Compassion is defined as the emotional response to another’s pain or suffering involving an authentic desire to help.  In the medical profession, one would think that compassion should be a cornerstone of caring for patients, it is currently debatable if health care providers (HCP) compassion is merely an “ought” – a moral imperative out of respect for patients that is rooted in the art of medicine or if HCP compassion itself is an evidence-based intervention with measurable beneficial effect belonging to the science of medicine. The new term, compassionomics refers to the emerging field of compassion science in healthcare as a branch of knowledge and scientific study of the effects of compassionate care on health, healthcare, and healthcare providers.

One study is cited that shows when patients received a message of empathy, kindness and support that lasted just 40 seconds their anxiety was measurably reduce.  Fifty-six percent say they don’t have time to be empathetic.  Compassion also seems to prevent doctor burnout.  “We’ve always heard that burnout crushes compassion.  It’s probably more likely that those people with low compassion, are the ones that are predisposed to burnout, “Trzeciak said.  “That human connection – and specifically a compassionate connection – can actually build resilience and resistance to burnout.” In a report entitled “Compassionomics: Hypothesis and experimental approach” authored by Stpehen Trzeciak, Brian W. Robertsand, Anthony J. Mazzarelli, they offer the following statistics;  “A study in Sweden found that among patients requiring emergency care, one of the most common lasting memories five years later was a lack of compassion from HCPs.  A public inquiry into the Mid Staffordshire National Health Service (NHS) Foundation Trust in the United Kingdom (UK) found, among many quality concerns, a wide-spread and striking lack of compassion from HCPs.  This report prompted the UK Prime Minister to call for an urgent renewed focus on compassionate care.  A survey of 1400 United States (US) adults found that nearly two-thirds had an experience as a patient in which HCP compassion was lacking, and 93% believed that a lack of compassion lowered the quality of care. Another survey study of 1300 patients and physicians in the U.S. found that nearly half of patients and physicians believe that the US healthcare system does not consistently provide compassionate care, despite the fact that three-quarters of patients and physicians believe that compassion is so important for treatment success that it could be the difference between life and death.”

Studying compassionomics is an urgent matter for public health because there is now enough data, and an abundance of it, in the medical literature and lay press indicating that we are in the midst of a compassion crisis – a lack of (or inconsistency in ) compassionate care in our health systems – and this may have measurable detrimental effects on patients, patient care, and those who care for patients.  For Canadians the timing is almost perfect in that we are in the planning stages to install a national drug plan and expanding the services that medicare has to offer.  Currently we may have fallen out of the top tiers in terms of developed countries offering the best health care to its citizens, however, we can look to the opportunity presenting its self to truly create a world-class program that not only looks at the dollars and cents of providing health care by also the providing compassionate health care which in the long run reduces financial strain on the the service providers as well as the patients.

Suffering: Health Equity vs Health Equality

Consider the following stories: “How did 80-year old Ambrose Wald fall out of a hospital chair specifically designed to stop patients from falls? It’s a question to which his daughter Irene Wald, a nurse of almost 35 years, has never received an answer.” or ,”It is every patient’s worst nightmare. You are prepped for surgery, you’re given a general anesthetic and you drift off into sleep. But then you regain consciousness prematurely, during the surgery. That’s a horror story that became all too real for Donna Penner one day back in 2008.” or, ”  Nine months before Jessica Barnett died at 17, her neurologist dismissed her fainting spells and seizure-like episodes as psychological. “There’s nothing wrong with you. Go home and learn how to breathe through this,” he said. To her mother, Tanya, he added, “Don’t waste your money on an ambulance.”  or stories about the ability, or lack of it, to engage with patients marks healthcare staff as either “heroes” or “villains” in the eyes of one cancer survivor; disregard of the patient voice contributed to critical errors in treatment; critically delayed cancer diagnosis reveals gaps in healthcare communication processes; needless suffering caused by misdiagnosis or; Lack of mental health care places teenager at risk.  These are real life  stories of the realities of patient lives when dealing with healthcare.

Our compassion crisis is so wide-spread we now have web portals, sections to medical sites dedicated to just telling stories and sharing of our hospital and medical experiences.  Granted not all stories are bad, in fact, there are many heart warming and inspirational tales but not enough of them to indicate that we are not in the midst of a compassion crisis.  Historically, compassionomics have been evaluated more on the side of the attitudes of the physician, nurses and medical staff, their approach to and managing stress, fatigue and emotional exhaustion.  However, in studying compassionomics and its effects, researchers should also consider the intersection of compassionomics with the principles of health equity and equality.  In many of the stories that are shared there is a common theme threaded through each story that is told and that is regard for basic human dignity can very well much improve, whether it’s the hospital staff or even the doctor who are not treating their patients like a human being rather than a number.

