Follow the Incentive

Why everyone inside a system can fail without doing anything wrong (AKA A lesson in the Canadian Medical System)

This is the companion to “What Economics Taught Me About My Body.” I started writing that one and decided I had to split it into two parts. That piece is about my body. This one is about the machine around it: who built it, why it runs the way it does, and why nobody inside it has to be a villain for it to keep failing the patient.

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In my last post, I raised a simple question: I may still have active cancer in my body — or I may not. So the obvious next step, at least to me, was to find out. A scan would clarify what comes next.

Instead, I was told it wouldn’t change the plan.

Here’s the frame I want you to hold for the rest of this. You go to a doctor because you’re worried about your health. I did. But my health is not the first thing being optimized in that room — and not because my oncologist is a bad man. Because the system he works inside is pointed at something else, and he is doing exactly what it trained him, paid him, and protects him to do. The distance between why I walked in and what’s actually being protected — that’s the whole story.

When the system would rather spend fifty thousand dollars treating me than fifteen hundred finding out whether I need the treatment at all, the natural question is: what exactly is being optimized? And who benefits from that math?

I started with the money, because money is the easiest place to see incentives clearly.

In the United States, I’d have found it. Oncologists there mostly work on a “buy and bill” model — the practice purchases the chemotherapy, gives it to the patient, and bills the insurer for the drug plus a markup, often around six percent. More drug, more margin. A single six-doctor practice can buy roughly eight million dollars of chemotherapy a year and sell it for about ten. The incentive to keep treating is built right into the business.¹

That isn’t my system.

In Ontario, the expensive HER2 drugs I’m on are funded centrally and reimbursed to the cancer centre at cost — there’s no markup to capture. The delivery itself is paid through a bundled hospital payment priced to cover cost, not to turn a profit. And my oncologist isn’t a small-business owner buying and reselling my chemo; Ontario oncologists are paid through a mix of salaried plans and modest per-visit fees.² ³ As one Canadian oncologist put it plainly: here, no one makes money giving more expensive drugs.²

So the honest answer is: nobody is getting rich on my cycle count. I want to say that clearly, because the easy version of this story — the doctor profiting from the poison — is the American version, and it isn’t mine.

But “no profit on the drug” is not the same as “no incentive.” Push past the money and the incentives are still there. They’re just quieter, and most of them aren’t financial.

The protocol is the safe ground

Start with the one sliver that is financial. Oncologists who bill per visit are paid for each encounter. On chemo, I see mine every three weeks. In follow-up, I’d see him every three months. Active treatment is simply more billable visits than a healthy patient in surveillance. Any single fee is small, and a salaried doctor doesn’t even have that — so this is the weakest thread. But notice its shape: the system meters my contact with it by how much it is doing to me.

The stronger pulls never show up on an invoice.

“Standard of care” isn’t a medical phrase. It’s a legal one — the yardstick a court uses to measure a doctor against his reasonably prudent peers.⁴ Clinical guidelines get used in malpractice both ways: following them is a shield, departing from them is a sword.⁵

Here’s what that standard is being applied to. There are over 200 distinct cancer types, 800+ named subtypes, and fewer than 200 approved drugs to treat all of it. In Canada alone, 1.5 million people are living with cancer — 53 million worldwide — each one a different body, a different genome, a different ecosystem of metabolism, immunity, stress, and history. And the system’s answer to all of that variation is a single protocol per cancer type. I’ve looked at that logic directly — it doesn’t hold⁶.

So when I ask my oncologist to stop early, to refer me out, to treat my response status instead of the calendar, I’m asking him to step off the legally defensible ground onto the one spot where, if anything goes wrong, he is the one who broke protocol. Doing the standard thing protects him whether or not it’s the right thing for me. When he told me I didn’t need a cardiologist, that wasn’t necessarily indifference. It was the protocol answering: a referral isn’t in the script, and the script is what holds up in a courtroom.

The protocol confirms itself

Then the quietest pull of all. The twelve-month treatment standard for HER2-targeted therapy — established before any trial directly compared it to a shorter course, and later shown to be no better than six months for most patients⁷ — is the thing every oncologist was trained on, tested on, and credentialed inside. Following it validates the framework that produced them. Questioning it questions the framework. It is far easier, and far better rewarded, to be the doctor who delivered the standard than the one who improvised and has to explain why.

This is the part that should unsettle you more than greed would. Greed you can follow and expose. This you can’t — there’s no one to catch. Just a system in which the protected choice and the prescribed choice are the same choice, taught the same way, decade after decade, until the rule stops looking like a rule and starts looking like reality.

