In the anatomy of a system for change, clinicians are the feet that do the walking. They can also be the feet that drag.
This is especially, though not exclusively, true of my own profession. Along with nurses, rehab professionals, mental health professionals, and so many others, doctors roll up their sleeves every day to take care of people who need our services, with skill and passion. But unlike many other groups, doctors often see themselves as separate from the system. Until they see themselves as part of it, large-scale change will be blocked.
In an environment where nearly all the money for doctors’ payments comes from one source—the government—you’d think Ministries of Health or health regions would somehow be able to require that all patients with a particular condition get access to the same high standard of care.
This is not the case. Canada has a highly decentralized model of health care, with enormous power residing at the level of the individual physician. Ministries of Health, health regions, and hospital CEOs have surprisingly little sway in influencing how doctors practise. The high degree of physician autonomy is the result of our history. In Canada, when doctors were first brought under medicare in Saskatchewan in the 1960s, many resisted the change; a doctors’ strike tried to stop the Tommy Douglas government from requiring that they bill the provincial insurance plan for their services rather than having patients use private insurance or pay out of pocket.
In the face of massive public support for medicare, the doctors eventually backed down. But in the compromise that was reached, they wouldn’t become employees of the government. Instead, doctors would continue to function as independent entrepreneurs, billing the government for their services but having minimal accountability for the type, number, or quality of those services. Importantly, the money transferred to physicians, unlike the salaries of employees, is purely for the provision of clinical services. There is no requirement to participate in initiatives to improve the quality of care we provide, although in some provinces that’s starting to change.
This doesn’t mean that doctors can do anything they want without repercussions. Physicians in Canada, like most health professionals, are subject to the policies of our professional colleges. We have to behave ethically, we have to practise medicine within reasonable bounds, and we can’t intentionally harm people. Of course, most doctors are skilled professionals who care deeply about their patients and work hard to do right by them. But much of the difference between how two physicians approach the same situation falls into the grey zone of professional preferences, or “practice style.” It’s unlikely that a physician would be reprimanded for failing to address her long wait time for an appointment using tools that are known to work, or having a Caesarean section rate higher than the norm. It’s even less likely when we often don’t even know her wait time or her C-section rate.
The result is that physicians have a striking degree of autonomy, even compared to other health care providers. As doctors, we’re taught that such autonomy is necessary and desirable. The highly independent nature of medical practice is usually framed within the medical community as a good thing for patient care. The pervasive cultural belief has been that, as independent practitioners, doctors are best able provide patients with the individualized care they need, and that anyone who tries to tell us what to do—administrators, other providers, or the government—is putting some other interest (often financial) ahead of the interests of our patients.
It’s laudable to hold tight to the notion that patients’ needs come before all else. But physician autonomy has at times been an excuse to either resist important changes that would help patients or passively avoid participating in those changes. The fallacy that patients’ needs and the system’s needs are mutually exclusive is what’s held us back.
Our medical education system has been trying to move with the times, increasing its focus on the profession’s social accountability as well as its training in areas like quality improvement. But change takes time. New doctors still graduate into a culture where it’s common to view accountability to society for our own practice as optional at best and inappropriate interference at worst.
In training, doctors learn over and over that the individual doctor–patient relationship is a sacred one. I believe this is true. But when it’s overemphasized, medical students can come to believe that any outside force is a threat to that critical bond with the patient. It’s too easy to interpret this to mean that “the system” is something from which patients must be protected rather than the very infrastructure that allows doctors to care for patients in the first place.
The fact that they function as independent contractors instead of as employees within the system has divided doctors from their colleagues in nursing, allied health, support services, and medical administration. As someone who’s chosen to participate in hospital administration, I sometimes see this in the way my own colleagues perceive me. I get angry emails from doctors I’ve never met who hear me talking about a system issue on the radio and accuse me of having “lost touch” with what it means to be a physician. They assume that because I work for the hospital I can’t possibly understand patients’ needs, or that because I talk about improving the system I somehow value those needs less than I did when I was solely a clinician.
Because of this mistrust, some doctors—even those who really believe in social accountability—come to see the health care system as something that exists alongside them rather than something of which they’re a part. Nurses and doctors are both publicly paid, but in most cases they have very different degrees of accountability: one is an employee of a frontline organization like a hospital or a regional health authority, and the other is paid by a remote entity called “government.”