Whether its the ‘butt showing’ hospital gown, peeing in a cup or wetting the bed (or worse), while under examination being poked in strange areas (i.e. colonoscopy or a PAP), hallway medicine- being treated in a public common area thus in effect feeling publicly humiliated having to answer personal questions  exposed while the doctor/nurse examines your body. It’s the feeling of being treated as a number, or lack of compassion when told you have months to live or given a diagnosis of a debilitating disease.  It’s all in the delivery, in the way a patient is informed that could make a world of difference in terms of patient care.  Consider the following statistic; people who repeatedly show up in emergency rooms can cost the hospital as much as $1-2 million a year; 1995 study indicated that assigning a person to be kind to them – nothing more- decrease hospital admission for these patients by ore than 30%.  Often they simply want to be treated with dignity, and when that occurs their anxiety and fear decrease.

Health care can be defined as services aimed at improving (or maintaining) health, which may (and should) also include preventing disease.  WHO defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”.  The 1974 Lalonde Report argued that the health of populations was affected by the following four categories: human biology; environment; lifestyle and health care organization.

Human biology refers to the biological causes of diseases, including genetic inheritance.

Environment refers to both physical and social environmental factors over which individuals would have little or no control, including such things as air and water quality.

Lifestyle refers to personal decisions that could contribute to how healthy a person is, for example; getting enough exercise, too much alcohol drinking, smoking, eating unhealthy food, substance abuse etc.

Multiple factors that contribute to the detriments of health according to Public Service Alliance Canada‘s (PSAC) 12 key detriments of health, it is the following: income and social status, social support networks, education and literacy, employment and working conditions, social environments, physical environments, personal health practices and coping skills, healthy child development, biology and genetic endowment, health services, gender and culture, also known as social determinants of health.

Provincial plans are divided into two categories: covering people 65+, people on social assistance and second universal covering all across the province.  Provincial per capital drug expenditure is split into a few components reflecting drug cost, dispensing fee, number of claims will provide and indication of the importance of the factors selected.  The major factor that seems to account for inter-provincial differences in drug expenditures is the number of claims at least between the two high cost provinces and two low-cost provinces.  Why so high? Consider the size of eligible population, the proportion that claims under the program, the cost of drugs, the dispensing fee, and number of claims per beneficiary.

“Health equality aims to ensure that everyone gets the same things in order to enjoy full, healthy lives. Like equity, equality promotes fairness and justice, however, it can only work if everyone starts from the same place and needs the same things.

“The right person enables the person enables the right care in the right setting, on time every time.”~ Stephen Duckett

Health equity focuses on ensuring and treating those who require care in ways that are appropriate to what they need to enjoy full, healthy lives. It aims to remove unjust and unnecessary differences, requiring us to consider the possibility of making different arrangements for resource allocation, or social institutions or policies.” [EQUIP Health Care]

It is defined as the absence of avoidable or remediable differences among groups of people, ensuring that all people have full access to opportunities that enable them to lead healthy lives, such as:

Quality affordable healthcare:   education, safe housing, environmental quality, public policies, stable income & job security and food security, social support networks.  However, evidence shows that people’s daily experiences and their access to these services intersect in ways that are highly dependent on their sex/gender, ethno-cultural heritage, socioeconomic status or class, sexual orientation, religion, ability, nationality and other fluid intersections.

Health Inequities refer to socially constructed, unjust and avoidable difference in health and healthcare between and within groups of people, whether those groups are defined socially, economically, demographically or geographically.  These can include differences due to socially and structurally modifiable barriers such as poverty, discrimination, cultural barriers to accessing healthcare, and poor governance.

This inequalities are seen in many areas of society including within the health care system.  Our health care system was designed to be  an ‘equal opportunity’ service that is based on five criteria which draws its strength from Section 15, Equality Rights, of our Charter.  Those five criteria are: public administration, comprehensiveness, portability, accessibility and universality. When we have a system that advertises itself as a system that provides equal access but operates just the opposite, lacking in providing the care and  services  that its citizens need, a system that operates opposite from its mandates ideals, having individuals acting within its authorities that doesn’t give a moral agent or a shred of respect worthy of a minimum amount of justification you run the risk of a revolt.

For example:

Consider ‘the strange case of the Socialite who sterilized her daughter” back in the 1936.  In the matter of inequality of the socialite, the article states, “When Peter Cooper Hewitt died in 1921, the inventor and entrepreneur left two-thirds of his estate to Ann and one-third to Ann’s mother, his wife. ” heiress Ann Cooper Hewitt was suing her mother in a San Francisco court for $500,000 (roughly $9 million today). The plaintiff claimed that her mother paid doctors to “unsex” her during an appendectomy in order to deprive her of an inheritance from her millionaire father’s estate. The defendant argued that she was merely protecting her daughter — and society — from the consequences of Ann becoming pregnant.”

But the will stipulated that Ann’s share reverted back to her mother if Ann died childless. Knowing this, Ann’s mother purportedly paid two doctors $9,000 each (about $165,000 today) to remove her daughter’s fallopian tubes along with her appendix when Ann presented at the hospital with stomach pains. This occurred merely months before the plaintiff’s 21st birthday, after which point Ann’s mother would have no further say in her medical care because Ann would no longer be a minor.  Ann’s mother insisted that she took this action because Ann was “feebleminded,” citing an intelligence test performed by a psychologist shortly before the procedure. A History Magazine story on the case by G.S. Payne reported that Ann could not answer questions such as “How long is the longest river in the United States?” and “What is the term of a U.S. president?” The defendant further claimed that her daughter was morally degenerate, referencing Ann’s addiction to masturbation, love letters between Ann and her chauffeur that contained the young lady’s pubic hairs, and Ann’s “erotic tendencies” with men ranging from bellhops to “Negro” train porters.

