Ecclectica: The Politics of Medicine

The word Medicine like the word politics has come to mean differing things to different people at different times. Medicine for the purposes of discussion has been interpreted to mean both the practice of medicine by doctors and the health care system Politics has been restricted to discussion of the interactions of the five main players in this sector- government, administrators, pharmaceutical industry, nurses and doctors.

Medicine used to be a much more straightforward. Doctor's nurse's administrator's technicians all had well-circumscribed roles and boundaries. Occasionally, one group or one individual would stray across the boundary but when this occurred the system would act rapidly to restore the accepted equilibrium.

However the past decade has seen dramatic changes inside and outside the system. There are new players and new roles for existing players. This, in turn, has changed the game.

Most important among these changes has been the rise of a management group or class; which, in collaboration with government, has overturned the long accepted order. It is instructive to examine the changes to the equilibrium as a means of understanding the current tensions and as a framework to gauge predictive models. Everyone wants to know What is going to happen to the system, can it survive, what can and what will be done Many offer judgments about what exists and why. Others proclaim the benefit or lack there of certain actions It is into this. miasma that we perhaps, foolishly, venture. Administration, management really controls most of the levers that nudge the system at large on to various paths. How this came to be is the story of the political evolution of the system in a nutshell

When political systems evolve there is a lot of pain lots of dislocations. This is especially so if there is, as in the health system, a duality of participants. In this case: those implementing the changes, those resisting; those mainly affected, those less so; those who are the system and those who the system acts upon (in this case the patients.)

In this multiple act play parties nominally left or right wing have reacted remarkably similarly. Publicly, they use different terminology, different signifier words and phrases, but in practice certain policies have become accepted constants. Much of this has to do with a similarity of circumstances in different provincial jurisdictions.

Parties, when elected to government, are faced pretty rapidly with the travails of and the chores necessary to the maintenance of a working health system. Whatever they have said during the election campaign, when crisis' loom they turn to existing power structures for quick solutions. It seems to make little difference if the new government was critical of or passively ignored the questions surrounding the health care related performance of the previous government. Health care is a black hole with the gravity to pull in all of a government's energy and much of its finances.

The allocation of scarce resources means that Health ministers are often at loggerheads with their cabinet colleagues. The health portfolio consumes much of the budget and ministers are always looking for the few discretionary dollars that are available, creating friction within, and I would argue tensions that undermine concerted efforts to reform.

There are always difficult issues in the field of health care and the temptation to prevaricate is enormous. Do we need more imaging? Do we need more or less beds? Should we close rural hospitals and if so which ones? Seemingly innocuous decisions explode into controversy .New ministers of health, even if they were previously the health critic and therefore cognizant of the issues, are overwhelmed by the unrelenting interest of media, the huge departmental budgets and the technical components which make each decision fraught with peril.

The system in its current Byzantine splendor is oddly like a small town, unless you've lived there you can't understand what's going on and ministers of health have seldom lived there.

So governments, unable to trust their own intuitions, bereft of first hand knowledge of the system or the players, default to the one group that they see regularly- the group that they feel they control and, I would argue, the group that they have come increasingly to resemble- the health care bureaurocracy. Political systems like order or, more accurately, abhor disorder. Once elected, governments are in essence as much the remnants of military rule as they are of the Athenian polity. This is in spite the more general societal trend towards cooperative group action.

Real decision-making power is concentrated in a few hands with only routine matters delegated downward.

Those few hands at the top tend to know little about health care, although strongly held but poorly thought out belief systems are common. Combined with the natural inclination of elected government to give orders, leads inevitably to hierarchical structures and planning.

