Professor Louis Francescutti recently published an editorial on the CMA website that proposed a ‘radical idea’ about medical professionalism. He talked about the need for physicians to take a bigger leadership role in the redesign of a dysfunctional health system. He wrote that we need to hold each other more accountable. That doesn’t sound too radical to me. It sounds like common sense. I think most physicians would agree with the premise.
The piece garnered a lot of feedback, which in and of itself is a good thing. We should be thinking and talking about professionalism. We need to be system leaders and only physicians have the expertise to hold other physicians accountable.
I agree with many of his high level thoughts. However, I have very strong objections to how he proposes that those high level principles should get implemented.
I’ll start by saying that I have a professional relationship with Dr. Francescutti. I was a member of the Canadian Medical Association Board of Directors for two years. During the second of those two years Dr. Francescutti was also a Board member as the President-elect. I left the CMA Board to serve as President of the Ontario Medical Association. So during the time that Dr. Francescutti was President of the CMA, I was President of the OMA. Louis was very supportive of the OMA during his time as CMA President.
I always found him to be thoughtful, respectful and incredibly bright and funny. I deeply admire Dr. Francescutti.
I was very disappointed to hear how contemptuous he is of Provincial and Territorial Medical Associations (PTMAs) including, presumably the OMA. The PTMAs “all say the right things (the patient comes first) but a quick reality check tells us otherwise”. I served on the Board of the OMA for a dozen years and I firmly believe that we always considered first the well-being of our patients. Dr. Francescutti offers no proof for his opinion so I will waste no time in providing proof of my rebuttal.
Dr. Francescutti’s suggestion that physicians all be in “salaried positions on one-year contracts that can be renewed if they continue to meet performance standards” is troublesome from my point of view. The suggestion is apparently inspired by the Cleveland Clinic, which Dr. Francescutti visited while CMA President.
That model may work very well in the United States. Physicians there who lose their positions can move across the street or across the state and practice in another setting. Here in Canada where there is a single payer, being thrown out by one’s peers would effectively end a physician’s career. There are no other options. It is actually illegal in Ontario to practice outside of Medicare.
Can you imagine someone losing their ability to practice medicine because their peers thought they ordered too many ultrasounds?
And there is more to it than that. An academic ED physician might be able to pack up his practice over-night but for a community based family physician like me the costs would be enormous. I have a five year lease. If I’m shut down by my peers in year two, I’m on the hook for over three years rent with no hope of return. I have employees who have worked for me for 25 years. Can you imagine the severance I would have to pay? I have no pension, no benefits and at age 56, I can’t afford to retire. I guess Dr. Francescutti’s plan suggests that after 30 years as a physician, I should have no job security. And yet this plan is supposed to improve my morale and increase my sense of engagement.
And what about the administrative nightmare of doing quarterly reviews on 70 thousand physicians. That’s 280 thousand peer reviews a year. At $500 per review, that’s $140 Million per year. I checked the arithmetic twice on that one.
It would also tie up 560 physicians working full-time for 50 weeks a year, assuming they could do 2 peer reviews per day. I don’t think we can spare the manpower. But maybe I could get a job lie that. At least I’d have some security.
“We, as physicians, need to stand up and accept responsibility for what is going on in our dysfunctional health care systems across Canada. If we won’t fix the problems, who will?”
It’s a great question. It’s a great premise.
But can’t we do all that without beating up our colleagues? Can’t we find constructive and realistic implementation plans that help our patients without destroying ourselves?
Scott D Wooder, MD.