Three problems, three solutions

Solution: An FP-focused med school campus Dr. Jane Philpott says Queen’s new family medicine satellite school just outside of Toronto could be part of the fix for comprehensive primary care. Former federal minister of health Dr. Jane Philpott says there’s a twist for the new campus for Queen’s University’s medical school: it will only be training students who are going into family medicine. With a shortage of family doctors in Canada and fewer medical students choosing to go into family medicine and fewer of those opening up comprehensive general practices, Dr. Philpott, dean of the faculty of health sciences at Queen’s, says the time was right to try something new. Q: How did this idea come about? We took advantage of the fact that Ontario, like many other provinces, is growing the number of seats in its health professionals programs, both medicine and nursing. Ontario announced 160 new seats in medicine—the bulk of them going to the new medical school (Toronto Metropolitan University). But the others were divided amongst the current medical schools and we got 20 new seats. We have a longstanding partnership with the Durham Region of Ontario where Lakeridge Health is our clinical partner there. It’s a health system that includes seven different hospital sites and we’ve sent learners there for years, including a longitudinal integrated clerkship. But they were interested in partnering to have a full medical school site in Durham Region. It was the perfect opportunity when we had these 20 seats. But rather than just doing it like a regular branch of what we’re doing, we said, “what if we actually made that a family medicine-focused campus?” So we are specifically recruiting from our general large number of applicants students who pre-select on commitments to becoming family doctors. In the admissions process for that site, we’re looking for people who really want to be family doctors and are so determined that they’re ready to commit to that right now. Q: They are somehow pre-matched for family medicine? They will go through the four years of medical school, and they will then stream directly into family medicine residency. There are provisions in the resident matching program that allow for these exceptional circumstances where they don’t have to go through the match. This is something that’s been done in other countries, but never been done before in Canada. Q: What is the timeline on this? It’s been about a year in the making. Beginning of 2022 we started on this and we’re taking our first group of 20 students in September of this year. Q: Those first 20 already know? So at our base program here in Kingston, Ont., we get about 6,000 applications for 100 seats. What we did in January once we knew for sure that this program was going to happen, we sent a letter to all of those applicants, and invited them to submit a supplementary application if they were interested in becoming family doctors and wanted to be considered for this stream. We got a very good response to that, and they are now in the process of interviews and final reviews, and they’ll find out in May who gets those spots. Q: This is our ‘politics’ issue—how do you suggest other doctors lobby for a change they see as important to the health system? One of the best pieces of advice I would say, in terms of talking to funders, i.e., government, is making sure that we are providing solutions for the problems that are presenting themselves to the politicians. There’s no question that right now, at every level of government, people are hearing from Canadians that they are worried about their lack of access to primary care so this is a real opportunity for physician groups, medical schools, associations to actually say: “We are here to help you solve your problem: Your problem is that there aren’t enough doctors. We have a solution that will help you get there.” I can tell you for sure they pay very close attention! Solution: Unique patient identifiers Dr. Alika Lafontaine argues we need the kind of data that can see a patient’s whole use of medical and social services. Though we do know the provinces must commit to “modernizing the healthcare system with standardized information and digital tools” as a requirement of receiving the new federal health funding, we don’t yet know the details of what is in the new bilateral and Canada Health Transfer deals from the federal government. However, there is evidence that the funding could lead to unique patient identifiers—something Canadian Medical Association president Dr. Alika Lafontaine is behind. (That evidence comes from Premiers Scott Moe of Saskatchewan and Danielle Smith of Alberta saying—perhaps appealing to their political bases—that the health deals might lead to the creation of “digital identification” for every Canadian, and vowing they will not share their citizens’ “private health information” with the federal government.) But Dr. Lafontaine, an anesthesiologist in Grande Prairie, Alta., argues that “persistent identifiers for both patients and hopefully providers soon” could solve a lot of problems. Unique patient identifiers, he said, are not the same as patients’ provincial health card numbers. “Our current way of identifying patients across health records is very convoluted. We have a provincial health card number, which is how we are identified in certain provincial databases. But we also have a hospital record number assigned when we have a