Concerned about primary care in BC? Learn more below.

Is Trauma Behind the Physician Compensation War?

This is a work in progress. Feedback welcome. Some people may find it triggering.

The public may not always see it, but amongst some family doctors, there is heated division around compensation. Mostly it's behind the scenes, but you catch glimpses of it in letters and articles whenever "fee for service" is mentioned. It's either the cause of all our ills or the path to salvation. Deeply polarizing. Frankly, the extreme reactions and pure vitriol are hard to make sense of, especially in a group of intelligent professionals. This isn't just about logical arguments but intense psychological reactions.

For the sake of patients and our healthcare system, we desperately need to establish more common ground and mutual understanding. Not being a family doctor, I've been trying hard to make sense of these divisions and listen to different perspectives. I think we need what both camps are looking for, and if it's just one or the other, we're all in deep trouble.

I initially thought maybe the divisions were a result of typical physician infighting. Usually, this is seen as the specialist vs. family doctor divide. Was it just a zero-sum game issue? If you're all paid out of a fixed pot, a dollar going to someone who practices differently is a dollar not going to you.

Or maybe it was intellectual insecurity, a need to show that the way you're practicing is best, and that means others are wrong. Not unreasonable motivation for a group of people who have been high-achieving stressed-out competitors for most of their lives.

But neither fits with the intensity of what we're seeing here.

While this is just a theory (and could be a result of working too long with my psychiatrist wife), I think I better understand what could be going on.

Trauma

Trauma comes in many forms, not just "classic" PTSD. Trauma is about our lingering reactions after a negative experience and how they shape our future actions. Abuse and neglect of all kinds, both experienced yourself or seeing happen to others, can lead to trauma reactions.

Trauma is a self-defence mechanism we use to protect ourselves from further pain. It can lead to thoughts, feelings, and behaviours that, to the outside, appear extreme or illogical. Trauma-based reactions are frequently disproportionate to the actual risk of future threats. From an evolutionary perspective, trauma lives in the ancient parts of our mammalian brains that respond to fear, threats, and physical safety. These predate the more recent additions that help with planning and problem-solving.

Sources of Trauma

The idea of doctors being victims of many different forms of trauma is not new. A great introduction to this is Dr. Jillian Horton's book, We Are All Perfectly Fine: A Memoir of Love, Medicine and Healing.

How is this relevant to the decidedly not "head about to be bitten off by a tiger" issue of physician compensation? And why would family doctors, who as a group share so many common experiences, end up on polar opposite sides?

Traumas center on negative experiences that leave a profound impact. They're amplified by long-term abuse and neglect, which has been experienced by family doctors in many forms, both financial and professional.

Family doctors regularly experience system failures that often have catastrophic outcomes, both personally and for patients. Care not received. Patients neglected and abused, and harmed or dying as a result. Being forced to leave a job they love and abandon patients, at great personal cost.

These are things that are often entirely preventable in the eyes of the doctor. Something that didn't need to happen but did anyway. Most physicians have an intense moral core and sense of right and wrong. The hurt runs deep when things go badly, especially for what they consider less than noble reasons.

Here are two examples of common reasons why these events can occur. Any physician who can't think of dozens of examples of either one is kidding themselves. For the rest of this essay, I'll use "bureaucracy" and "self-interest" as shorthand for these and a range of other related causes.

Bureaucracy

Some policy or procedure or way of doing things, for reasons unrelated to patient care, interferes with doing what's best for patients. This can be a direct barrier (e.g., not enough people on shift or the wrong people). It can also be indirect. This is often related to large sums of money wasted on useless activities that could be devoted to providing front-line care instead. Tied into this is a feeling of helplessness and not having control or influence to make the situation right.

Self-Interest

When decisions are made by others for reasons of self-interest (perceived or actual) that negatively affect you and your patients, that hurts. For example, someone else prioritizing taking their breaks, leaving early, or doing the minimum amount of work needed to generate the maximum amount of income, all at the expense of patient care. Again, when other people do this, you're left with feelings of helplessness and lack of control.

Repeated Exposure

Disastrous outcomes (personal and on patients) can potentially stem from just about any system failure in medicine. Any single incident could impact a doctor enough to qualify as a traumatic event.

