Brexit, the Donald and the tPSA

There is a common thread that ties together the United Kingdom’s vote to leave the European Union, the American Presidential election, which surprised many folks and the overwhelming decision by Ontario’s doctors to reject a proposed Physician Service Agreement between the Ontario Medical Association and the Government of Ontario.

The tie that binds all three results together is not the superficial similarity of a majority voting contrary to the wishes of the establishment. That would be a wonderfully simple view of the world that would let the OMA leadership (including me) off the hook. “We couldn’t expect anything different, look around that world and see people reject authority”. We need to look deeper or the OMA will not learn and will be doomed to repeat the same old mistakes.

The common element between the three elections is that people who proposed positive actions defeated people who warned that voting for the other side would send us all to hell in a handbasket.

People voted for hopeful change

I don’t have a deep understanding of the twists and turns of the Brexit campaigns. The Economist, June 20 2016, has laid out a summary of the main arguments for the Leave and the Stay campaigns. The Leave side made strong positive arguments. Immigration, complex regulations made in foreign capitals, jobs and the economy would all improve if the UK left the EU. It doesn’t matter for the purpose of my argument if those assertions are true or false, the point is that they speak of a positive result. The Stay side’s best arguments were that leaving would lead to a ruined economy. There is no mention of the positive things that would accrue to the UK if they stayed. There were no positive arguments.

A similar thing occurred in the American election. Mr Trump talked positively about policy. Again, forgetting for a moment the practicality of the policies, he spoke about building a wall, bringing jobs back home and re-building the Military. If Trump was elected foreign powers would fear and respect the United States of America. Make America Great Again.

Ms Clinton’s main arguments were all about Mr Trump’s unsuitablity. He was a buffoon. His perceived misogyny, racism and intolerance of foreigners were all she talked about. “A man who can be provoked on Twitter should not be given the Nuclear Codes.” It’s a good line, but it’s not enough.

I know she had dense volumes of policy papers—somewhere, but that’s not the message she got out. She talked negative. She got crushed in the Electoral College.

Anyone who thinks that her win in the popular vote is significant doesn’t understand power. “Winning isn’t everything, it’s the only thing.”-Red Sanders UCLA

What happened to the OMA during the recent vote on the tentative PSA? I’m afraid that the OMA leadership lost their way.

There were plenty of problems with the content of the agreement, there were plenty of problems with the negotiations process and there were plenty of problems with the ratification process, but the vote was won and lost during the 6 week ‘campaign’.

The OMA forgot to articulate the positive changes that would result from a ratified PSA. We should have focused on primary care enhancements, relativity, fee modernization, which would have including lowering some overvalued fees and increasing some undervalued fees. We should have talked about the leadership opportunities for physicians in health care transformation. We should have focused on our patients.

Instead we talked about the dire consequences of the status quo. “If we don’t agree to this contract we will be worse off.” It’s not a catchy slogan and worse it’s not a good reason to support something.

I’ve gone back and re-read an essay I posted on this site called “I Vote Yes”. I Vote Yes  It does lay out positive reasons for voting in favour of the proposed deal. Later on, I changed my tone and spoke about the bad things that would happen if we turned down the tentative deal. I originally said that we needed to talk, that we needed to trust and that our patient’s need a relationship between doctors and government. Somehow, somewhere I switched my message to a darker place.

The No side did much better. Turn this down and we can negotiate something better. It almost didn’t matter what the ‘better’ meant.   The fewer details the better.

No sold hope, Yes sold fear. Guess who won?

I’m not naive enough to think that the results would have been different with a different message. The margin of victory was too large for me to think that. But the Yes side had no chance with such a negative message.

Next time a decision is sent to OMA members, the OMA should forget about using fear of the alternative as a reason for Doctors to support something. Tell them the facts and let them make up their own minds.

Scott Douglas Wooder, MD

 

Addendum

I almost didn’t publish this piece. I’m not trying to criticise others, I’m trying to learn through self reflection. I publish it because I personally made major errors in the tPSA process that I hope I can learn from.

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11 thoughts on “Brexit, the Donald and the tPSA”

  1. Scott it’s not the OMA leadership’s job to convince the membership what is best. It’s their job to represent the members. You wanted a yes vote. The majority of the members wanted a no vote. That’s all there is to it. Instead of representing our wishes, you tried to convince us that we were wrong, and that’s where you went wrong.

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  2. You are quite incorrect in almost all of your assertions. This was a stand against a despicable government whose sole claim to fame is the sheer number of scandals and shocking fiscal incompetence. Rather than Brexit, it was a courageous defeat of principle over complacency, and a stalwart defence of patient rights (including their privacy) at a great personal risk to each physician who stood in defiance against a corrupt government and a complacent, anemic, ineffective OMA.
    A better analogy would be to compare the No side to the Elderly Fukushima Volunteers, who also risked personal harm in order to avoid an unprecedented disaster.

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  3. Thanks Scott. I’m glad you posted.

    I would add that one of the major reasons docs voted No was that the tPSA would at best maintain status quo. Docs on the frontline see that healthcare is at a point where patients face unreal waitlists for specialist comsults, investigations and procedures; where surgeries are cancelled every week from lack of funding; where bureaucracy has over-run common sense; where the government continues to encroach on the doc-patient relationship; and where healthcare resources are far outstripped by patient need.

    Some of the issues healthcare faces are system issues and would not be fixed by a tPSA. But docs are at the point where they need this government to commit to massive system change. Endorsing an agreement, a tPSA, that offered no change from the status quo was unacceptable because the status quo sucks for the average patient. My sense is that that was why the docs voted No: this is their line in the sand.

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    1. All valid point Nadia

      My point post is not about the quality of the deal, which the majority of the profession found to be unacceptable.