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A strange case of Health Inequities:

The Curious Case of the Socialite Who Sterilized Her Daughter

 

 

 

 

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This story developed in the era of the eugenics movement where women were sterilized for all sorts of reasons mainly because  they wouldn’t make good mothers with the belief that their children will become a burden to society for having to care for them.   Or consider the institutionalization of the “fallen women”, such as former prostitutes, unwed mothers and racialized women, who were banished to work in laundry factories  in the same era, cleaning the clothes of the wealthy.    These laundry facilities existed all over the world including Canada; and they existed for the same reasons that the women were sterilized in fact they were probably sent to work in the laundry facilities after they were sterilized.

Or in Canada Liliani Muir who’s mother also had her sterilized because she was thought to be dumb. She experienced a rough childhood as her mother often beat her and didn’t provide her with regular meals. As a result, Leilani often went hungry and began to steal classmates’ lunches at school.   Leilani was taken to the Provincial Training School for Mental Defectives (also called the Michener Center) located in Red Deer, Alberta.  Leilani, not knowing at the time why she was placed in the centre. She was termed a moron and brought up before the Alberta Eugenics Board. Despite answer questions successfully, however, she still was deemed a danger of transmitting mental defects to progeny and incapable of intelligent parenthood. In 1957, at the age of 14 years, Leilani was told that she was undergoing surgery to have her appendix removed. The surgeons and staff did not mention that she was being sterilized by having her fallopian tubes removed.  Muir was the first person to file a lawsuit against the Alberta provincial government for wrongful sterilization under the Sexual Sterilization Act of Alberta.  She also ran for the NDP provincial election after her court case and continued to the time of her death in 2017 help women and young girls.

Unfortunately, forced sterilization is a practice that still exists today and performed within our healthcare institutions.  Many will remember Jane Philpot in 2018 having to handle the investigation into indigenous women reported that they had recently been sterilized with out their knowledge or consent.  Forced or coerced sterilization violates the rights to equality, non-discrimination, physical integrity, health, and security, and constitutes violence against women. In some cases, this could constitute torture and/or cruel, inhuman or degrading treatment or violation of the right to life.

According to a CBC report, “A proposed class-action lawsuit alleging the coerced sterilization of Indigenous women in Canada is turning up reports from more than 100 women who say it happened to them. “Some of the women did not realize that physicians, nurses, other health-care professionals, the government — couldn’t make decisions for them about their bodies,” said Alisa Lombard, a Saskatchewan-based lawyer and a partner of Semaganis Worme Lombard. …More than 77 per cent of Indigenous people who underwent sterilization were declared “mentally defective” and could be sterilized without consent, her research states.   Lombard said that despite the repeal of sterilization legislation, sterilization without informed consent has been performed as recently as 2018 in Saskatchewan.”  NDP Health Critic Don Davies asked the RCMP for a criminal probe – a direct result from gender and/or racial discrimination and a violation of equality rights of women – to date not a single perpetrator had been charged for committing this crime.

It is these same levels of inequalities, these barriers that are erect to keep certain people out but sooner or later the resentment that they had been shamed,  humiliated and disregarded by their authoritarian governments, employers, parents, teachers  – basically anyone in authority that treated them at best as children, and at worst as subjects to be cheated by corrupt politicians (employers, parents  teachers basically anyone in authority who treats others so poorly), exploited economically, or used as cannon fodder in wars – eventually, people will rise up and you’re going to have a revolt on your hands.  That’s what happened with the women’s movement, civil rights and gay movements and so on.

“Why We Revolt: A Patient Revolution for Careful and Kind

A quiet revolution in fact has already begun and what’s unique about his revolution is that it is not specific to any geographic location.  People around the globe are needlessly suffering and are upset that their governments has not responded in way that it is careful, kind and compassionate. It’s not that governments are deaf and blind to the suffering of others, it more of the fact that they are selective in which projects will receive their compassionate attention vs those that do not.  For example, the Greneville towers in the UK vs. The Notre Dam Church fire in France.  There are glimmers of hope, however, for we look to political leaders who in their actions provide good examples of compassionate leadership as in what we saw with New Zealand’s prime minister, Jacinda Arden in her response to ChurchChrist  the massacre of Muslims in a place of worship and her well-being budget that strives to put people first before profit.  Another promising prospect is found in Zuzana Čaputová, a 45 year old lawyer and civil rights activist and Slovakia’s first female president, also known as “Erin Brockovich of Slovakia”.  “Čaputová ran on the slogan “stand up to evil”, complaining about corruption and cronyism among Slovakia’s ruling elite. She resolutely refused to engage in personal attacks on her opponents [during the elections], instead focusing on institutional reform and political interference in the judiciary. She wants to take the spirit of the campaign with her into office.”