A key feature of trauma is the intense response designed to prevent a repeat of the original trauma. But it doesn't have to be a carbon copy of the original. It may be something else with enough similarities that it reminds you in some way of the original. Given how prevalent both examples of perceived bureaucracy and self-interest are in healthcare, doctors will experience multiple events that they associate with that experience. And the personal toll of these events is amplified by the intense moral code that most physicians hold about fairness, justice, and right and wrong.

Some physicians will be "victims" of bureaucracy more often, or it will affect them deeper. For others, being "victims" of others' self-interest will dominate.

And each time, that reinforces the need to prevent a similar thing from happening again.

Avoidance

The trauma reaction centers on avoiding having to experience something similar again. So tying it back to this whole compensation debate and fee-for-service, what are family doctors trying to avoid? Let's look at both "camps."

The "Pro" FFS Camp

They're trying to avoid experiencing situations where excess bureaucracy, directly or indirectly, leads to disastrous outcomes. Where they couldn't do what they needed to provide care for their patients because of someone else's actions. Where they had no control over the situation. Too many examples to count.

Because of that, they want to ensure the option of having control (e.g., independent practice) is always available. They feel that option is threatened because the current setup isn't viable. I agree.

The "Anti" FFS Camp

They're trying to avoid experiencing situations where someone else acted in a way that was selfish and resulted in disastrous outcomes. Where they couldn't do what they needed to provide care for their patients because of someone else's actions. Where they had no control over the situation. Too many examples to count. But, I'll explicitly mention doctors prioritizing maximum billings over other considerations.

Because of that, they want to stop seeing so many situations where people do what's right for themselves at the expense of patients. End the greed.

Struggle for Survival

I had a hard time understanding why there seemed to be so much energy devoted to demonizing FFS and arguing it's not fixable. In the "fix FFS" camp, saying "let's have both" seems more acceptable. But I think I understand now.

FFS for family doctors has been so badly broken for so long in BC. Doctors have learned to adapt, favouring too-short appointments, one-problem-per-visit policies, etc. It's deeply entrenched and not good for patients.

Some family docs don't believe it's as dominant as I think it actually is. Or that it's not a big deal, or that it's about not trusting doctors, or that the cost of dealing with the "small number" of people abusing the system is too high. These docs are more traumatized by bureaucracy than self-interest and want to avoid bureaucracy more acutely. They're sick of people they see as lazy and not contributing. They want to preserve a system that rewards people for effort and hard work. Which is, of course, driven mainly by providing the best care for patients. At the extreme, they feel any bureaucracy is threatening. But most are more willing to accept both. They've lived in a world where FFS has been so dominant and can't picture a rational universe where it doesn't exist that doesn't result in utter chaos.

Others see how widespread destructive behaviours rooted in self-interest are and are affected more deeply by them. They've been living with the results for years, repeatedly exposed. They're more traumatized by self-interest than bureaucracy. They attribute the effort other doctors put in, especially the high-billers, as being motivated almost entirely by money at the expense of patient wellbeing. Greedy doctors take resources out of the system and put little back. At the extreme, they feel any environment that encourages self-interest is threatening. And they also feel that whatever changes are made to fee-for-service, too many people will continue acting overwhelmingly in their own self-interest.

Interestingly, both sides feel they're the underdogs in this struggle. The "pro-FFS" group feels attacked by the massive bureaucracy that has taken control away from them. They're fighting for the "little guy" against that. The "anti-FFS" group has lived with FFS as the only paradigm for so long. They see it as the goliath threatening to keep them from establishing a way of working that eliminates the dominance of self-interest in medicine.

Both feel they're being victimized by the dominant paradigm. Existential threats to survival.

Avoiding Negative Over Experiencing Positive

For victims of trauma, the benefits of avoiding the negatives associated with their traumatic events grossly outweigh any positives that might be associated with not avoiding things. The more intense the trauma, the more true that becomes. It's definitely not healthy.

An extreme anti-contract stance (avoiding bureaucracy) ignores the potential benefits, including a reasonable stable salary. It amplifies the potential risks (money wasted, etc.). The worst fears are total government control of everything. The likelihood of that is overblown.

An extreme anti-FFS stance (avoiding self-interest) ignores the potential benefits, including greater autonomy. It amplifies the potential risks (poor quality of care, etc.). The worst fears are that all behaviour is driven by greed and money, and the likelihood of that is overblown.

That leads to all kinds of cognitive distortions, especially all-or-none thinking, overgeneralization, and magnifying and minifying. And as a result, each side wonders why the other can't see what's so obvious and assumes some sinister purpose behind their actions.

