If you have read my blog before, please pardon me while I explain this question in view of not getting the “benefit of the doubt” from others reading this. I have worked in and with a wide range of health care organizations. As a citizen of Ontario with children, a spouse, siblings and parents in the province, I have a vested interest in the current and future system reforms working. I see a greater possibility for success if the right kind of collaboration takes place so that the right people are able to make the best (not easiest) decisions.
With that context, understand my sincerity in asking “What is it with doctors?”
In my writing and my client work, in- and out-group dynamics come up a lot. Doctors are perceived as a very specific constituency in the system… with good reason. The extent to which this perception stands is fascinating:
At lunch recently with a fellow consultant in the health care system said to me: “We seek to inform the doctors, but all we hope is that they don’t actively resist the work we are doing.” Working with a hospital group recently, the historic specter of the doctor vs. nurse divide reared its head. An academic mentor of mine with whom I consulted before launching my practice suggested: “It won’t work if you don’t get the docs on board, and I don’t think you will.”
There are a number of reasons why doctors could view themselves as very removed from the system: degree of training, stature that crosses most/all cultures, different employment structure with the hospital/community system, etc. But do they see themselves as that different? Some may, some may not.
If I were a doctor, I think that I would be proud of my accomplishments, and I might develop an ego. I also might think that it is my job to make decisions and may actually not appreciate what I perceive as challenges from other staff (RNs, RPNs, etc.) who (although they are only trying to help) are trying to make those decisions for me. What if they are wrong? If I were time starved, as many doctors are, I may not be able to take the time to “soften” my message or think about the “how” of my communication skills.
If doctors are removed from the workings of the system, they can take responsibility to “engage” more. If they don’t those working around them can accept the out-group reality and behave accordingly. The right information to save and prolong lives can still get through. Like many things, it is easiest if both sides work together. Some doctors will; some won’t or can’t. It is the latter group that could tip the scale one way or the other. As some of the tougher reforms come through, it will be interesting to see if the perception (and reality) of doctors change.
This week’s Longwoods newsletter (www.longwoods.com) lists instances of LHINs “starting to show some muscle” in enforcing balanced budgets for hospitals. The tally of resolved vs. delayed agreements from the London, ON, area is on the Longwoods Healtcare Blog. There is specific mention of a resolution, whereby the South East LHIN lent one of its area hospitals the shortfall to balance the budget for 2008; and of a conflict, whereby the North West LHIN and the Thunder Bay Regional Health Sciences Centre dig in on there competing positions.
The people working in these negotiations must feel like Gary Sinise in Apollo 13 when he is trying to simulate the landing procedure while not exceeding an unprecedented voltage level. In the movie (and the real story), he does it, which provides more evidence that the impossible is attainable when we work together.
What if the impossible is really impossible?
I can guarantee you that the word “impossible” has come up in the discussions and negotiations between Ontario’s hospitals (legally bound to budgets) and funders (LHINs whose job it is to enforce this accountability). I am equally certain that, in the end, some of the things deemed “impossible” were so in actuality, while others were not. The only way to separate the two is discussions (apparently still ongoing in Thunder Bay) that remain open and solution-focussed amid a cloud of rising tension. This is no mean achievement.
Unfortunately, “out-of-the-box” solutions are not always there, but they won’t even be entertained if there is a breakdown in the shared goal, which is getting a sustainable health care system in place. If a situation is truly unmanageable, then there is a responsibility to find a solution together. It demands a different approach than traditional “us vs. them” negotiations. A healthy dose of mutual trust will be necessary for resolutions or re-evaluations.
I am intrigued by the cost savings at Quinte Health Care from implementing third-party (Murphy Walsh) consultant recommendations for improved quality of life for nursing staff. Such experts can add tremendous value in honing systems. Of course, time tells whether the dollar return on these efficiencies will help with the budget shortfall. People also have to embrace the changes, and time also tells whether the changes are actually workable for the staff. One hopes that there is a peppering of “sell” in the “tell” for any change required.
Tom Blackwell raises a the dynamic of the “right to choose” in this piece on canada.com. The question is: who gets to decide what is best for a sick child: parents or doctors? I think we can all take comfort that the situations where this sort of dispute escalates to the Children’s Aid Society are “rare,” and needless to say, “emotional.”
Both doctors and parents, one can assume, have the best interest of the child at heart. But it may be more complicated than that: I recall hearing commentary on an instance in Vancouver–raised in the above article–whereby the parents of sextuplets refused blood transfusions because their Jehovah Witness faith did not allow the procedure. The commentary (I will try to find the source; you will have to trust me for now) was that in such instances, loving parents need to be legally forced, because it allows them to save the child, while also saving religious face.
If, in fact, both parties are focussed on what is truly best for the child, both are responsible and accountable. Parents need to be ready to make their case with more than just “this is what we want” or, worse “this is what our child wants.” With all due respect, it should not take a psychiatrist to determine that a child is unfit to determine the cancer-fighting procedures that they will receive. The medical profession must be granted some degree of trust and authority to make these decisions for people. This sort of latitude should be granted, but also needs to be earned.
Information is everywhere, and Google could probably help find a source to support that a diet of raw vegetables beats chemotherapy or that alternative care in Mexico will be more effective than Ontario hospital care. If these sources of information are being given the nod over what the doctor says, the doctor has some “selling” to do. Understanding the real concern takes time, and usually requires (1) creating a relationship of trust and (2) asking questions. Did the doctors do this? Did they have the time? the skill? Not everyone is going to take a doctor’s word as gospel; nor should they.
