“Stalemate, Mr. Shandro.”

Chess fallen queenChess is a game of extraordinary—sometimes infuriating— complexity.

Sixty-four squares, thirty-two pieces: it seems simple enough, on the surface.  But after just four moves, more than 288 billion different positions are possible.

To play the game well one must look seven or eight moves ahead, mentally mapping out the consequences of each possible move while weighing the potential responses and strategies of your opponent.  Placing a single piece in error can lead to disaster.

The best chess players—the grandmasters—craft opening moves with endgames already in mind.  Like top field generals, they hold the entire battlefield in their minds with perfect clarity.

Each piece on the chessboard plays a vital role.  But by far the most versatile piece, and hence the most critical to success, is the queen. (The king, technically the most important, exists only to be protected.)

Unlike chess, health care administration is not a game.  But like chess, it is extraordinarily, sometimes infuriatingly, complex—requiring careful deployment and coordination of numerous pieces.

Roughly 10,000 physicians, in collaboration with more than 100,000 hard-working employees of Alberta Health Services and supported by massive infrastructure, deliver medical services to the people of Alberta.

Again, just as in chess, each piece of the complex enterprise plays a vital role.

But the piece that is most versatile, the one most critical to success of our health care system, is primary care—care supplied by family doctors.

Tyler Shandro, Alberta’s new health minister, is the system’s political master.  Alas, as has become painfully apparent, he is less grandmaster than rank amateur.

The file he was handed is enormous and complicated, and Mr. Shandro is a lawyer, not a health professional.  This is all new to him: it’ll take him time to master the complexity of his portfolio.

I have no doubt that he will—he’s a smart and talented guy.  As Russian-American chess expert Irving Chernev once noted, “Every chess master was once a beginner.”

For the moment, however, Mr. Shandro is dependent on the counsel of others.  And he’s receiving atrocious advice.

By slashing, as one of his opening moves, the pay that primary care doctors receive for delivering complex care, Mr. Shandro has sabotaged his “queen” and dug himself into a subterranean position.

Any chess player who sacrifices his queen early in a match faces an improbable path to victory.  Garry Kasparov himself, arguably the greatest grandmaster of all, would find it difficult to recover.  And Minister Shandro is no Garry Kasparov.

The moves he is making are more suited to darts, not chess.  And he’s missing the dartboard badly.

When the Minister dropped his grenade of proposed cuts on doctors just before Christmas, I—like hundreds of similarly alarmed colleagues— wrote him a letter of protest, copied it to my local MLA (Mike Ellis) and to Premier Jason Kenney, and dumped it on social media.

The response (to my carefully crafted letter) from the Minister, from Mr. Ellis, from Mr. Kenney?  Outside of a single dismissive comment by Mr. Shandro on Twitter, deafening silence.

A few weeks ago on a Sunday morning I buttonholed a UCP MLA who happens to attend my church. (I won’t name him, lest I land him in trouble).

Minister Shandro, he assured me, was simply “trying to start a conversation”; but, he said, the response of the Alberta Medical Association was “hostile”.

That the AMA reacted strongly to an authoritarian thumb suddenly jammed against its jugular is hardly a surprise.

But there was certainly no “hostility”.  AMA President Christine Molnar and her executives simply applied critical analysis to the Minister’s proposals to expose their many flaws and inaccuracies.  If that was construed as “hostility” then I fear for Mr. Shandro’s psyche should he be confronted by real animosity.

The storm of protest we generated seemed to have an effect, at first—the lack of response to our letters notwithstanding.  Mr. Shandro shelved the cuts, set to take effect February 1, 2020, in favour of continuing discussions with the AMA.  When those talks proved fruitless, he agreed to a period of mediation.

But it was all for show.

Last Thursday, after the AMA failed to knuckle under to Mr. Shandro during mediation, he ducked arbitration and abruptly ended the so-called “conversation”.

Swinging his ministerial machete, he severed with a stroke the long-standing master agreement between the two parties, and decreed that the cuts he proposed last fall would proceed unchanged, effective March 31, 2020: not just cuts to pay for complex care, but a host of others—including cuts to the critically important funding physicians receive to offset the enormous cost of malpractice insurance.

In no accident of timing, last Wednesday the government announced, as smokescreen for Minister Shandro’s next-day act of petulant dictatorship, $137 million in new funding to expand the Peter Lougheed Centre’s emergency department.  The message to the public was unmistakeable: “See, the government is increasing access to health care!”

I wonder if similar funding windfalls are slated for the rest of the province’s emergency departments.  Because they’re going to need it.  The fragmentation of primary care and the obliteration of patients’ “medical homes” is certain to escalate the pressure on already stressed emergency rooms.

The degree of disrespect shown by the Minister and his government to our venerable profession—smearing us as greedy and dishonest—is shocking.  Mr. Shandro’s father is a retired surgeon: one might have expected a measure of respect for doctors, and some insight into our profession, to accrue to his son.

I love being a doctor—it’s brought great meaning to my life.  It’s an honour and privilege to attend to my patients.

But it’s worth pointing out that in the course of their work doctors often put their own well-being on the line—sometimes their very lives.  That truth is amplified every time there is a new pandemic, like the Covid-19 virus that has begun to spread around the world.