This top down approach of government contrasts strongly with the organizational and operating structures of healthcare-related professional groupings. The political forms of the professional associations share power collegially while moving inside interlocking organizations. This approach seems foreign, perhaps even quaint to those working within a hierarchical structure. For these groups order must prevail and order as it is understood is from the top down. The two competing paradigms do not coexist well. The question; "If the hospital system has a military culture or at least a military history, why is it so uncomfortable with a military style government culture?", can be answered only by reflecting upon an odd phenomenon both physicians and nurse evolved inside military style organizations however doctors became liberated from this straitjacket by independent practice. They then became effectively like small businessmen fiercely independent and vociferously egocentric. There is an old adage that when you have ten doctors in a room you have eleven different opinions. One for each and a consensus opinion, which of course everyone disagrees with. Medicare with its infusion cash only accelerated this process. The health system has been a bicameral house and this is the ground that has been shaken

It has been my observation that the parts of a system often evolve at differing rates. The complex set of interactions that typify the health system in general and modern hospitals specifically have only recently come back into anything that might be called balance evolving into a new body politic of health care.

What is this new shape and what energizes its' direction? As the old paradigm of collegial professionalism is eroded and replaced with a top-down bureaucratic model healthcare professionals have been forced to see themselves in new ways. They are no longer the system but merely work in the system. It is management who "owns" the system. This is a sea change. It represent s the ending in a way of the power base of independent medical practitioners and the birth of a new often-troubled landscape

In addition to the new ascendancy of management, there is another powerful new force interleaving itself into the fabric of everyday health decision-making. Drug companies have come to exert enormous influence in the system, though often through obscure or perverse means. Any discussion of the politics of medicine needs to include reference to the pharmaceutical industry.

Fifteen years ago medications were a small fraction of the cost of care. Now the cost of drugs exceeds the cost of doctors and while medical cost are increasing not significantly faster than inflation drug costs are consuming increasingly unsupportable amounts. To have been able to do this, drug companies have had to insinuate themselves into the process of drug creation, evaluation and distribution. That is to say into the process whereby the decision is made to use one over another medication

They have been so successful in this, that to talk of drugs without referencing the major drug companies now seems bizarre. The only disagreement seems to be whether generic drug companies or overseas copycat drug companies will be able to seize market share from the majors. Drugs, especially new drugs, have become synonymous with the major drug companies.

This was not always the case. Many of the breakthroughs in treatment were created by independent researchers and developed in universities. (Penicillin and vaccination insulin to name a few)

We are told that drugs are incredibly expensive to produce and to market. $100million being the figure often bandied about to get a new molecule to market.

I would, however, argue that drug companies, especially the larger ones, have provided active encouragements to make the regulatory process longer and considerably more expensive than it really needs to be.

This is done not to produce safer drugs but rather to raise the barrier to less well capitalized rivals. The windfall financial gains from a popular prescribed drug are enormous and the rush to get these drugs prescribed is frightening we have seen in recent years the toxic effects of poorly done or willfully blind research. Drugs deemed safe are withdrawn, lawsuits are filed, and patient care is compromised.

There are subtle and not so subtle ways that the choice of drugs used is influenced. Recently it has been revealed in a major American journal that 70% of the experts on panels that make treatment recommendations are conflicted due receipt of funding or direct payment by the drug companies that make the drugs they are evaluating. The recommendations these panels make go forward and are enshrined as the right, the best way to treat patients. Doctors in the community accept these judgments because if they differ they are coerced. Older cheaper and often safer treatments are sweep aside and the practitioner is made feel inadequate or antiquated if they do not toe the accepted "best practices" line.

In significant ways this "Best Practices" has eroded the political interaction between nurse and physician at the ward level. This is oddly disconnected from the efficacy the treatment. Guidelines are published and in their most cookbook form become the basis for pressure to be placed on the physician when treatment decisions are being made. Anyone can read the recommendations and if the diagnosis is X and the guidelines say do "this" as opposed to "that" woe is the lot of the physician dissenter.

Management also likes guidelines as they form a seemingly rational, a "right as opposed to a wrong", and way to manage. A patient or a disease.