record created when we visit a hospital. We have a patient record number assigned when we have a record created when we visit a community clinic. When we travel to a different province or territory for medical treatment, even more of these identifiers are created,” he said. Dr. Lafontaine argued that we need a way to consolidate these identifiers into a single, persistent identifier across the digital records and that does not exist right now in how the system is structured. He said the “standardized information and digital tools” commitment in the new health funding “really is the revolution that we’ve been asking for” as doctors have been calling for better data for at least 20 years. He does think the identifier should work across every jurisdiction in Canada: An Albertan who has a heart attack in Toronto isn’t going to want to hear that doctors couldn’t access their health info. Dr. Lafontaine spoke to the Medical Post last month outlining what unique digital IDs can do for the health system. Q: What problems would unique patient identifiers fix? Many task forces have said this is a necessary step to understand the difference between where we are—and where we need to go. We don’t have a clear line of sight on how many of the things we have done impact the healthcare system; we’ve made broad assumptions. We say we’re going to invest $100 million in this type of intervention and as a result X will happen—but there’s not a clear, direct line between the funding and that actual impact. For example, in the operating room—which is where I work—it’s underappreciated how much the front end actually does to take off the non-clinical workload from people inside the OR. During the day, your front end deals with all the communication for cancellations or rescheduling and they often field questions from people in the clinical team and are that person who goes around and actually finds the information. After hours all of those responsibilities get shifted onto the charge nurse and the providers who are in the OR. The only way to measure that now is through feedback. That is difficult on two sides. The first is that in order to get attention to something that’s central to what you do, you have to speak up and spend a lot of your time advocating for change. Then the second is administrators just aren’t equipped with the numbers and metrics that they need to argue that (something) needs to be brought back into place. Q: How would this help FPs? I think family doctors across the country aren’t just overwhelmed by the amount of work but they’re also very frustrated by the inattention to the parts of work (they have) that need to get redistributed to other folks. (Say right now we have simple data that says the average FP appointment is 10 minutes) well that’s very low on the data hierarchy because it doesn’t provide any context. Was that 10 minutes actually enough to cover the needs of that specific patient? Did that patient have to come back again for another 10 minutes? We know that if a person is seen the first time and gets what they need, healthcare utilization drops. How often do patients go through multiple different doors? What happens right now is you as a patient, go see a clinic, go to a hospital, go to social services—it is a different identifier in every one of those databases. If you consolidate all of that, we get a longitudinal look of all the touch points that this patient had to go through. You can start to see, “Oh, look, the touch points actually decreased because we increased the time in this one place.” Q: How would this help patients? So how do we provide information back to patients and providers in a way that helps them filter through all the data to get conclusions? This is where dashboards come in. Right now, we don’t actually know (much about queues). Like we know that you’re in a queue for a specific location. But where are you in that queue? How long have you been waiting? Why are you in that position relative to another position based on your need? We really have no nuance. If it’s clear to patients that they can just go somewhere in a dashboard and know where they are in a queue for specialist or surgery, imagine how many phone calls that’s going to save your average family doc and how many uncomfortable conversations that will save them when they’re trying to justify something they have no control over. I think the goal is to make it clear (for patients) “What are you actually getting out of the sharing of your data?” Q: What can doctors do to make it happen? I would really encourage docs to start following folks on social that talk about these issues and encourage them to, you know, pop open those emails they get from the CMA that talk about data. The biggest challenge in healthcare right now to system change is this overload that we’re currently in. We have such deterioration across all of our health systems—and then also information overload—so sometimes people just tune out and put their head down, trying to just get through their day. But we can’t be passive consumers because if we passively consume what’s going to happen over the next two or three years, it’s going to be put in place and we’re going to be stuck with whatever system we end up with. Solution: Regional medical licences N.L. Premier Dr. Andrew Furey says the goal is national licenses but options like the Atlantic Physician Register are a good start Dr. Andrew Furey, the premier of Newfoundland and Labrador