May 15- Generalism, unity and training
I trained in the old system. 4 years of medical school, rotating internship, go out into the world and practice. Some went straight into a specialty, having found a passion during the internship. Some locumed for a few years and then picked a specialty. Some tried a few places and settled into General Practice. Possibilities seemed to be limitless, restricted only by your interests and aptitudes and available residencies. The culture of training was more egalitarian and the goal was to train to be able to practice basic medicine safely. Anything more you learned on the job, or you went back for more training.
Times have changed. Now everyone is a specialist and certified by either the College of Family Physicians or the Royal College. Early career choice has greatly curtailed flexibility and the ability to change a path once started. Areas of practice have become increasingly siloed and certain specialties appear to be valued much more highly, particularly in the area of remuneration. We are increasingly disconnected both in our clinical practices and in the profession as a whole. The majority of problems in our health care system in general can be linked to lack of communication between providers, between providers and patients, and inefficient and poorly coordinated delivery of care and lack of support for appropriate infrastructure. Instead of functioning as a team with overlapping and complementary skills and services we compete for resources. Ultimately the victim is the patient, but this also generates frustration and dissatisfaction within the medical profession as well.
The move towards generalism in medicine is a deliberate plan to repair these fractured relationships, integrate care in all practices and between all physicians and other health care providers, and to center everything on the patient. Generalism is a philosophy of care that focuses on breadth of practice and collaboration within the larger health care team to respond to patient and community needs. It applies to both primary care and specialty care. It is a way of empowering our trainees to be supported in learning a wide scope of practice and a way of looking at the patient and system as a whole even in subspecialty practice. We need to give them the skills they need to embark into the exciting profession of medicine where every day you learn something new. The principles of generalism are being embraced by the SRPC, the CFPC, and the RCPSC as we review medical education together in a number of forums. One is the Advancing Rural Family Medicine Canadian Collaborative Task Force, which I Co-chair. The principles, however, apply to all aspects of medicine and have the potential to bring the profession together and improve health care for all Canadians in all communities.
“There are, in truth, no specialties in medicine, since to know fully many of the most important diseases a man must be familiar with their manifestations in many organs.” Sir William Osler 1904
May 11- Wait lists, balance and perverse incentives
We have been attempting to monitor, prioritize, and reduce wait times for care in Canada for well over a decade. In and out of the news are stories of folks waiting interminably for knee replacement surgery or, worse yet, dying while waiting for cancer care. The Canadian Wait Time Alliance was founded in 2004 and has been releasing an annual report card about the performance of each province in meeting targets that have been designated as “reasonable” times to wait for specific procedures. Benchmarks are determined by the various specialty societies for how long a patient should wait for a particular service. Initially there were 5 key areas: joint replacement, cancer care, sight restoration, cardiac care and diagnostic imaging. The areas monitored have since expanded to 12 specialties, and a yearly grade on each province’s performance is given. Overall Canada’s performance is not good and BC is one of the worst with regards to wait times for surgery.
So how accurate is the wait list data in Canada? Not very, as it turns out. Each province has different start and end points for how they do the calculation. The wait to see a primary care physician is not included in surgical waits. Some provinces measure starting from the time your family physician refers you to the surgical specialist. Some only measure from the time the surgeon puts you on a wait list for a procedure. There are no controls for patients who are entered on multiple wait lists. Data is kept regionally, not centrally. And there is not clear data separating the wait for those who need a procedure urgently from those who need it on an elective basis.
A problem with wait lists is the selective identification of priorities. When there were only 5 targets identified there was priority funding for just those areas, and waits for other types of surgery got longer. Politics abounded in who got their area prioritized which did not benefit collegiality within the medical profession or improve the overall functioning of the health care system.
