Whatley's Book
I have just read a 2020 publication called “When Politics Come Before Patients” by Dr. Shawn Whatley. The author’s knowledge from working decades in the Canadian healthcare system is more than obvious. An in depth view of this system especially from the history and policy perspective is packed into 228 pages with 737 references. The main message is that the system is now primarily there to employ people rather than treat patients.
He chunks this story into two parts: the why and the how. The why is a historical account of Canadian healthcare that is totally readable and totally believable. Spoiler alert: Tommy Douglas is not a god when a more revisionist history (ala Malcolm Gladwell) is considered. The how has mostly to do with how patients have become secondary to government management of the system. Ditto on the readability and believability. Obvious spoiler alert: governments move slow and waste money.
The why section basically says doctors provide healthcare and governments distribute healthcare. There is a conflict here. This “how” section says the insatiable appetite for healthcare leads to it being a real financial burden for which governments are helpless to do anything about, except, of course, politics. There is, again, a conflict.
Best Hypocrisies Described
Dr. Whatley talks about various mucky mucks up high in the healthcare power structure denying a private pay option to the public but totally shifting gears when it comes to them. The author also talks about this privilege extending down to the regular working stiffs in the system who may perhaps get on a shorter waiting list if they are “in” the system and have a “doctor” connection or two.
The second best hypocrisy described has to do with why a waiting list for healthcare occurs in the first place, namely lack of healthcare in a system that tries to create equality. I guess the theorists are right when they say that freedom and equality are mutually exclusive.
Things Not Described
It would have been great to see such an informed author comment on the obvious money paradoxes of the system when it comes to paying doctors under a fee for service arrangement.
In a nutshell a very small percentage make millions and the rest gross a few hundred thousand dollars. This is due to either, to doctors gaming a high volume practice or fees that have not changed as technology has advanced, like turning a surgical procedure of 3 hours 30 years ago into 3 minutes when done today.
The author does an admirable job of showing how complex the system is, given its complicated context. It would have been nice for Dr. Whatley to chat about some of the now very old theory of complexity like effective control of a system having to be as complicated as the system it controls (Ashby’s Law) or trying to reduce a complex system’s behaviour to any formal description makes things more complicated not less (from John Von Neumann). But there is only so much room in a book you actually want people to read.
I also couldn’t help wondering what the author thought of the current government’s fixation on the number of operations done in a province as a proxy for how well they are managing the system. Goodhart’s Law actually states that a measure (like number of surgical procedures in this case) that becomes a target ceases to be a good measure.
Most Memorable quote
On page 215, Whatley says, “In the 1960’s, socialized medicine seemed to offer a cultural transition, like going from horses to cars. But it has left us with lease payments on a Lamborghini, as our only vehicle, in a country covered in snow six months of the year.” Brilliant!
Suggested Solutions
Dr. Whatley’s solutions are things most of us in the business have heard many times before like adopting patient care as the one overriding purpose, aligning incentives, and trying not to fix medicare from top down. That is all well and good but all that has really happened is tinkering.
Private insurance is recommended to a certain extent by the author. There is no question that the market is a better information gatherer than the government so that error correction can be applied to experimentation.
He does recommend paying physicians by salary although this is loaded with as much financial gaming-of-the-system potential as the fee for service...think city workers repairing a pothole.
The real power in our system lies with the government but governments know that voters generally don’t like their politician but generally like their doctor. They know full well that massive changes to the system mean taking responsibility which means losing the next election. This type of massive change is only going to happen with some sort of massive financial calamity like a provincial bond market crisis.
Nobody in politics wins by telling the healthcare truth, the whole healthcare truth and nothing but the healthcare truth. Nobody in a position of political power will openly question whether there is overall benefit to a society with some medical intervention when the entire equation is considered. No minister of health is going to stop healthcare (sick care) that is done at huge expense at a patient age that is far past peak regenerative capacity of the human body. And nobody that wants to get elected will say that the population has a responsibility for their own health by not poisoning themselves into early aging with excess booze, cigarettes, or food.
Dr. Whatley’s book has given us a lot to think about.