We’ve reached a watershed moment where we’re not going back to the way things were: CMA president

B.C.-based writer Ann Graham Walker spoke to Canadian Medical Association president Dr. Alika Lafontaine about a range of challenges facing doctors Q: It’s no secret that Canada is grappling with a very serious healthcare crisis right now, with six-million people lacking a family doctor, and all the downstream results of that. We’re seeing a number of provinces respond by making it easier to draw in international medical graduates (IMGs), to backfill and create better access to doctors as quickly as is safely possible. Do you think that is a good way to turn things around? The focus on international medical graduates and the benefits that can come from better utilization, not only of those who are in the country, but also coming into the country, is one of many solutions we have to implement at the same time. No single change is going to fix the whole system, the problem is just too big. This is one area that could have immediate impact. . . . We’ve seen provinces start to move forward with recognition of credentialing that they feel confident reflects the standard of care that’s practiced in Canada. You know, one example being Ontario and Nova Scotia, simplifying the process for U.S. practicing physicians to make their way to Canada. But interprovincial movement of physicians still has high barriers, and so I think as we have this conversation about IMGs, we should ensure that we don’t (assume) it’s a different conversation. What we really are struggling to work our way through is an evolution of how we regulate the practice of professionals across the country, and their mobility from one place to another. Read: Three problems, three solutions Q: You see this as a problem in search of a national solution? The way we manage health human resources in Canada does not work. And as we resist changes that could solve some of the issues, the problem is only going to get worse. So we can either lean into what we’ve heard for the last 15-20 years, that a national licensing regime would be a solution . . . or we can continue to resist and double down on what we’ve always done. There’s not only the issue of getting physicians into the country and moving within the country, there’s also the issue of privileging within hospitals, within a specific province. There’s a problem with the way we track what people do in those communities. We may bring in somebody under the registration of a family physician, but they may not practice in the sort of way that provides the needs of that community. And the same thing happens with specialists. . . . I personally feel that we’ve reached a watershed moment where we’re not going back to the way things were. Q: The Medical Council just set up a national physician registry. That’s a very exciting announcement in the way that we are for the first-time planning to collect more nuanced data related to, not just the general registration category that a physician would be placed in, but specifics about how they practice and the types of services they could provide. Q: So where do we go next? I think the role of the federal government is to help the provinces and territories rethink the way that they administer their health systems. . . . So I would say that, although there has been resistance to fully move into pan-Canadian licensure, we’re seeing the fruits of the federal government creating that space. You know, (for example) the Atlantic Registry in the four Atlantic provinces. You are starting to see a momentum building toward changing the system. I’m of the personal opinion that the majority of problems that we’re going to run into as we fix this pan-Canadian licensure issue are problems that have always been there. It will be tough for health systems to make that transition. But in the same way that we made the transition into quality improvement back in the late 90s, early 2000s, in the same way that we’re moving towards true team-based care versus siloed care, we’re at a point where it’s an inevitability that we’re going to move towards regional and eventually pan Canadian licensure. Q: Recently Doctors of BC spoke out on the critical staff shortage that has begun to close emergency rooms across the province. Is this the kind of issue you think a pan Canadian license and its rapid mobility might help to fix? As problems get more complex and severe, multiple solutions are often required to be deployed simultaneously to address acute crises and rebuild stability. In circumstances when providers are in short supply, Pan-Canadian licensure is part of the solution. A national pool of eligible physicians to fill locums would allow physicians to become available where they are needed the most. There are a multitude of physicians who have scaled back from clinical work in one place, who may be willing to help out in another place in Canada. Pan-national licensure would enable these physicians to respond to urgent calls for support in days, versus the current system that takes weeks or months. Q: Where do you see the leadership coming from, to drive this change? You know, the leadership of every kind of healthcare change has always come from patients. So I think that the political will, has its roots in patient advocacy. . . . I think the challenge for healthcare over the last two decades has really been being trapped in the same ideas and trying to do them over and over and over. With the quality improvement revolution that happened in late 90s and early 2000s, there was a shift toward measurement and evidence- based practice. That was positive. But it was only part of the change that needs to happen. With evidence-based practice, we started to shift away from the value we get out of healthcare, and we just focused on the cost. Like if you look at what we built, it’s a variety of mechanisms to get the highest amount of volume at the lowest possible price. And the challenge with that is we don’t make widgets. We’re creating environments where people can come with complex problems—and have a welcoming environment that helps them share what’s going on with their body. I think that in the last 20 years, we’ve dehumanized medicine, because we forgot about the people. Now we need a big shift to put people at the centre again, whether it’s patients or the people that work in the system. Q: There were 100 unfilled family practice positions, at the end of the (2023) CaRMS match. Can we fix things without understanding why that is happening? You know, there’s a general rule in economics that capital, whether it’s human, or fiscal, or otherwise, always goes to where it’s treated best. I actually think we know why people aren’t filling these residency spots. We know why folks are leaving certain parts of medical practice. It’s because the working environments are so stressful; they can’t keep up. If we don’t fix working environments, we’re just going to be moving into the cycle of exposing new people to burnout and having to leave. And that’ll be the system that we create. You know, we’d be a lot better off just making the changes now, huh? Q: What is the smart way you’d like to see this approached right now? The 2002, the Romanow report came out with 47 recommendations, but we only adopted a handful of them. We can’t afford to do that again. The crisis is too severe. And when you think about solutions that we can implement, that will have a near term effect, (we come back to) fixing licensure. So there’s free mobility of physicians and other health providers across the country. Another thing is moving towards team-based care, where we create environments for people to work together. We’ve seen these: there’s the primary care networks in Alberta, there’s the family health teams, in central and eastern Canada. We know they work. They’re costly to start up, but there’s lower costs longitudinally over the life of the patient. And then the third thing is, we really have to get serious about improving working environments. When you have a provider telling you that something’s happening, we need to shift from simply acknowledging to seriously thinking, is this something that we can actually solve? I think that the best time to start these things was yesterday, but the second-best time is right now. I think for family physicians, (what draws) people to that as a career is its focus on longer term relationships and having a variety of different skill sets and opportunities, not only in community clinics, but also emergency rooms, surgical assists, delivering babies and everything in between. I think if we double down on being able to bring that joy back to work—which requires us to fix the negative parts about working environments like paperwork. We saw that study out in Nova Scotia with the millions of hours physicians spend on paperwork every year. And the requirement of people to jump between three, four or five different types of EMRs, to do something simple that requires five clicks. These types of things we can fix. We just have to get on to fixing them. Q: You’ve mentioned some of the systemic issues that have been driving younger doctors away from longitudinal care. One of the things that I’d actually say to those doctors is come to rural practice. . . . Your average grad who has only trained in a big city doesn’t realize just how amazing rural family practice can be. That’s another big benefit of creating mobility of physicians across the country. You’ll have these young physicians at a time in their life where they haven’t yet set down deep roots. I would fully expect that if they were able to be mobile across the country, they would check out places like the Yukon, or northern Manitoba. Places where they know they’re needed. And they would get exposure to (scope of practice) opportunities that they haven’t haven’t been exposed to before. Q: Not every provincial registrar is ready to embrace this idea of a pan Canada license outright. The (head of) College of Physicians and Surgeons of B.C. made her reservations clear in the March/April 2023 College Connector. I think for any folks who are against the movement towards true mobility of providers, the question that I’d ask is that that is the system we have right now. Is it working? And I think the clear answer to that is no.

We’ve reached a watershed moment where we’re not going back to the way things were: CMA president

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