A frequent suggestion with regards to surgical or diagnostic wait lists is to have more private facilities able to deliver care. This would decompress the public wait lists by allowing those who can afford to pay or have private insurance to get care elsewhere. Certainly this solution works well for those facilities and the patients who are able to access them. Unfortunately it tends to worsen access in the public system because there is already a shortage of nurses and allied health professionals who are absolutely essential to the functioning of facilities. Pulling resources away when actually we need more of them to maximize efficiency in the public system is a major concern. This “trickle down” theory of access to surgery is about as effective as the “trickle down” theory of urban/rural medical staffing. The idea there is that you train enough doctors and nurses to overflow the cities and eventually some will settle in the country because there is nowhere else for them to go. Research has shown the opposite- you must recruit and train specifically for each area of practice to develop a stable workforce. Likewise we need to plan and recruit to make our public system more efficient and effective.
Patient focused funding, where the funding follows the patient, can promote efficiency in a high volume setting dedicated to performing a certain number of procedures or tests by fostering competition between hospitals. It does not work in community settings, where volume may be erratic, but core services must be maintained (particularly in rural areas). It does not work well for complex medical or psychiatric conditions where stabilizing the patient is a more time consuming and long term issue. It does not work well for cancer care.
We already know many ways to improve access. Work in Scotland has dramatically decreased wait times by implementing consistent measurement standards and implementing innovative organizational models to deliver care efficiently. Closer to home, Saskatchewan has invested in a plan to decrease wait lists with huge improvements. A number of local initiatives across Canada have improved access on a regional level. We need to learn from and translate such initiatives to the BC context and continue the process of resuscitating our health care system.
May 10, 2016- How to fix public health care on a provincial level
The current system of regionalized delivery of health care services in BC is based on the concept of integrating services over geographic networks with care flowing from primary care through local facilities and up to higher levels of care when necessary. Each level of the system would provide a certain level of care, all complementary, supporting physicians in practice in the community right up through the most complex clinical problems which are best addressed on a provincial level- like the BC Cancer Agency, or higher level neonatal care at BC Children’s Hospital. Standards of care would be consistent and measurable, as every patient would get the care they need, when they need it, as close to home as possible. The problem is that imposing such a system on pre-existing communities and facilities without the support of all involved is not likely to succeed- or at best will be a time consuming and uphill battle.
At the beginning infrastructure was purged relentlessly. Beds were cut, and small hospitals were closed or downgraded to something less than an acute care facility. Services and programs were centralized without ensuring access or quality would remain reasonable for the local patient. All was done in the name of efficiency and improvement but without a doubt motivated by the desire to cut the costs of an increasingly expensive system.
The biggest casualty was staffing levels. From a management perspective using the least amount of staff to do the most amount of work makes sense. It works if you are a company with a specific product and you can reliably forecast workload. The problem with health care is that the volume and intensity of needed services varies from hour to hour and day to day. Accidents, emergencies and sudden illness are the wild cards that place unpredictable demands on our system. If there is no surge capacity- which in real terms means having enough extra bodies available to call in to work, then the system flounders.
Apply this thinking to operating rooms. If a big hospital runs a number of scheduled ORs and reserves one for emergency cases, maybe the emergency OR does not always have a full slate. Why not eliminate it and fit in your emergency cases between the booked ones? You will save on a whole OR full of salaries from your budget. The problem, of course, is that there is no flex in the scheduled ORs. The only way to fit in the emergencies is to bump or postpone elective cases. You either need a second shift of nurses or to pay the existing ones overtime. Potential budgetary savings are eliminated by the need to deal with emergency cases. In contrast, small rural hospitals with an OR have underutilized capacity. Days are scheduled according to anticipated volume and rooms sit empty in between. OR nurses lose skills when they seldom use them and nobody wants to be continually on call when you rarely get scheduled time in the OR. But we need the OR to maintain rural obstetrics in isolated settings.
The number of full and part time nursing positions has decreased dramatically. Managers rely on casual staff. Casual staff cannot afford to live on unpredictable and intermittent work. They leave, and then those with jobs work short staffed, lots of overtime (because they are ethical and won’t leave the hospital unstaffed and the patients uncared for) and they burn out and leave. It is a vicious cycle.