Medical research and past results are not the only forms of evidence, but will only be effective if the other party is listening. Fostering a dialogue can get people to open up to some grim realities. It must be a horrible decision to pick between a grueling medical procedure that might help, and a less extreme treatment that almost certainly won’t. That decision, however, should not be the parent’s, and definitely shouldn’t be the child’s!
You can’t take politics out of the health care system, which would suggest that George Smitherman gets some latitude in his public commentary, as do all politicians. Who takes politicians comments at face value? At some point, however, the gamesmanship and negotiation-style posturing will get in the way of achieving a sustainable system. This position receives support from Dr. Yoel Abells in his column in today’s National Post. Dr. Abells rightly scolds Minister Smitherman for using a confrontational approach to negotiating funding with hospitals. The basis for the criticism is that the Minister is picking fights that the LHINs—the funding messengers—are going to have to finish.
NOTE: If you are asking, “What’s a LHIN?” as many a layperson will, visit www.lhins.on.ca for details on the newish player in Ontario health care.
I wish that more people shared Dr. Abells’ perspective; he is in the community and in a hospital. He also takes enough interest in the solution to share his views with the public. I think that his arguments are valid, but I believe that assigning blame defeats the purpose of any health care reform.
Previously, I have written about the movie Apollo 13 (here): is there any clearer example of necessity mothering invention? Ed Harris’ statement “Failure is not an option” is taken as gospel. This type of collaboration (us and us; not us vs. them) fosters true innovation. Making the most of the available resources gets beyond the status quo gamesmanship whereby hospitals grumble in March about under funding only to be topped-up in April for by a government looking for political points.
The LHINs are at the front lines of reform. Granted, posturing from the Minister and his office doesn’t help the situation, nor do tactics from hospitals. Both will have to reach across the fence for things to work for the long term. Time will tell if the LHINs gain enough credibility to broker these handshakes.
I heard an interview with Peter Walker following York University’s release of plans to build a new medical school. CBC’s Matt Galloway kicked off the interview by suggesting a new medical school would be less effective than expanding existing facilities in the province. This may be valid question for someone who is removed from the health care system. Those in the system (professionals, patients and families) might have preferred a different lead-off. Walker’s answers, however, hit the right chords for me.
The response was much less about building capacity, than it was about changing the system. The new school will have hospitals working with the communities, and will also bring together “the variety of disciplines – including social workers, nutritionists, even business experts” (Globe and Mail article). In the same article Walker suggests the result “is going to change the system.”
One of the things that, I believe, slows and complicates change is the extent of “groups” that are historically entrenched in hospitals and health care as a whole. Any discipline has “us vs. them” orientations, but the combinations in the health care system are endless.
Much of the focus on my work in the health care area is on providing skills to recognize and overcome the in-group and out-group dynamics that develop. Ensuring interaction in a systematic manner will foster easier collaboration in the end. There is an interpersonal element beyond the system. Ignoring this can create/exacerbate tension and interpersonal noise caused when “us vs. them” groups come together.
Perhaps this is where the aforementioned “business experts” come into the equation. I would be interested to see if one of these experts is Schulich Business School’s (York University) Dr. Brenda Zimmerman. She is co-author of “Getting to Maybe,” which discusses change in complex systems. If so, this projects appears to have tremendous potential to bring necessary change to Ontario’s health care system.
This week the National Post ran an article (here), and an editorial (here) on the topic of doctor’s being able to choose their patients.
This is one issue that I believe is tough to find “neutrality.” As I think is the objective of many editorial pieces, I think it strikes enough core beliefs that you have to be selective of those with whom to discuss the issue.
In the spirit of the right solution being able to sidestep all the noise created by conflicting philosophies and values, I wanted to bring light to the position put forward by a doctor in a letter to the editor by Dr. Susan Piccinin in Ancaster, Ontario.
She talks about insistence on narcotic-based medication being a “red flag” for physicians when talking to patients. The ensuing dialogue in an initial meeting might look something like this:
Patient: I have a back problem and I have been taking [narcotic-based medication] for it. Can I get some of that from you?
Doctor: Using that kind of medication for any length of time is going to build up dangerous addictions and won’t help your back at all in the long-term.
Patient: I am not addicted; it’s just the only thing that works! Please, give me the prescription.
Doctor: Sorry I don’t prescribe these medications, and for that reason we a not a good match.
Note: The last line is a direct quote from the letter to the editor.
There would have to be a fairly involved exchange of information between the doctor and the patient to get to the above dialogue. For this to work the patient would have to be open and trusting with the doctor (Will this happen if the patient feels a danger of being screened out?), and the doctor would have to devote the time to probe the right information, in a fairly sophisticated manner. (Do doctors have the time? Do they have the skill?)
If this doesn’t work, emotions will cloud the exchange long before we arrive at the “I need the drug/You can’t have the drug” impasse, which, I believe, is a legitimate position for the doctor to hold. Objectively, a doctor should be able to refuse care to a patient who will not allow care to be delivered. (e.g. You are not going to listen to me, so why should I talk to you?)
If this is indeed the case, I think the “selecting patients” issue becomes quite simple, although a number of other complicated issues arise, such as “how does this patient get the treatment they need?” The follow-on issues are much better fodder for articles and editorial pieces, which would create more practical discussion.
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