It’s time for a new professionalism in medicine, one that is emerging in Canada and needs to be nurtured. It will be built not just on doctors’ legitimate devotion to patients, but also on their willingness to participate in improving the system. Dr. Don Berwick has called this professionalism “an embrace of citizenship in the greater whole that is health care, even when caring for a single patient…. This means asking, not just, ‘What do I do?’ but also, ‘What am I part of?’ ”
Berwick himself has been lauded as the embodiment of this perspective. An American physician who’s held some of the most important leadership roles in that country’s health care system, he has that elusive bifocal vision: the ability to see patients up close, in all their vulnerability, and to apply his skills to help them; and the ability to see around him all the broader systemic factors that have led those patients to the moment they’re in now.
Indeed, no one has better summarized the duty to see the system beyond the patient than Berwick did in a commencement speech to the 2012 graduating class of Harvard medical school, which he dedicated to his deceased patient, Isaiah:
Now you don your white coats, and you enter a career of privilege. Society gives you rights and license it gives to no one else, in return for which you promise to put the interests of those for whom you care ahead of your own. That promise and that obligation give you voice in public discourse simply because of the oath you have sworn. Use that voice. If you do not speak, who will?
There are many, many other physicians who feel what Berwick articulates so beautifully—that our role as physicians is not only to take good care of our patients, but also to lead the charge for better social conditions. Many doctors who share that passion don’t get involved in such traditional medical politics as sitting on the boards of medical associations, negotiating contracts, and becoming leaders in their hospitals or health teams. Some may instead choose academia and channel their desire for change into their research, or they may participate in important advocacy work outside the mainstream medical community.
We need doctors in all these critical roles, pushing for large-scale system improvement. But we also need doctors who see themselves as citizens to take on traditional medical leadership roles in our hospitals, our primary care teams, and our medical associations. That change is underway, but is by no means complete.
We can nudge progress along, bringing change to medical culture by seeking greater accountability from doctors, paying them differently, and training them in the skills they need to be team players. But the crux of this change has to come from within the medical profession. Our view of our purpose needs to reflect an aspiration not only to heal the patient but to heal the system, as a core aspect of the oath that we swear.
Making change is always about the art of the possible. Sometimes it would be great to pass a piece of legislation requiring hospitals or doctors to do something, but it just isn’t feasible. At other times it would be better to engage physicians and inspire them to drive change locally, but sometimes they’re frankly unwilling or unable to do so. We might have all the goodwill in the world, but the forces aligned against change may be too powerful. Change requires that providers and policy makers be brave when too often we’re just tired, trying to get through the day.
The established way of doing things always takes on a life of its own. Organizations and systems develop protocols and procedures that maximize pay or other benefits for the providers or the institution. Change can thus mean a loss of money, power, or prestige for someone, perhaps a doctor, a hospital, or a corporation. The only way to overcome resistance, then, is with a combination of data, political courage, and physician engagement.
Across Canada, health care innovators have proved themselves capable of delivering better care. We know how to do it in our local communities, clinics, and hospitals. The real obstacle in Canadian health care is that we haven’t figured out how to do it for everyone, everywhere, all the time.
Unless we can get better at bringing change to every community that needs it, none of the other Big Ideas in this book can be implemented successfully. If we can’t effectively spread and scale our success, we can’t deliver on the promise of medicare.
Our system generates tons of data, but doesn’t yet report it in a timely or public way to stimulate change. So we have only part of a brain. Our policy makers see the need for the spread and scale of successful innovations, but they often lack the courage to make it happen. So we only have part of the heart we need to get the job done. Our physicians are committed to serving patients, but they don’t always see it as their job to help improve the system. So our feet can’t do the walking.
Implementation of any Big Idea requires us to invest time, energy, and money into that anatomy of change. Each particular Big Idea will also require other body parts to support spread and scale. Information technology, for instance, will often be a necessary connector; well-developed organs are useless without a circulatory system to connect and feed them. Good IT connections can link different environments, making care safer and more efficient. But throwing technology, money, machines, or providers at our problems won’t resolve them if the focus always remains local. The building blocks are in place to implement the solutions every Canadian deserves. If the brain, heart, and feet are aligned, things can move.