Once upon a time, in my rural hospital, an administrator looked at the yearly budget and realized he was paying 3 full time nursing positions in overtime. He created a new position and flexed this extra nurse over anticipated busy times. It made a huge difference in smooth functioning of the facility and staff morale, and by the way, it saved money. It was one of the happiest times in the history of our hospital. What happened next? Well, we regionalized and local autonomy to create innovative solutions disappeared. We lost beds, we lost nurses, and now every day is a challenge to ensure adequate staffing.
We need innovative solutions, from the local level up, to address how our system functions. We need realistic health human resources planning so we have enough nurses and other health care professionals to run our facilities to capacity. Why not bring in specialists to use rural ORs? Why not train and hire enough nurses so that we are not always running at minimum capacity? In the long run this will save us money and make health care more affordable due to increased efficiency in the system. We need to plan our physician resources to meet community needs and properly align our graduates with future work. No Canadian medical graduate should go unmatched, and no new specialist should be unable to work in their field. This requires physician leadership at all levels and the ability to partner with universities, governments and health authorities to fix the system.
May 8, 2016- Diversity, governance, and conflict
The 2015-2016 Doctors of BC Board consists of 37 directors. It is a big board. Of these 37 doctors there are 6 women, 9 specialists (all men), 4 rural physicians, and 4 physicians under 40 (all men). Yes, these groups are underrepresented on the Board. Other demographics have no representatives on the Board. Where are the young women? Where are the indigenous physicians? Where are the physicians from the LGBT community, to name just a few?
We have struggled for years with our governance model. Members are sick of referendums about changing the size and composition of the Board. However it is a real problem to figure how best to achieve balanced representation and how to govern effectively. The two issues are complementary but they are not the same. Within the coming year there will be recommendations from your Board on what structure will best address these problems. The internal governance review is ongoing and nearing completion. Stay tuned. But despite the internal angst about structure, Doctors of BC has accomplished a number of things I am proud to have been involved in.
One of these accomplishments is the work over more than a decade to develop a positive and collaborative relationship with the Ministry of Health, while not backing down on issues of importance to patients and physicians. Physicians need to be involved at all levels in system reform and designing the delivery of services because we are such a major player in providing those services. I have been directly involved in negotiating our contract and in developing policy that sets the direction for our organization and the health system. During my Presidency of the Society of Rural Physicians of Canada, I learned in order to leverage change in our system one must develop positive respectful relationships with other organizations and individuals. I am puzzled how my opponent intends to maintain a respectful relationship with the Ministry of Health while involved in legal action where they sit on opposite sides of the table. How would this impact Doctors of BC?
May 6, 2016- Unity within the profession
Medicine is a house divided. In many places the tension between generalists and specialists, community based and facility based, has progressed to the point where the functioning of the system is affected. The referral process is cumbersome, communication between GPs, specialists, and patients can be difficult or limited, and by no stretch of the imagination do we have a streamlined patient focused continuum of care. That, however, should be our goal. When we flip the lens to focus on the needs of the patient and organize the health system in such a way that care can flow appropriately from generalist to specialist, with all of us well supported to deliver care utilizing the full scope of our abilities we will see the points of contention between physicians greatly reduced.
There are significant pay disparities between certain specialists that must be addressed as part of this process, but we struggle to address this because it implies some specialists are overpaid and some are underpaid and nobody has ever managed to figure out a reasonable differentiation in scale between GPs and specialists. Underneath the pay issue lies the deeper concern of how we are valued and supported in our work. If the system were better functioning and we did not have to struggle to accomplish the things necessary to do a good job, much of the need for more pay would dissipate. There are days when nobody can pay me enough to do my job because so much of it is aggravating. Insurance forms, waiting to talk to a specialist for advice, arranging appropriate tests (especially in rural, where folks need to travel) and dealing with multiple levels of bureaucracy can ruin an otherwise satisfying day at the office.