So the patient becomes the watchman

Here’s where the cost lands. When the people deciding your care are pointed — for reasons none of them chose — at a target that isn’t quite you, somebody has to watch the rest. That somebody turns out to be the patient.

I’m the one reading the studies. Getting the second opinions. Laying my own scans side by side. Writing the letters. Sending faxes to have my clinical notes updated with data. Tracking the slope no one else is tracking. That work is real, it’s exhausting, and it should not be mine. And it’s worse than unfair — it’s unequal. I can do this. Plenty of people in those same chairs cannot, and the system gives them no reason to think they need to.

The damage to my body never appears on the ledger the system is actually optimizing. It’s pushed off the books and onto my future — the one place no incentive in the room is pointing.

The referral the system didn’t make

I’d been raising my blood pressure numbers with my oncologist for months. The cardiac data was there — echo results, diastolic trends, the mitral regurgitation progressing from trace to mild. I wasn’t asking him to panic. I was asking him to refer me to a cardiologist so someone qualified could look at the slope and tell me what it meant.

The answer, each time, was some version of not yet.

What made this harder to accept is that none of it was surprising — not medically. The drugs I’m on carry known cardiac side effects. Left valve regurgitation issues and elevated blood pressure aren’t rare developments. They appear in the literature. They appear in the consent forms. They happen to a meaningful number of people on this exact protocol. Which means the system already knows this territory exists. It just hasn’t built anything to navigate it.

It was my naturopath who finally moved it forward. I was telling him about the ongoing standoff — the data I was bringing, the referrals that weren’t happening, the specific frustration of watching numbers trend in a direction no one seemed authorized to address — and he mentioned a name. An oncologist about an hour away who had left her local cancer centre because she found the approach too formulaic, too protocol-driven, not focused enough on the person in the chair.

He gave me her information. All I needed was a referral from my GP — which I got — and I could see her. No special access, no out-of-pocket cost, no permission required from the system that hadn’t been listening. She operates as a tax-subsidized resource and we meet virtually. The barrier was lower than I expected. I’m sharing that because most patients don’t know it’s possible.

The first thing she asked me, before anything clinical, was what I wanted. What was important to me in this treatment.

I wasn’t expecting that question. But I was very ready to finally answer.

The space between “you’re fine” and “you’re broken”

She also gave me a frame for something I’d been struggling to name.

The problem with the medical approach, she explained, is that it’s designed to fix a problem — as the system has defined it. There’s no mechanism for what comes before the threshold. So when I bring my blood pressure readings, my echo results, the visible slope of my cardiac function over time, everyone in the room can see the direction. But until a number crosses the line the system has agreed to act on, the answer is: not yet.

For a patient who doesn’t fully understand what the short and long-term effects of these drugs will be — who is already managing treatment, side effects, fear, and uncertainty — “not really that bad” offers nothing. No timeline. No plan. No explanation of what crossing that threshold will actually mean or what comes after. Just a waiting room with no clock and no one at the desk.

That conversation crystallised something I’d understood instinctively for years but never had the language for. A naturopath — or most integrative practitioners — treats the whole body system. Medicine treats an ailment. They are not different approaches to the same goal. They are different goals.

Integrative practitioners ask: what is happening across this entire person, and why? They look at the whole system, try to determine root cause, and work to prevent the problem from developing further. Physicians ask: what is the problem, and how do we stop it? They arrive after the fact and work to eradicate what’s already there. Prevention isn’t in the mandate. The soil that grew the problem in the first place isn’t the question being asked.

This is why I had always gravitated toward integrative care. It wasn’t ideology. It just made more sense to me. This is how I approach consulting; I don’t just look at one factor (as NOTHING exists in a vacuum.) A system that looks at sleep, stress, metabolism, immune function, and emotional state alongside the thing being treated is looking at more of the picture. The medical system, by design, is not — and that’s not an accident or an oversight. It’s the direct consequence of treating the ailment as the unit of analysis rather than the person.

And here’s what I keep coming back to: the cardiac side effects of the drugs I’m on aren’t a mystery. They’re known, documented, and predictable enough to appear on the consent form. We are not in unknown territory. Which means the question isn’t whether some patients will develop problems — it’s which ones, and how soon. That sounds exactly like the kind of question worth asking before something goes wrong, not after.

Why would anyone want to wait for a major problem when there’s a possibility of avoiding it altogether?

That experience — real concern, visible evidence, documented risk, no action — is how patients end up feeling gaslit inside a system that is technically functioning exactly as designed. The data is real. The trend is visible. You bring the numbers in good faith and leave having been heard by no one.

Patients can live in that space for years.