Outsized Reactions

Trauma is associated with a range of behaviours we've seen exhibited whenever the topic of compensation comes up among doctors. Irritability, hyper-vigilance, excessive reactivity, aggression, negative beliefs about others' motivations, strong negative feelings, paranoia.

Basically, all kinds of reactions that are outsized and utterly disproportionate to the objective reality of the magnitude of a perceived threat. Again, these are all things we do to protect ourselves.

Consequences

Okay, let's say you buy all that. Now what?

First, recognize that doctors being divided weakens their negotiating position. And with the current level of division, whichever side feels they "didn't win" is going to do the "screw you guys, I'm going home" thing and leave family practice or move. In the worst case, both sides will feel they didn't win.

Second, understand that the "other side" is not wrong. Both are overreacting and not acting entirely rationally. It doesn't mean they're stupid or evil. Understand what different people are trying so hard to avoid and why. Appreciate that you're discounting the downsides of your own approach and the benefits of the other approach.

For those in the "fix FFS" camp, please consider:

• Many doctors have practiced for a long time in a way that can at the least be perceived as motivated by financial gain that has impacted patients and led to negative consequences.
• This bothers many doctors a lot more than it may bother you. Don't dismiss it as a minor concern.
• Bureaucracy bothers you more than most. Some bureaucracy is inevitable. All doctors want to reduce it, but may prioritize other considerations higher.
• Some doctors working under contract may be lazy slackers who take advantage of the system. Far fewer than you think.
• Central organizations can work effectively. Your "worst case" scenarios are not necessary and may not be representative. Fighting for accountability mechanisms to promote that benefits everyone.
• Listen to examples of successful organizations where doctors are on a fixed salary, are happy, and patients benefit.

For those in the "kill FFS" camp, please consider:

• Bureaucracy, laziness, and inefficiency have led to unnecessary disastrous negative outcomes.
• This bothers many doctors a lot more than it may bother you. Don't dismiss it as a minor concern.
• Self-interest over patient-interest bothers you more than most and deeply offends your sense of fairness and ethics. Self-interest may be an essential component of fee-for-service, but that doesn't mean it dominates.
• Some docs will apply the rules of whatever fee-for-service system strictly to maximize income, no matter the cost. Far fewer than you think.
• Fee-for-service systems can support and encourage spending necessary time with patients, provide enough income to cover admin work, and promote team-based care.
• Most doctors who want to work in a time-based fee-for-service system feel that it gives them the best opportunity to provide great care for patients.
• Listen to examples of successful compensation systems where fee-for-service is the primary mechanism that physicians are compensated, are happy, and patients benefit.

This is not about right or wrong, good or evil.

Recognize that whether the cause is bureaucracy or self-interest, the actual end effects on doctors and patients are likely exactly the same. And in the end, this continued division is harmful to you and your patients, precisely the (real) situation you're trying to avoid.

As an outsider, I haven't been traumatized by these things in the same way. Yet, I'm still sensitive to excess bureaucracy and doctors who grind through high volumes of patients but add little value, as is pretty obvious from my writings. I think it's pretty clear there needs to be room for both compensation models. But to avoid continually triggering each other, we also need to be honest and open about the flaws in each one and the legitimate potential for abuse and work to address them. At the same time, recognize that what others are suggesting may not necessarily represent the downfall of civilization. It'll never be perfect.

Right now, people are basically fighting for something they want like it's a utopia, but that others perceive as an absolute catastrophe. Each is ignoring the downsides of their own approach because of the need to win. Or more precisely, the need not to lose.

Moving Forward

What does that mean, and how should physicians and their leadership respond? Good question, and right now, I don't have any brilliant answers.

Healthcare is a stressful environment, there's more work that needs doing than people to do it, and people have to make choices and prioritize every day. These decisions have ripple effects. You can't always predict the effects of your decisions, or the full rationale of those others make.

You're familiar with the saying that we have two ears and one mouth so should listen more. (We also have ten fingers which maybe explains the volume and intensity of online clashes.).

Listen more. Trust that your colleagues are intelligent and may have good ideas. Tone it down. Work to strengthen them rather than destroy them.

Recognize many of your reactions are coming from a place of pain and are disproportionate. Other people's reactions are coming from different pains. Recognize flaws in your own ideas that concern others and work to correct them.

This is a work in progress. Feedback welcome. Some people may find it triggering.