When Covid-19 arrives in force in Canada—as it almost certainly will—front-line physicians will rise to the challenge, attending to the sick and to the worried.  And we’ll put ourselves—and by extension our families and our loved ones—at risk of acquiring the virus.

Primary care workers are always the most at risk during outbreaks:  witness what transpired with SARS, with the Ebola outbreak, and now with the current situation in Wuhan, China.

Doctors go to work in the face of pandemics knowing that they risk getting sick—that they may even die.

But we go to work anyway.  Because we’re doctors.

It’s a safe bet that you won’t find Tyler Shandro on the front lines putting himself at risk as Covid-19 invades our communities.  He’ll be holed up in his ministerial offices, no doubt concocting new ways to smear hard-working doctors as grasping self-interested charlatans.

Mr. Shandro continues to blather on about moving doctors from the current fee-for-service model to an Alternate Relationship Plan (ARP).  But he made deep and sudden cuts to fees before physicians had any reasonable prospect of having an ARP in place.  That’s not just putting the cart in front of the horse: it’s placing the cart where the horse is nowhere in sight.

Mr. Shandro and Premier Kenney continue to assert in public that there will be no cuts—that the amount of dollars allocated to physicians’ fees will remain exactly the same.

Yet every doctor I know is facing steep reductions to his or her remuneration—decreased fee-for-service rates, reduced support for malpractice insurance costs, erasure of stipends for being on-call, and other clawbacks.

Out of one side of their mouths Mr. Shandro and Mr. Kenney say to the public: “We’re not cutting their pay.”  Out of the other side of their mouths they say to doctors: “We’re cutting your pay.”

The government continues to run an advertising campaign of propaganda and misinformation, telling the public over and over again, for example, that physicians in this province are paid $90,000 more on average than physicians in other provinces—a figure that is completely and demonstrably false.

Mr. Shandro and Mr. Kenney are peddling falsehoods to the general public.  If it’s deliberate, that’s despicable.

They are playing the public and our patients for fools, erecting an illusion of thoughtful reform while achieving exactly the opposite: wrecking physician finances, destroying doctor morale, and endangering quality care for patients.

The manipulation of the public for political gain, using our patients as pawns, is most upsetting of all.

The welfare of patients is never—must never—be negotiable.

Patients should be treated—always—like the king on a chessboard and protected at all costs.

In the words of another bygone chess expert, French composer François-André Danican Philidor: “Pawns are the soul of the game.”

It is patients who are the soul of medicine.  Not politicians.  Not doctors. Not bureaucrats.

And it is patients who are endangered by this government’s scattershot approach to “reform”.

It is patients whose care will be fragmented.

It is patients who will suffer from restricted access to quality primary care.

It is patients who will languish for hours in emergency department waiting rooms stuffed to the rafters with the unwell.

Perhaps, before too much damage is done, Mr. Shandro will wise up to his rookie mistakes and reverse course.

Perhaps he’ll recover from his disastrous opening moves, and go on to do everything else right.

I sincerely hope so.

But I’d remind him of the wise words of Bernhard Horwitz (yup, another chess master):

“One bad move nullifies forty good ones.”

One of the classic blunders in chess is to wander into a stalemate, frittering away a win by leaving an opponent with nowhere to turn: a move in any direction puts him into “check” and is therefore illegal.  Nobody wins, and the game is declared a draw.

That, I fear, is where we are headed in Alberta.

Mr. Shandro is blundering into a stalemate.

And in a stalemate, let me repeat, nobody wins—not the government, not the doctors, and most definitely not the patients.

So what, my colleagues might ask, should doctors do?

In the game of chess, if you lose your queen, it’s possible to get her back by mobilizing one’s pawns and shepherding them safely across the board.

In the same vein, we must mobilize our patients.

We must rally the public to speak up loudly and in large numbers, to demand that this government stop steamrolling doctors and destroying access to care—before it’s too late.

We must ensure that our patients are not fooled by false advertising and political calculations.

I’ve portrayed doctors in this essay as the opponents of government.  It doesn’t have to be that way.  It shouldn’t be that way.

We should be partners, not enemies.  We should engage in dialogue, not war.

In the end we’re on the same side.  We have the same goal: the best possible care for the patients of Alberta.

But we demand respect for our profession, respect for the sanctity of contract law, and respect for the process of fair negotiation.

Above all, we demand respect for our patients.

 

 

5 Replies to ““Stalemate, Mr. Shandro.””

  1. Minister Candro wants the political credit for proving free universal healthcare. However he wants to run it at the same or lower level of cost as a completely private healthcare system. This is not possible due to the added level of oversight required for gov’t programs as well as the extra costs incurred when healthcare is seen as free. If Chandra wanted to lower the costs of basic care his job was to find inefficiencies. I don’t see how cutting family physicians and the rest of healthcare workers’ remuneration falls into that category. It’s like a pickpocket who feels he is doing a service by lightening the loads of his victims.

  2. Well said and so true. The analogy I have been using is that medical treatments require a certain level of evidence before they become standard care. I fear that the UCP’s level of evidence is way too weak to support their actions. The numbers in the Mackinnon report are not strong enough to justify the decisions made. I do hope that for all of our sakes, the AMA will be able to get this to court where it can present its level of evidence to support its solution to the problem. Meanwhile, all the pawns have to get out there and organize a protest. But will it be enough to get this government to back down? The loss of just one doctor in a community is tragic. Imagine losing more than that?

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