This new revolution is called the compassionate revolution but you’ll find its variations depending in which context you are referring to for example in this entry we are referring to the compassionate revolution in terms of health care and as such it is called the Patient Revolution, coined by Victor Montori.  In a recent article found in MacLean’s Magazine refers to Why We Revolt as a  a scathing critique of “industrial medicine” that argues healthcare has been opted by economic interests.  Mayo Clinic endocrinologist Victor Montori makes a more forceful call for insurrection in his 2017 book Why We Revolt: A Patient Revolution for Careful and Kind Care, a scathing critique of “industrial medicine” that argues health care has been co-opted by economic interests. (He founded The Patient Revolution, a nonprofit dedicated to advancing careful and kind patient care, in 2016.) The problem isn’t only greed, Montori says; it’s a fixation on performance standards. Yet performance metrics also pave the way for change, evident in acceptance of mindfulness and now, increasingly, compassion.

Compassion research offers a host of selfish reasons to behave kindly; those who do are more ‘self-empowered’, happier, less lonely, and less prone to anxiety and depression.   “Helper’s high” has been linked to the release of the feel good neurotransmitter dopamine that is also found in oxytocin and seratonin.  Studying compassion, however, also reveals a problematic paradox: it can be inhibited by the very fear, greed and tribalism fueling the call for compassion.  To be compassionate people have to feel safe.  The biological mechanism that drives our nurturing and care giving can only emerge if we are more habitual in “self-preservation” and “vigilance” to threat systems (i.e. fear, distress, anxiety, hostility) are not front and center. This is also not to be confused with empathy.  Empathy is the state of mirroring  or understand another’s emotions or the emotional experience of another’s feelings where as; compassion is the action or a desire to take action to alleviate another’s suffering.  Empathy = feelings, Compassion = action.

“Revolution means the process of radical changes on all levels of the society and in all domains of knowledge. The revolutionary potential can be defined as the capability to realize these radical changes. The revolutionary potential is usually developed within an educational space that nurtures critical thinking, dissidence and creativity. But dissidence and creativity are both mandatory for the revolution to happen. Dissidence embodies the dissatisfaction about the status quo and the turmoil for change. Creativity is the engine that fuels our dissidence by giving us the ability to imagine alternative realities and transcend the strictures of our lived reality.” [Big Think]

The topic of human suffering and the many ways we can find solace and even a remedy have been the topic of discussions in many ancient  and historical literature.  The strongest that comes to mind is the story found in the bible about Job. It is a biblical account about human suffering, first of the suffering Job had to endure because of a bet made between the devil and god about the extent of Job’s faithfulness.  From what I remember in our Humanities class we were told that Job never existed and that it was just a story, a powerful one in that it won its rightful place in the scriptures. We are just as guilty for doing the same thing as Job, he puts God on trial lamenting of all the suffering he sees around him and why God hasn’t come to humanity’s rescue. Throughout the centuries even to this day  many have tried to answer the question of human suffering, a dilemma offering all sorts of thoughts and opinions.  I bring this up because when humans are suffering, there are three places where we can go to ease our pain; the hospital/medical community, to church and government. And when you can’t find solace in all three or your suffering is because of any or all of these three – the places that are supposed to take care of you – well then you run the risk of apathy or having a revolt on your hands, most likely both.

 

A Philosophical Perspective

There was one individual who rather found the  subject quite objectionable found a few ways to succinctly communicate it’s remedy.  Author, Cynthia Halpern in her book, Suffering, Politics, Power: A Genealogy in Modern Political Theory provides an excellent overview of philosopher, Jean-Jacques  Rousseau (1712-1778)  advocating a new political ethos, a moral (even ascetic) ideal of civic freedom and responsibility, of equal human willing, of commonality and participation among citizens.  He felt that political legitimacy can only be brought about by the willing agreement of men to join together into a community made just by its radical equality and the common will of men and citizens exercised in moral freedom.  Rousseau defends radical political reform and even revolution in order to bring such a new polity into being.  That is to say, the correct modern response to suffering is to create a new and perfectly just political order.  If history itself is the source of suffering , a new political founding, one that can escape history by being perfectly balanced in the present by the continual exercise of the general will, will enable its healing. (this too requires some crafty explication)

Rousseau is a moralist, he attacks the causes of suffering in modern society as arising from false values, destructive property relations, and deformed cultural structures, the inegalities, servitude, and deformations of the selves and institutions that modern society has produced.  (Has anything changed from the 1700s to today?) He does so on behalf of the suffering of the subjective self and of the people, especially those who are marginalized, excluded from power, and dominated by others in society (except women, who need to be dominated).  He defines domination as being under the control or even the influence, of others, a loss of self that he himself experienced as an unparalleled agony.  Domination is not only external but also internal.  It is a disease of the will.  He proposes a radical political and moral solution for such suffering. Suffering, for him, is a moral and political problem and must be remedied by a moral and political human transformation, a transformation of the will and of the polity.