I have a patient with complex medical issues, whose care involves regular specialist follow up and diagnostic testing in a city 3 hours away. His last set of 3 appointments was scheduled over 5 days. He had a choice between staying in a hotel for the 5 days, driving into the city 3 times, or missing some of the appointments. He decided he could afford to stay for 2 of them. There was no ill intent in the scheduling of these appointments. They were dictated by the availability of both the technology and the specialist. The follow up was good, the tests were the proper tests, the medical care overall was appropriate. However nobody considered the practical realities of access for this patient. This is a failure of bureaucracy and organization. This is a fixable problem.
We must break down these silos of care and organize our health system so it is user friendly for patients, health care workers, and physicians. We have the building blocks but they are neither well integrated nor properly supported. To fix this, physicians must be involved at every level in decision making, planning a delivery of health care. We need functional teams and networks that will deliver better care and make our work lives more satisfying. This is the work I will do if elected. We are better together.
May 4th, 2016 – Access to healthcare
These are my thoughts on access after attending a meeting of the Advancing Rural Family Medicine Canadian Collaborative Taskforce. The meeting was spent contemplating how best to meet the needs of care in rural communities, in the wider context of the Canadian health system.
Health “needs” begin with an individual but are influenced by context. Providing the basic needs to modern communities including clean water, basic sanitation, and reliable electrical power have done more to improve the health of communities than specific interventional medical care. Add in education and income security with the ability to access employment and we go a long way towards prevention of many of the illnesses we currently are treating.
It is appalling that there are many places in Canada where these basics do not exist, most in isolated indigenous communities. Beyond the basics of life, physicians promote individual and family health and treat illness. Rural physicians work with populations that are older, sicker and poorer than the Canadian average. These patients struggle to access primary care, and also develop complex medical conditions requiring access to higher levels of care. This is where rural interfaces with the larger medical system, and rural understands we must promote improvement at both a provincial and national level to provide access that is truly patient centered.
In rural, access issues arise because of both logistical and systemic barriers. There is the problem of having to go physically “somewhere else” to see a doctor or get a test. This is layered on the basic problem of limited access to services, in particular specialist services. Primary care must be delivered locally, and depending on degree of remoteness a basic core basket of secondary services should exist- a hospital or diagnostic and treatment centre, with emergency services, +/- inpatient care, +/- operative care. Services are supported by a limited number of health care professionals, often working as teams. Larger communities have more specialists, more ancillary support, a wider variety of allied health professionals, and more diagnostics. Ultimately the urban communities have lots of services and lots of health professionals, but these are not necessarily organized in a way that provides good access for patients.
Let me tell you a story of a patient I will call Janie. Janie is pregnant and she has high blood pressure. She is only 34 weeks pregnant and needs close monitoring and probably delivery early. She may need to deliver in a larger community 3 hours distant. It is December. Her husband does not drive. How much care can we provide locally? Ideally she should have all her prenatal care in community, with regular doctor visits and ultrasounds and blood tests. We link with the obstetrician in the next larger center and develop a management plan, and depending on how early she needs delivery it happens locally or down the road. The problem is we no longer have regular ultrasound service and she absolutely needs weekly ultrasounds. She is marginally employed, off on medical leave, is new to Canada and has limited resources. This resulted in multiple drives in the winter in the mountains for testing. This did not improve her blood pressure.
So why don’t we have an ultrasound? We have the machine. We have a job that has been posted for two years since the original technologist retired. But we live next door to a place with many job options for ultrasound techs, where there are large signing bonuses at the private radiology clinics. Is this the only reason we have a vacancy? No, but certainly it is a factor. With limited resources we must distribute and utilize them appropriately.
So why do we have so many problems in Canada with access to health services? Is the problem in not enough doctors and nurses, not enough hospitals, not enough funding? I believe that the problem starts with how we organize, deliver and utilize the resources we do have. There are resource gaps that lack appropriate professional availability and inadequate infrastructure for many services. The root of the problem however, lies in how we organize and deliver care, which has evolved into a culture of negativity around health care delivery. We have the basic building blocks to have a world class health care system in British Columbia, but we need to organize them better, provide appropriate infrastructure, fund them appropriately and change our culture. Ultimately the solution lies in primary care teams and networks of care on both a local and a provincial basis. We must develop the solutions together.