and an orthopedic trauma surgeon, has been a lead advocate for the new Atlantic Physician Register, which starts May 1. The registry allows doctors licensed in one Atlantic province to opt in and practice in any of the other three. In 2011, Dr. Furey co-founded Team Broken Earth, a volunteer task force that did relief work in Haiti following the 2010 earthquake. His experience in philanthropy gave him the desire to do more and in 2020 he won the leadership of the Newfoundland and Labrador Liberal Party and thus became premier (he got his seat by winning a byelection shortly after). Dr. Furey spoke to the Medical Post about how to expand beyond provincial medical licenses. Q: How would you go about convincing other provinces of the value of a regional medical licensure like the one the Atlantic provinces are bringing in? I certainly think that mobility of physicians is important within Canada—and between countries. We have established in Canada free trade between provinces and, for some reason, that has not been applicable to certain professions, and medicine in particular. We recognize that there is value in that mobility within Atlantic Canada. And I can tell you that from the discussions at the premiers’ table nationally, that is something that most jurisdictions, if not all, would be interested in pursuing. I can tell you from firsthand experience during the pandemic, when we were shifting Newfoundland and Labrador (N.L.) physicians to Toronto to help in the ICUs in Toronto, there were no barriers with respect to the credentialing and licensure to allow for that mobility. I think it is something that most premiers share as a priority actually: to allow for the mobility of physicians and surgeons across the country. One of the counter arguments is always, “Well, you have them in your own jurisdiction and if you make it easier to move then people will move more freely and then you’ll lose them from your own jurisdiction.” I don’t really believe that to be the case because the barrier to movement is not so intense as to preclude a physician moving from one province to the other. This is unnecessary red tape in my opinion. . . . With respect to physicians practicing throughout Canada, we have eliminated a significant amount of red tape to allow them to come to Newfoundland and Labrador within days of an application. They no longer need the onerous task of copying their medical degree and copying all your old exams. Right now we have a fast track in N.L. for Canadians who have a full licence in an existing jurisdiction. It really only requires an application, one reference and a code of conduct from the existing college. So N.L. has been quite aggressive and we’re happy to work with our Atlantic partners to create regional licensure for the Atlantic region, but I truly believe the national licensure is the best. Q: I think most doctors know, but what case would you make for why this is good for physicians? I think there is an existing group of physicians—and it’s my feeling anyway that it’s more prominent in the up and coming generation of physicians and surgeons—to (want to) experience different professional experiences. For me, for example, that was in traveling to other countries in the world: Haiti, Ethiopia, Guatemala, Bangladesh and other places. But there is a significant volume of (doctors) who would like to travel around the country and experience the vast beauty and differences that is Canada—while practicing. So in N.L. for example, we are fortunate in some ways to have a healthy expat population scattered amongst the rest of Canada. (They can) come and practice intermittently in N.L. to meet some of the locum needs. And I’m sure other provinces could claim the same (about their expats). There is a significant portion of physicians who would like to benefit from that mobility. And if you’re sitting, for example in St. John’s today and you’d like to perhaps take a two-week vacation and work one week in P.E.I., you could take your family and experience something different in P.E.I., you’re not probably going to fill out two days worth of paperwork and pay some ridiculous fee just with the uncertainty attached to that to then take your family and then go and may or may not work. So eliminating the barriers, I think would be eliminating the red tape and reducing the bureaucracy attached to it allows for that mobility—and checks the boxes for that sense for adventure for physicians—and particularly young physicians. Q: What advice do you have for doctors on lobbying? First of all, let me just comment about how important advocacy is. Having lived the OR lounge advocacy—screaming in the OR lounge does nothing. You need to be active in an advocacy role, whether that’s through your local medical association or through your local representation, provincially, federally, to ensure that your voice is being heard. I’ve sat in the OR lounge, I’ve sat in the premier’s office—the voices in the OR lounge don’t make it to the premier’s office. I’ve worked with so many brilliant physicians with so many amazing ideas that they don’t know how to get those ideas out. I would say that it’s through your local associations—here it is the Newfoundland and Labrador Medical Association—through your professional association. So for me, the Canadian Orthopedic Association or through your elected officials, your MLAs, MHAs or MPs.

Three problems, three solutions

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