 

Suffering and morality are intricately and inextricably related.  It is in terms of suffering that morality and political revolution are justified. While both Hobbes and Nietzsche see suffering as natural and human power and agency as the proper response to it (however differently they interpret both nature and agency), Rousseau sees suffering as historical and man-made, and he develops a politics of pity to condemn the oppressors and rescue the victims.  He creates a moral ideology to explain the connections among victims, exploiters, oppressors, and rescuing benefactors.  He develops a political narrative drama with three of four opposing roles and a plot that explains to the public spectator who is good and who is evil.  He devises a politics that will be a remedy for evil because it involves the transformation of a society based on evil into a society based on good.  He thus begins taking us down a long road toward ideologizing theories that will first condemn and then redeem the world through political revolution.  This perspective takes for granted the ability of the spectator to identify who are the deserving poor and suffering ones, as well as who are the persecutors.

Rousseau presents, if not an actual or factually accurate history of Western society, at least a proto-history, a moral developmental narrative, showing the past as a process of change, the present as a process of power, and the future as a process of virtue.  In contrast  to many philosophers of the enlightenment in the eighteenth century, Rousseau does not take for granted that we are, as a civilization, improving and progressing into ever greater rationality and enlightenment.  On the contrary, he argues that what has been called “progress” has been a falling away from an originary ideal.  History has delivered man into slavery and misery, and only the enlightened wills of virtuous and far-seeing lawgivers and the good habits of common citizens can remake the world into a place fit for human beings to live.

Medicare: A People’s Issue

“Every person, regardless of geographic location or economic circumstances, has a right to a uniformly high quality of medical services.”

~ Saskatchewan Government Brief to the
Royal Commission on Health Services

Politics Today

One would think that after listening to the video clip above that I would open our discussion today about a sad story of hospital neglect but I don’t have one…well I do but it’s minor compared to other stories I’ve heard…. and that’s a good thing! However, the same cannot be said for the thousands of people who rely on hospital services who not only can’t get the care that they need but also the attention they need.  I didn’t realize how bad it was until I started to follow NDP’s Andrea Horwath’s team during the Ontario elections where she had promised better health care for Ontarians to a cheerful crowd.  Almost emotional listening to individuals from the audience share their stories about the cost of drugs, deteriorating conditions of some hospitals and seeing glimmers of hope as they feverishly clapped cheering for Andrea for a new health care agenda.

That was Spring 2018, I don’t normally follow provincial politics, I am a federalist, but I wanted to learn more about the ins-and-outs of the political game and what better way to do so than to volunteer and support your preferred candidate’s by attending their rallies.  Ontario NDP’s Andrea Horwath  finally presented her teams vision for the province. We  were invited to the conference room at the Toronto General Hospital for her presentation and rally and I must say the event was well attended.  I sat and again  listened to Andrea recount the many stories she has heard from constituents worried about health care, the conditions of hospitals and more importantly the astronomical costs for pharmaceutical drugs, we also heard from nurses themselves proud of their jobs yet seeing the need to do better.

She pulls out a shiny brochure which listed her parties priorities; 100% dental coverage, end hallway medicine, Change for the Better! “Andrea Horwath and the NDP will make Ontario the first province with universal pharmacare by 2020”, says her brochure. “Pharmacare: so you can get the medication you need!” wow, that’s a big whopping promise… “Ontario Public Dental: covering seniors and the most vulnerable”…um yeah,  how’s that going for you? “Ontario Benefits: dental care for everyone!” Wow! Yipee! where do we sign up? “$12-a-day child care: quality, affordable care for our kids!” Phenomenal!  “We will create 2,000 new hospital beds right now!”  Uhh…I just came back from the hospital and  I sat in a chair waiting for six hours. “We will create 40,000 more long-term care beds, including 15,000 new beds over the next five years!” and the list goes on, and on and on.

We came in second place.  Not bad at all! but what happens to all the promises during the campaigning phase?  Do they drop to the wayside while we run defense trying to block every move the government makes?  That wastes a lot of time and the NDPs are the first to admit it.  Cutting counsel in half, the Toronto District School board, fight for kids with Autism, cuts here, cuts there, cuts everywhere. If the NDP won how much cutting would they be doing and how much focusing on what was promised in the platform would they be honoring.  It seems that whomever won the election would inherit a huge deficit that would naturally affect what was promised during the campaign.  Did we not know how bad the budget really is?

Is the budget really that bad or is Doug Ford using the budget as a convenient excuse so  he can promote some personal agenda? Perhaps he’s just flamboyantly enjoying his newfound power and freedom because I do recall that he won the election without a campaign platform – no plan – except “We the people – for the people!” Smart in a sense that we can’t hold him accountable to his election promises because he made no promises! I cringe to see what cuts he’s already made in healthcare.  Yet in the meantime the Liberal Feds finally tabled the report on a national pharmcare plan.  Darn! Had Andrea won, we would have been well ahead of the game with an implementation plan and take the lead on this portfolio, because the feds have absolutely no clue on how they are going to go about implementing a national drug plan (especially so close to the elections – they gotta win first) all the report has managed to establish is what we already know – that we need a pharmacare plan.