I’ve spent a long time as a business consultant. If I sat across from a client and said: I can see you’re losing customers, I can see the revenue declining, I can see the trend — but let’s wait until you’ve lost two thirds of them before we do anything about it. No client would accept that. No consultant would propose it. It would be a professional failure by any standard.

That’s the logic being applied here. Except in the business example, we’re ONLY talking about revenue. In this one, we’re talking about a human body that cannot be restructured after the fact.

Why I’ve stopped calling it ‘health care’

I stopped calling it the Canadian health care system. I call it the Canadian medical system now — because that is what it is. It is focused on medicine, not health.

I tell my clients: if you’re plotting a course on a ship and you’re one degree off at the start, that’s the difference between hitting Africa and Australia. That’s what this feels like. The system can remove the cancer and create a boatload of other problems I now have to manage — or it could get me to a healthy state. Medicine doesn’t seem to offer that option.

Think about what we accept from every other professional we hire. A financial advisor who watches your portfolio decline and says not yet. A mechanic who sees the warning signs and says come back when it breaks. A consultant who watches you lose clients and waits until two thirds of them are gone before picking up the phone. We wouldn’t tolerate it. We’d fire them. We’d leave reviews. We’d tell everyone we know.

But when a medical system does the same thing — when it watches documented, predictable, known-side-effect damage trend in the wrong direction and says not yet — we call it standard of care. We thank the doctor on the way out. We make the next appointment.

When you take out health and care, what’s left is the third thing every large institution eventually gets good at: protecting itself.

Once you see that, you can’t unsee it. And once you can’t unsee it, the question stops being why isn’t the system doing more — because you already know the answer. The question becomes: what do you do when the system won’t move?

You move.

You find the GP referral nobody told you was available. You ask the question the appointment wasn’t designed for. You find the practitioner who left the cancer centre because she wanted to know what mattered to you. You track the slope yourself, bring the numbers, and refuse to leave without a record that you brought them.

That isn’t cynicism — it’s just the incentives, added up. A doctor protected by following the protocol. A protocol protected by being the standard. A standard protected by the people it trained. Each part shielding the next, around and around, while the patient — the one the whole thing was supposedly built for — is left holding the parts no one else is paid, trained, or protected to hold.

This one just happens to have my heart on the table.

Nobody has to profit from the farm for the farm to keep running exactly as designed. But you don’t have to keep waiting for permission to protect yourself.

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This is what the system looks like when no one is doing anything wrong — and still something is going wrong by design. The harder part is what it does to the people who see it clearly: not agreement, not outrage — just a kind of quiet disorientation with what you’re now expected to participate in.

The next piece goes there. That’s where it starts to get uncomfortable — and that’s where I’m going next.

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¹ On the U.S. “buy and bill” model and its incentives, e.g. KevinMD, “Do oncologists have an incentive to prescribe expensive treatments?” https://kevinmd.com/2012/07/oncologists-incentive-prescribe-expensive-treatments.html.

² Cancer Care Ontario, “New Drug Funding Program,” https://www.cancercareontario.ca/en/Funding/New_Drug_Funding_Program. On the absence of a Canadian profit incentive, see “In support of Canada’s health care system: an oncologist’s perspective,” PMC2913838, https://pmc.ncbi.nlm.nih.gov/articles/PMC2913838/.

³ Cancer Care Ontario, “Systemic Treatment – Quality-Based Procedure (ST-QBP),” https://www.cancercareontario.ca/en/cancer-treatments/chemotherapy/funding-reimbursement/systemic-treatment-quality-based-procedure; and on physician compensation models, Ontario Physicians Recruitment Alliance, “Physician Compensation,” https://opra.ca/resources/physician-compensation/.

⁴ “The Role of Practice Guidelines in Medical Malpractice Litigation,” AMA Journal of Ethics, https://journalofethics.ama-assn.org/article/role-practice-guidelines-medical-malpractice-litigation/2011-01.

⁵ “Medicolegal Sidebar: Clinical Practice Guidelines — Do They Reduce Professional Liability Risk?” PMC7000047, https://pmc.ncbi.nlm.nih.gov/articles/PMC7000047/.

⁶ “The Syllogism of Cancer Treatment,” https://really654643.substack.com/p/the-syllogism-of-cancer-treatment.

⁷ Earl et al., “6 versus 12 months of adjuvant trastuzumab for HER2-positive early breast cancer (PERSEPHONE): 4-year disease-free survival results of a randomised phase 3 non-inferiority trial,” The Lancet, 2019. DOI: 10.1016/S0140-6736(19)30650-6. PMC6615016.