – NOT INDIVIDUAL PHYSICIANS – GETS A ROUGH GO IN PUBLIC, WHEN NEGOTIATIONS ARE FRAUGHT AND FRUSTRATIONS BOIL OVER. OVERALL, WHAT PHYSICIANS ROUTINELY SAY ABOUT GOVERNMENTS – READ YOUR OWN POSTS HERE, THEY DRIP WITH CONTEMPT – IS FAR LESS RESTRAINED AND DISMISSIVE THAN VICE-VERSA. (IN CASE YOU ASSUME I AM SPECIAL PLEADING ON BEHALF OF MY CLAN, AM NOT A PUBLIC SERVANT.) I’M ALL FOR FOOTWEAR EXCHANGE – IT’S CALLED EMPATHETIC REASONING. IF YOU WANT RESPECT AND CIVIL DISCOURSE, MODEL THE BEHAVIOUR. IF YOU WANT TO BE TAKEN SERIOUSLY, TAKE OTHERS SERIOUSLY. IF YOU WANT TO ARGUE ABOUT EVIDENCE, READ THE EVIDENCE. AND IF YOU IGNORE OR DISMISS THE VOICES AND PERSPECTIVES OF PEOPLE LIKE DR. NG, YOU ARE DENYING YOURSELF AN OPPORTUNITY FOR REFLECTION AND WILL CONFINE YOURSELF TO AN UNNECESSARY MISERY. WE ALL NEED THE LESSONS OF POGO, MICHAEL JACKSON, AND NOT-YET-JADED FUTURE LEADERS. LOOK LONG AND HARD IN THE MIRROR BEFORE POINTING FINGERS.

  5. Manu Arora

    Thanks for writing a nice article that is based on the topic of health care.

  6. Ernest Young

    “It is time for more physicians and trainees to participate in initiatives such as these. We are not helpless victims of a flawed system; we can rise to the occasion and embrace our roles as stewards of that system, despite its finite resources and complex issues.

    As a medical trainee, I look to staff physicians to teach us not only to denounce the barriers in health care, but to do good in the system despite the barriers, and where possible, to step up and make change.

    We have the power, and we have the responsibility. Let’s embrace that.”

    Spoken like a true medical student without the actual responsibilities of a staff physician. Melody, once you are operating as a resident or even as a staff, you become familiar with how much there is to do and how little time there is to do it. You may also have a family someday (if you want one) and realize how important work life balance is. The reality is that there are 24 hours in a day, and most doctors are pretty tired at the end of each 24 hour period. We somehow have to find a way to care for our patients, do all the administrative work required to achieve this, and also take care of ourselves and our families. There isn’t a lot of extra time left to engage in QI efforts or systems reform- and these things take time. It’s maybe ok for people who work in academic hospitals (although they have a lot of responsibilities to live up to their academic mandates- publishing, doing research, teaching etc.)- specifically, those who choose to work in the QI stream. But I think what you set out is unrealistic and ignorant of the realities of medical practice.

    • Melody Ng

      Hi Ernest – thank you for your thoughtful and honest response.

      I agree that physicians juggle many responsibilities, including both professional and personal ones.

      I have a couple thoughts in response:

      1. All examples of QI I have cited in my article are in fact, led by full fledged practicing physicians with such responsibilities that you mention. As a project manager in the past, I also had the privilege of working with numerous dedicated staff physicians in community hospitals (not just academic ones) who were participants in initiatives to improve care.

      2. Your point about competing priorities is absolutely valid. I wanted to point out though, not every physician needs to spearhead a brand new initiative. *** Even small efforts to participate across the profession will have huge impacts in the long run. It doesn’t always have to take a lot of time. ***

      3. Most of all, it is about a change in culture and mindset: we all have responsibility to contribute to change, not merely complain about a flawed system for all our troubles.

      My message is not meant to be a burden to dedicated clinicians. Quite the contrary, it is well documented that job satisfaction correlates to how much employees feel they can influence their work environment.

      In sum – I agree with you that it isn’t every physician’s calling to dedicate themselves to QI. That isn’t what I’m advocating for. Any of our efforts to consider and participate when able are what will make all the difference.

      Thank you again for your comment.

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