Now let’s contrast this with what’s happening in British Columbia, the only province currently with an NDP government at the helm.   Rachel Notley’s Alberta NDP government I suspect wasn’t focused so much on health care, she was probably too busy fighting for her pipeline and the province’s future of the fossil fuel industry. But turning to British Columbia, in 2016  when the NDP government was in opposition, the BCNDP Women’s Caucus tabled their report  for the prior year and as opposition this is what they were able to accomplish;  BC had a problem providing MRI’s, during 15 years or so of Liberal domination, some people couldn’t get treatment because needed an MRI first for a diagnosis but had to wait up to two years suffering in pain.  Wait times in BC were the worst in Canada and reported to be the worst in the developing world.

“Again, we took action, by speaking out and sharing people’s stories in the B.C. Legislature and through the media.”

“The added public pressure forced the Premier to finally take action. Funding for MRI’s  would increase by $20 million over the next four years. That’s 65,000 more MRIs to be performed across B.C., an increase of 45 per cent for each health authority. More importantly, that is 65,000 people who will get the treatment they need sooner.” Judy Darcy, B.C. NDP Health Spokesperson.  As opposition, they were also successful by working closely with patient volunteers from across B.C.

“...we were successful in getting the government to cancel the privatization of the Patient Voices Network.  This valuable program – which engages patients, and draws on their own experience, in order to improve the health care system – was in danger of being turned into a profit-centered program. Patient volunteers spoke out and wrote. I issued an open letter to the minister of health on Twitter. And two days later the minister responded on Twitter cancelling the contract with Deloitte. This was an important victory for patients, and a reaffirmation that our health care system is about people, not profits.“

I do recall following at the edge of my seat all the  way up to the announcement a couple of days after the election that the NDP won a majority two years later,  May 2017!

Leaders and Group Decision-Making

When you think about leadership in a government, typically we would imagine a single individual – a president or prime minister – perhaps in an idealized way, reviewing case or project files, thumbing through its contents, and weighing various options provided by members of his cabinet. After some deliberation,  a final decision will be made by selecting the best option that will most likely meet whatever political and police objective has been set.  You’re right to envision decision making to happen in this way, it’s a scenario that does at least resemble how decisions are made at the highest levels.

Group decision making, on the contrary, are somewhat useful and seems to be more typical than a unilateral variation.  When making decisions in a group setting the final decision that is being made will seem to have greater legitimacy having several perspectives voiced at the table and all agreeing on one course of action rather than the lone ranger, unilateral approach.  Group decision making also provides the leader an opportunity to ‘cover the ass’, one would say, basically giving them a layer of protection in sharing the responsibility if the wrong decision was made. “It’s not just me – others have signed on to it.”  Therefore it reduces the level of public criticism the leader might have to bare if a policy leads to a significant level of failure. In addition, group decision making will also expose the leader to a variety of perspectives that otherwise might not be considered, people see things differently and when you can look at a situation with a variety of points of views, exposed to new information, interpretations and possibly dissenting opinions, ensuring that the leader will have more facts to consider rather than being narrowing minded or tunnel visioned on a personally preferred course of action.

“Currently our provinces share a power that is dispersed equally among each other and they banter with the feds to get the best possible deal for their people.  In their book Essence of Decision, Graham Allison and Philip Zelikow develop a famous model of decision-making – the governmental politics approach or Model III – in which power is dispersed in precisely  this way, and decision outcomes are the product of bargaining and compromise.”  The creation of Medicare and the negotiating process Tommy Douglas and his team had to engage with the provinces and the provinces with the medical community just to create what we have was a fantastic feat in that there was no room, time nor energy to also fit in a national drug plan as one would have expected to have had that facet negotiated at the same time. “Each member holds sufficient power to thwart the wishes of other members, so whatever decision they come up with will by necessity have to involve a process of give-and-take.  If this is so, however, an interesting possibility arises: the eventual decision they reach may reflect no one’s real preferences.  Any decision arrived at may simply reflect the “least common denominator,” that things which they can all agree upon.  But that may not actually be something which anyone wanted, at least not as their first choice.”  Is this the scenario we face with our present medicare health plan and the reason for some politicians to prefer privatization? Could this also happen in the creation of our national drug plan?

Mediocrity – we must avoid at all cost!

We see this all the time and it’s not just in health care for example, the Electoral Reform Committee. Although I particularly enjoyed the cohesive manner in which all members worked together, it was remarkable of how things seemed to have fallen apart after the committee work was done and handed over for final decision making from our Leader.  Turned out he had a preferred system and didn’t tell anybody about it and trashed the whole project because they didn’t come to his conclusion.  Leadership is not “my way or it’s the highway.”