      My point is that one can’t convince people through fear of change.

      Stay tried and failed. Hillary tried and failed The OMA….

      The lesson for us to learn is that the facts of a deal should be given to the members to stand or fall on their own merits. Fear of something worse should not be an argument

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      1. Dr. Wooder, I am also confused. What would have been the positive and more hopeful spin on this tPSA that you think would have made the YES campaign more successful? I understand President Obama won with a message of ‘Hope and Change’ but what would have been the hopeful outcome of a YES vote and what would have ‘changed’ if the agreement were to be ratified?

        For many of us the ratification would have rewarded the current and future governments for negotiating with a gun to our heads. Not exactly negotiating in good faith and the change that we desire. As for the hopeful spin, not sure how placing a hard cap and barely meeting inflationary needs of the province paints a hopeful future for the profession and our patients.

        Unfortunately, you are still under the belief that the membership was simply not ‘informed’ enough and were ‘naïve’ to the political and fiscal realities that contextualized these negotiations. If the ‘OMA’ only did this, that, or the other, the membership would have also voted YES. (I believe this where you analogize to the uninformed Brexit or Trump supporter.)

        I submit to you that this vote was lost long before the campaign started, and certainly long before the likes of Dr. Jacobs et al. began their aggressive response. This campaign was lost the moment the Board decided to ignore the explicit instructions of the council (governing body of this organization) to secure a binding dispute mechanism.

        It is precisely this well-intentioned arrogance that led us to this large division between the membership. We don’t need to reinvent the wheel, simply listening to the membership will suffice.

        Respectfully (well deserved given your long record advocating for this profession),

        Roozbeh Matin

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      2. I agree. No “spin” would have changed the result.
        Some dogs won’t hunt and this is one of them.
        My thesis is that the members should have been given the details of the agreement, the facts, and been left to decide for themselves
        The function of the Board is to make a recommendation but they should only explain, never sell

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  4. Dr. Wooder, I am also confused. What would have been the positive and more hopeful spin on this tPSA that you think would have made the YES campaign more successful? I understand President Obama won with a message of ‘Hope and Change’ but what would have been the hopeful outcome of a YES vote and what would have ‘changed’ if the agreement were to be ratified?

    For many of us the ratification would have rewarded the current and future governments for negotiating with a gun to our heads. Not exactly negotiating in good faith and the change that we desire. As for the hopeful spin, not sure how placing a hard cap and barely meeting inflationary needs of the province paints a hopeful future for the profession and our patients.

    Unfortunately, you are still under the belief that the membership was simply not ‘informed’ enough and were ‘naïve’ to the political and fiscal realities that contextualized these negotiations. If the ‘OMA’ only did this, that, or the other, the membership would have also voted YES. (I believe this where you analogize to the uninformed Brexit or Trump supporter.)

    I submit to you that this vote was lost long before the campaign started, and certainly long before the likes of Dr. Jacobs et al. began their aggressive response. This campaign was lost the moment the Board decided to ignore the explicit instructions of the council (governing body of this organization) to secure a binding dispute mechanism.

    It is precisely this well-intentioned arrogance that led us to this large division between the membership. We don’t need to reinvent the wheel, simply listening to the membership will suffice.

    Respectfully (well deserved given your long record advocating for this profession),

    Roozbeh Matin

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  5. Scott, you make some good points here. This was a bad deal from the beginning and had no chance from the start, but if the Board/Management is trying to be introspective on how to try and “sell” and better deal in the future, this is a small part of it (the biggest part obviously being get a much better deal before presenting it). Many of us repeatedly railed against the Execs continued hammering home of the “1.1B in cuts will come if you don’t sign”. Yet the exec failed to listen, and doubled down on the strategy. This constant barrage of negative spin alienated large swaths of the physician population, and quite frankly was just patronizing. This lack of judgment and insight is why many people so strongly believe the entire exec needs to step down. When an exec takes such a strong position and the members so firmly reject that position, the exec needs to own that (as you did in stepping down from Negotiations).

    As you admit, this deal was never going to fly. It doesn’t matter how positive the message was from the OMA. But by being so negative, the true consequence is that the exec has lost the trust of the members. That is just a fact. It was just a gamble the exec/Board made in presenting the tPSA this way, and there is no coming back from that. If the tPSA was presented in a positive way with genuine elucidation of its obvious shortcomings and telling members to vote whichever way they felt was best (not telling them to vote with a gun to their heads), then the exec/Board could have stayed on whether the tPSA failed or not. It did not, and as such, the entire exec needs to step down and move on. That is the real lesson from this debacle.

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    1. Birinder, thanks for taking the time to write. Agree or disagree I always find you to be thoughtful and fair

      I was not advocating for a positive message. I’m lamenting that a negative tone was used. “Agree to this or else” is not a suitable communication technique.

      I am advocating for an impartial presentation of the facts. It’s the tone that was used in 2008 and 2012. It’s more respectful of our colleagues and is more likely to result in an objective debate.

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  6. Dr. Wooder, despite being in the same room and listening to you speak about the tPSA during one of the many road shows, I believe we have a very different impression of how the ‘Yes campaign’ was sold. We were told how great the annual increases and one time payments were going to be and how economic analysis ensured we would stay under budget. We were repeatedly informed of how amazing co-management would be. We were told that it was our responsibility to suffer the cuts as individuals to try and sustain a failing system. The OMA message wasn’t about Fear in my opinion, it was about selling a golden ticket that was merely an illusion. The OMA campaign failed because it tried to sell a product with false promises and neglected to account for the empowerment of a new generation of physicians that have opened their eyes to critically appraise what the OMA is selling. The OMA failed because, instead of presenting the facts of both sides, it pushed with all it’s might in one direction. The tPSA was not another insurance product, and it should not have been presented like one.

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