By: Ian Gillespie, MD
Trouble in paradise: More litigation and the challenges of tribalism
Issue: BCMJ,
vol. 53, No. 4, May 2011,
Page 160 President's Comment
Each time we conduct a membership survey, the BCMA receives very favorable responses from a large majority of members. Our strength is directly proportional to our degree of unity. To achieve this, we need methods for resolving the issues that threaten to divide us so we can arrive at decisions by consensus whenever possible.
As we interpret our subjective view of reality, each of us varies to the extent that we use intuitive reasoning versus analytical reasoning, and that ratio changes according to the context. We also have different hot buttons—those triggers that cause us to feel betrayed, humiliated, or disrespected. As well, there are many cognitive traps that promote an attitude of refusal to work on conflict, as opposed to promoting negotiation.
Robert Mnookin, Harvard Law School’s chair of the program on negotiation, describes in his book, Bargaining with the Devil, the negative aspects of “tribalism,” which involve an appeal to a group identity, where you see your own group as familiar and reliable, and the other as a group that should be distrusted and disfavored. This perception may be operative in both directions simultaneously.
Another negative trap is the call to battle, often involving a leader mobilizing his or her “troops” for a fight in a righteous mission against evil. This call uses the language of war and will often rhetorically draw upon tribalism, moralism, or seeing the other side as evil in some way. While the leader inevitably claims his or her motivation is only to do what is best for the group as a whole, the call to battle often serves the leader’s own political interests.
Far less common is the opposite extreme, a call for peace, based on the premise that almost any conflict can be avoided or ended through sensible peace-seeking initiatives.
Clark and Senik published an article at the Paris School of Economics in 2008 called “Who compares to whom? The anatomy of income comparisons in Europe” (www.pse.ens.fr/document/wp200865.pdf [article]; http://news.bbc.co.uk/2/hi/business/8008057.stm [news report]). They report on how looking at others’ incomes is a prescription for envy and unhappiness. Disparity between physicians’ incomes can provoke reactions.
The allocation process after the last negotiations was prolonged, expensive, and frustrating. The new two-stage allocation method—passed unanimously by the Board and by an overwhelming majority of the membership by referendum last fall—will pay attention to comparative incomes, both intra- and interprovincial.
Will that fix all the disparity problems? No. It is rare for either side to get all that it wants in even the most successful negotiations. Usually we see improvements occurring as an iterative and incremental process that builds on the foundation of previous agreements.
Recently, a number of anesthesiologists, including leadership of the BC Anesthesiologist’s Society (BCAS), have become increasingly critical of the BCMA and are ignoring the contractual agreement they signed in 2009. They state that their fees rank 10th in Canada.
Anyone who has experienced the benefits of a safe and well-managed anesthetic personally, or has had a loved one do so, knows how much anesthesiologists contribute to the health care team. Anything that limits the availability of anesthesiologists will directly affect patients and many others, especially colleagues in surgical and obstetrical specialties. The recent media campaign launched by the BCAS is evidence of the degree of dissatisfaction in their ranks, as are some notices of their planned nonrenewal of membership.
Physicians can resign or not join the BCMA for any number of reasons. Each year a small percentage of physicians choose not to be members. Since 1993, our agreement with government provides for charging a fee to nonmembers who wish to access any negotiated benefits. On 5 March 2011 the BCMA was served with a class action lawsuit alleging that this practice is unfair. The representative plaintiff in this action is an anesthesiologist who is not a member of the BCMA.
Promoting excellence in membership benefits leads the BCMA’s “key result areas” objectives. Negotiating those benefits is a very costly process, but successful negotiations, as well as other work by the BCMA, benefits members and nonmembers alike.
Consider this a call for peace. With modern approaches to managing conflict there has to be a better way. I am open to exploring it with anyone else so inclined.
—Ian Gillespie, MD
BCMA President
Thank you to Dr. Gillespie for your acknowledgement that the Anesthesiologists in BC are providing a valuable service. Unfortunately, the repeated and deliberate efforts of the BCMA to block any attempts to improve the competitive value of anesthesia services in BC have created a significant and worsening deficiency in the number of qualified specialist anesthesiologists in this province. "Underserviced areas" like the Lower Mainland are now added to the chronically “underserviced” areas of Prince George and many other jurisdictions that have struggled for years to attract qualified specialists.
Due to a shortage of Anesthesiologists, entire elective slates are now being cancelled on a regular basis at many hospitals around the province. The prospects of this improving are not good and in fact are expected to get much worse as we note that the average age of practicing Anesthesiologists in BC is now 53 years with very few newly qualified trainees staying in the Province to practice. Attempts by the Health Authorities to attract qualified Anesthesiologists to their hospitals have been all too commonly unsuccessful. There is now a great deal of pressure to reduce the standards of care to allow non-FRCPC practitioners and even consideration of non-physician anesthesia providers to fill the shortfall. This is bad for our patients and our surgical colleagues.
How did we get to this state of affairs? Quite simply, we are no longer competitive to attract or keep enough qualified Anesthesiologists in the province. The brute fact is that Anesthesia fees in BC are the lowest in Canada and not by a small margin either. The next lowest fee schedule in the country, Quebec, pays on average 147% higher than BC. Right next door in Alberta, the schedule is more than double that of BC’s. There are now a good number of Anesthesiologists living in BC and working at least part-time in Alberta, Saskatchewan, Ontario & yes, even Quebec while leaving elective slates unfilled here at home. When people are willing to fly out of the province to work and still live here, how likely is it that we will attract good quality specialists from out of the province to come and practice here? How many other sections in BC can say that they are this far behind their peers in the rest of Canada?
Even the BC Government acknowledges that this is a real problem but cannot designate funds to fix it without the approval of the BCMA. There is a fix for this. It rests with the BCMA. Acknowledge that we have a real problem and stop fighting efforts to correct this gross fee disparity. This will go a long way to restoring appropriate levels of first class anesthesia care in the province and peace in our organization.
I have been a member of the BCMA since 1987 (24 years) but this year I decided that I will no longer belong to an organization that systematically and deliberately blocks any efforts to correct the issue that threatens the very integrity of my specialty.
I would love to rejoin the BCMA but not until they are willing to value my services appropriately.
-Evan Effa, MD, FRCPC
Victoria, BC