Remember the “Kitchen Cabinet”, how Quebec got left out of the decision-making and we Canadians were given the “Notwithstanding Clause”?  No body liked it least of all Trudeau, but the provinces were suspicious and didn’t want to lose their power to the superior courts and so the notwithstanding clause was the key to winning the negotiation – it had to go in – without it we would not have had our Constitution. It’s such a stupid clause in that it renders the whole constitution moot because anyone and all of them can pull out citing ‘notwithstanding’ if they don’t like something what’s the incentive of them not doing so.  I am also reminded of how the provinces conducted themselves during the Health Act (1984) and all the bantering between the Health Minister Monique Begin and the Premieres as well as members of the medical communities. How about the province of Saskatchewan and its Association of Doctors who were particularly vocal about their concerns about a national health care plan and their wishes to remain status quo .  Here are some other concerns when following the patterns of group-thinking:

• An illusion of invulnerability -the group develops excessive optimism which then encourages risk-taking;
• Collective rationalization – members discount warnings and fail to reconsider their core assumptions;
• A believe in the inherent morality of the group – members come to believe in the “moral rightness” of their cause and become blind to the ethical consequences of their decisions.
• Stereotyped views of out groups – the group develops an excessively simplified and negative view of the “enemy”.  Think of the war in Iraq and the “weapons of mass destruction” or BREXIT.
• Direct pressure is exerted on dissenters – members come under pressure not to dissent from the group’s opinions. You see this a lot within political parties  “whipping” party members in place on any number of important legislation.
• Self censorship – members fail to express their own doubts and deviations from the perceived group consensus.
• An illusion of unanimity – the majority view is assumed to be unanimous, but in reality some members may harbor personal doubts about it. Taking the final vote on Electoral Reform in the House.
• Self-appointed “mind-guards”  – members emerge who take it upon themselves to protect the group and its leader from dissenting views and information that might challenge the group’s assumed consensus.

However, it doesn’t necessarily mean that all decision making should be done at a group level or that groups make better decisions than individuals.  In groups where power is dispersed – that is where power is widely shared among a number of its members – compromises have to be made in order to reach a consensus position.  How about the Investors Dispute clause in the NAFTA agreement, or Trump in the new MUSCA (the new NAFTA) negotiating a  10 year monopoly on pharmaceutical patents before the generic companies can come in to create their own version of the drug.  Canada who gives 8 years and Mexico, 5 years, might not like that, so a compromise has to be made here.  Remember CETA and the Wallonians?  They held the whole agreement in the balance to negotiate a better deal for farmers. Or the Canadian Medical Association (CMA) Planning committee on Medical Care, trying to get general consensus when negotiating with the doctors for medicare.  Sometimes, the leader of the group, after all deliberation, should suck it up and make the call because in some instances its the leader that holds responsibility and accountability for the decisions that is made.   The public holds the leader responsible not so much the ministers. Remember Chretien saying “No” to the US for Canada’s participation in the Iraq war? Right on!

Citizen Assemblies – Do it again (but better this time)

In these types of decision making process, however, a voice that often gets left out is the collective voice of the people – remember us, the ones whom you’re making the decisions on behalf of?  And that’s what referendums in a democratic society are supposed to provide, an opportunity for the people to have their say and give direction to their governments.  Or to put it another way free prior and informed consent (FPIC); remember that group decision-making process with the indigenous communities? Referendums are not appreciated for a variety of good reasons and that’s why a citizen’s assembly is the next best way to go – and – we should be utilizing this process more often.

“A citizens’ assembly is a body formed from the citizens of a state to deliberate on an issue or issues of national importance – like healthcare, like a national pharmacare. The membership of a citizens’ assembly is randomly selected, as in other forms of sortition. The purpose is to employ a cross-section of the public to study the options available to the state on certain questions and to propose answers to these questions through rational and reasoned discussion and the use of various methods of inquiry such as directly questioning experts. In many cases, the state will require these proposals to be accepted by the general public through a referendum before becoming law. The citizens’ assembly aims to reinstall trust in the political process by taking direct ownership of decision-making. To that end, citizens’ assemblies intend to remedy the “divergence of interests” that arises between elected representatives and the electorate, as well as “a lack in deliberation in legislatures.”

Citizen Assemblies worked well for electoral reform and using this process might prove to be more useful in determining what a national health care and pharmacare program could entail as it would be brought to you by those who are directly affected.  It could be made up of doctors, nurses, cancer patients, educators, single parents, elderly, people dealing with chronic illnesses, others who have  rare diseases, pediatrician, nutritionists and dietitians, home care specialist, pharmacologist, pharmacists, chiropractors, dentists, physiotherapists, massage therapists, athletes, weight trainers, medicine men and women from the indigenous communities, opticians, reaching a broad spectrum of those who are in the medical field and others who are patients that rely on the system for long-term care and others who represent the general populace because, let’s face it – we are ALL a patients from one time to another in need of care. It’s been done before (almost 60 years ago), during the first attempt at universal health care which seemed contentious at best, therefore we can do it again – we’ve been demanding for better health care for years; we all know what’s at stake.

Go back to the drawing table.

