The King’s Healers
Health Care Practitioners: An Ontario Case Study in Policy Making
by Patricia O’Reilly
This book begins with a lengthy account of the methodology it uses to tell the story of the Ontario Regulated Health Professionals Act of 1991. It presents a clever intellectual framework for organizing the material and describes representations from the many professional, semi-professional and non-professional groups involved in health care delivery. It explains the assessment of their submissions by a special panel that made recommendations for the new act and assesses the impact of these changes.
The introduction argues that this history can be presented in two ways. The first “institutionalist” approach can be accomplished by giving an account of the differences between institutional structures and regulations before and after the passage of the act. The second “ideational” approach requires that one tell stories using the changing ideas and cultures that surround the different groups. The promise of policy stories enticed me to look forward to a gritty tale of colourful characters, pressure groups, smoke filled rooms, passionate debate - the kind of narrative that portrays the ebb and flow of politics and policy making in the world of Queen’s Park. Instead I was led through a rather abstract but still interesting process of well-mannered representations before a well-behaved committee which used a set of agreed upon criteria to test submissions. The struggles were between abstract ideas such as the scientific orientation of medicine versus the much more empirical approach of homeopathy. Other differences distinguished the power of already embedded professions from aspiring seeds scattered over the professional garden. There were no individual persons, few individuals’ words, let alone descriptions of their dress or what they had for lunch. Everything was presented at the level of professional bodies, how they positioned submissions to the panel, and how the panel responded. It summarised the results: who became more deeply embedded, whose professional seeds germinated and who never got planted at all.
Being a little disappointed after such a promising beginning, I decided to immerse myself in the book and try to find the hoped for stories. I could only come up with the following tale. I hope it captures some of the good things about this book.
Once upon a time not so very long ago there lived a king. One day he called all his healers to the court. When everyone from his stately court physician to the lowly foot masseuse had arrived, he said, “I would like you to tell me what you do, why you do it and what you think your rights and obligations should be to me and to the people of this fair kingdom.”
The king’s request for self explanation and justification was seen as insulting by the court physician who had spent years studying his science at great institutions of learning. He had built up a large practice with a staff of chemists, nurses and trained therapists. Why should he have to justify himself like the lowly masseuse who had only a modicum of education and was indistinguishable from a camp follower? But the King’s request had to be met. And each of the healers including those in the physician’s retinue made representations. The king himself had to attend to other business. He had a country to reign over, balls to go to, foreign dignitaries to greet and taxes to assess. Since there was such a large entourage of healers he appointed a blue ribbon panel of wise persons to receive submissions and make recommendations. He took their task seriously and so he worked with them to identify questions to be asked and criteria for assessing the answers.
The healers had different arguments for bolstering their positions. The already well-established physicians, who were deeply embedded in the garden, wished to retain and increase their hegemony by keeping all others out. The partly established, whose seeds had germinated, wished to increase their clinical autonomy while distinguishing themselves from physicians. The truly excluded wished merely to gain entry to the garden and be recognized as part of the healing bouquet. The criteria were important for the panel but as they listened they kept looking at the king’s face whenever he was in the room hoping to decipher who he favoured and who he didn’t. As a result some charming quacks were admitted because the king smiled at them and some worthy but less graced healers were excluded by royal frowns. In truth many of his facial expressions came from the quality of the lunches served to the panel. I could describe them but it is beyond the scope of this brief review and, to be fair, the panel was also influenced by communications from several patients and other advocates and enemies of those making representations.
In the end there were some changes in the array of healers. But most important the entire exercise made everyone realize that they fulfilled their roles at the pleasure of the king. None of them were as autonomous as before because at any moment they could be asked to account for their practice. (The king, for his part, died soon after and his heir had no inclination to repeat the exercise.)
One of the wise women on the committee thought the process was important enough to merit a permanent record. She gave one of her best students free run of the documents. The student immersed herself in the work, developed a conceptual frame and found a way to tell the stories without mentioning any of the players. She was so successful that she was herself certified as a wise woman and lived happily ever after.
Sholom Glouberman
Toronto
February, 2001
Published in CMAJ, Vol. 164 Issue 8; April 17, 2001.