Care can conform to "accepted " norms or it can be at variances. As management has accreted more power in the system it has greater scope to make itself heard. The problem of course is that if the data that supports the guideline is flawed then so to be the recommendations the breakdown of previously interactions at the ward level has been the result. The system has still not fully rebalanced itself to take into account theses factors and perhaps it cannot do so. Doctors are a mixed grouping of ages with the average age being in the late forties. Doctors see the system and their place in it in radically differing ways depending upon their age and the philosophies extant in the system in the formative years of their training and early years of their practice life.

Nurses, in response to the power shift and because of the increasingly unpleasant working conditions on the wards, have fractured into two groups: those who provide direct patient care and those who manage care provided by others. Their interests, goal and even there philosophies begin to diverge sharply from this point.onwardThere always have been nurses in management but now there is a whole corps of self replicating nurse managers and their functionaries. Traditionally, nursing was organized on military lines evolving from the need to treat large numbers of war wounded after the two great wars. Nurse worked on wards. They reported to a head nurse who in turn reported up a chain of command to a director of nursing Excessive-nursing management was anathema to a system striving for maximum efficiency.

Nursing staff was directed to act both by the physician in regards to medical matters and the head nurse in regards to nursing matter. If a physician wished to become involved in matters primarily pertaining to nursing, it was prudent to go to the head nurse. It had an order and, while often stifling the growing skills of the ward nurses, provided a framework for good patient care. With the evolution and changes of the power sharing models within institutions and the health care sector, there were profound effects all the way down to the ward level

Democracy is a living organism .It strengthens with use but weakens under conditions, which undermine its basic principals (Egalite Liberte Fraternity).

It can resist direct attacks much better than it can ndifference. The will to democratic action is nurtured and maintained in its practice.

The Body politic of health care has been eroded by the functional entities of it becoming undemocratic. It is relevant to see these two contradictory ideas. On one hand you have a military style top down government/management which may be defined as undemocratic and the other you have a collegial patient focused care model with nurses and doctors having more power, the essence of a holistic care type model.

Governments dictate, managers manage, and committee meetings of the workers become farcical as they become pointless. Decisions at the level of the democratic parts of the health system have been overwhelmed by the power shifting to government and management. There are numerous examples of this that are found in the headlines of our daily papers. Decisions by hospital committees of a hospital are circumvented by management, they try again and again they are frustrated. Recognizing that they do not have a tangible impact on the process, people become frustrated and drop out of the process. They feel that the "system" is less and less the conglomeration of them and more in the possession of others. So people withdraw. They do less and they become selective about what they will and won't do. They stop taking call; they pull back the borders of what they are willing in a professional sense to do. As the professionals withdraw it becomes apparent that the system relied heavily on the cooperative efforts of a lot of people who were doing significant amounts of work for which they "could say", they were not being reimbursed. So they stop doing this work, because, I would argue they no longer felt that it was "their" system. Management trapped between government demands for no bad P.R., patient's demands for timely service and the withdrawal of professionals are backed into a corner.

The current state of the health system is a direct consequence of the change in political relationships between the players and the resultant dysfunctional responses. It is not surprising that the response is dysfunctional.as the interrelationships have become pathological. In addition recently the courts have been enticed into this arena giving a complicated game even more complexities.

The supreme court of Quebec after a length period of litigation ruled effectively that governments could be held accountable by citizens for failure to provide appropriate care in a timely fashion.

The politics are complicated by reference to penultimate law, the constitution, by the question, if governments create a near monopoly situation in health care delivery what are their fiduciary obligation to provide timely and effective care? What are the standards and what are the legal consequences of failure to meet these standards?

And as a political corollary if they allow the system to become less monopolistic how can they maintain services in the face of the human resource reallocations of expanded private care.

As a practioner in the system for the last 25 or so years I have seen the ebb and flow the comings and the goings of ideas, plans, governments, and colleagues. There is now an unmistakable "Fin de siecle" feel to the whole health care system. Taken at face value there is a lot to be optimistic about health care. New drugs new treatments new hospitals new machines all enormously positive. However the breakdown of the political balance of the system hampers the care of patients generally and specifically to the point where the system will in my judgment inevitably fall. What replaces it will I think be the focus of the next 20 years.