Revolutionizing Medicare

Canada has fallen behind most countries in developing a comprehensive national drug plan and our medicare system that was once applauded as being one of the best in the world, has become fragile and compromised.  Results from 2015 Common Wealth Fund survey of primary care physicians in 10 countries did find some improvement overtime; 53% of Canadian doctors surveyed said that their patients could get some or next-day appointments, an increase from 2009 (39%) but still much worse than most other countries being surveyed coverage was 72%. Whether people can see their family doctor on the same day or next day when they are sick. Canada ranks near the bottom of the health care metric.

The power of compassion and caring can happen in a myriad ways, beginning with self empowerment, and  promoting the return on investment (ROI) of compassion within systems designed to reward those who aren’t compassionate.  In this case the ‘personal and political’ are deeply enmeshed. The nature of health professional practice is changing and must continue to evolve; but the emphasis is changing.    Health delivery is now more of a partnership, family members and other caregivers would now also have to be regarded as members of the health care team with each profession contributing its mite.

“The right member of the health care team enables the right care in the right setting, on time, every time.”~ Stephen Duckett

What also needs to change is the current balance of service provision; more emphasis on supporting self-management and expanding assisted living are two examples.  The change from managing acute diseases vs chronic illnesses requires a different mindset for the system and a different skill set too.  The skills of a physician or a registered nurse will always be required. Despite medical schools that often warn students not to get too close to patients, because too much exposure to human suffering is likely to lead to exhaustion, Trzeciak says. “..the opposite appears to be true: evidence shows that connecting with patients makes physicians happier and fulfilled.

According to Stephen Trzeciak, let’s consider a few more benefits in using compassionomics and implementing its principles to revamp our healthcare system:

“The significance of this research is that, if the hypotheses are confirmed, the results will have immediate and major implications for the landscape of healthcare delivery, including how we select candidates for HCP training, ow we train them, ans what we value in our health systems.  Importantly,, these hypotheses also align with the “quadruple aim” paradigm for healthcare improvement – i.e. improving patient outcomes, patient experience, and provider well-being and engagement, while simultaneously lowering costs.  In contrast to the development of a new pharmaceutical agent, which may require hundreds of millions of dollars (or more) to bring to market, sometimes with limited or narrow impact, compassionate healthcare interventions could be relatively low cost and immediately actionable in all healthcare domains.

In addition to being low cost, compassionate care may be cost saving through a reduction in discretionary healthcare resource utilization (e.g. better doctor-patient relationship and resultant better communication may reduce reliance on testing, technology, and specialist referrals), cost avoidance through higher quality care and lower absenteeism and employee turnover among HCPs as a result of a reduction in burnout.

In addition, patient non-adherence to prescribed medications has been associated with $100 billion to $299 billion (USD) of potentially avoidable healthcare costs annually in the US alone, and numerous studies have reported an association between compassionate care from HCPs and better patient adherence to medications and other therapies.  thus compassionate care has an opportunity for impact on the staggering costs of non-adherence, in addition to the patient-centered outcome that better adherence typically translates to better health.  We also believe that the hypotheses presented here represents opportunity for innovation, for the following reasons:

1. 1. 1. new healthcare innovations to increase compassionate care may be efficacious across a multitude of meaningful patient-oriented outcome measures;
      2.  the effectiveness of new therapies brought to market may be modulated i.e. either increased or reduced – bu the effects of compassionate care (or lack thereof) and
      3.  the hypotheses proposed here could impact a high proportion of all transactions in healthcare, a sector which in US comprises nearly one-fifth of the economy.

Therefore, we believe that compassiononomics should be of high interest to industry as well as the investor community.  In summary, the data generated by testing these hypotheses could be widely generalizeable with tremendous scope of impact for patients, payers, providers and public health.”

Although the situation doesn’t look all that promising in terms of funding and minimizing the politicizing  of the issues, for our health system, we can still view our present challenges as an opportunity use all available data to build a comprehensive world-class program that fits the needs and lives of our diverse population that exists in Canada today and well into tomorrow.

 

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References:

Canadian Dimensions, The Birth of Medicare: From Saskatchewan’s breakthrough to Canada‑wide coverage, Lorn Brown, Doug Taylor,  Accessed: July 9, 2019, Retrieved: https://canadiandimension.com/articles/view/the-birth-of-medicare

EQUIP Health Care (2017) What is Health Equity: A Tool for Health & Social Service Organizations and Providers, Vancouver, BC, Accessed:  July 11, 2019, Retrieved from: http://www.equiphealthcare.ca

Canadian History Museum, Making Medicare, The History of Health Care in Canada (1914-22207), Accessed: July 9, 2019, Retrieved from:  http://www.historymuseum.ca/cmc/exhibitions/hist/medicare/medic-5h04e.html

Medical Hypotheses 107 (2017) 92-97, “Compassiononmics: Hypothesis and experimental approach“, Stephen Trzeciak, Brian W. Roberts, Anthony J. Mazzarelli, Science Direct – Elseiver,  Accessed: July 11, 2019, Retrieved from: https://www.sciencedirect.com/science/article/pii/S0306987717303729

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