Kingston and the Islands MP Ted Hsu speaks in the House of Commons - congratulating Dr. Chris Simpson on becoming the CMA President-elect nominee. Click here to watch.
The past few weeks have been such a great pleasure – sharing ideas and hearing from so many of you on the issues that are important to our patients and to the profession.
I am so encouraged by what I have heard and by what I have learned from you. There is an incredible energy in the physician community in Canada – a genuine and sincere commitment not just to patients but to the improvement of our health care system. You display, every day, a deeply-held sense of professional obligation to our country and to the world through your advocacy, your commitment to the principles of health equity, and your adherence to the noble ideals of professionalism.
I have immensely enjoyed the campaign for CMA president-elect nominee. I am so grateful for the hard work and unwavering support of my campaign team – Nick Neuheimer, Pearl Behl and Kieran Quinn. Their tireless work on my behalf is deeply appreciated. To my Dean (Richard Reznick), my Department Head (Stephen Archer), my chiefs-of-staff (David Zelt and Dale Mercer), and my hospital CEOs (Leslee Thompson and David Pichora) – thank you for believing in me and for your very tangible support. To all my colleagues and friends in the Queen’s, KGH and HDH communities, the family medicine community and the specialist communities across Ontario and the country – thank you for your encouragement and support. To the medical students and residents – whose views on wellness and health human resources are held so passionately and articulated so resonantly – thank you for your advice, support and leadership. To all my other health professional colleagues from across the country, as well as administrative leaders in hospital, primary care and community settings - thank you for your emails, calls and texts of encouragement!
And to Dr. Gail Beck – a longstanding and tireless champion for children, women and all patients; and an eloquent advocate for mental health – your honourable, principled and respectful campaign has been an inspiring one to many people, including me. I very much look forward to working together with you in the coming years on these and other issues that are important for our patients.
As I look back on the campaign, I see it as a bit of a trail blazer – Dr. Beck and I both communicated extensively through social media – Twitter, Facebook, blogs and LinkedIn. The “Twitter Town Hall” in which we were invited to participate was a first for a CMA election, and challenged us both to “respond in 140 characters or less”. I was glad we had a moderator (thanks, @NarayanMD!) because the questions coming in were like a ticker tape – I didn’t even have a chance to read the question before it was scrolled off the page by the next questions! What a wonderful experience! It was fantastic to see so much interest and so many passionate questions.
Looking forward, we have a federal election looming and many discussions to have about the role of the federal government in both the delivery of health care and in the promotion of health. We have other stakeholders to engage as well – provincial governments, the Council of the Federation, the broad array of medical organizations across the country, our colleagues in the other health professions, our trainees, our patients, the public, and those who work in and lead our hospitals, our primary health teams and community agencies.
We have a lot of work to do. I believe passionately in the capacity of Canada’s doctors to be solutions providers. Together, we can help lead the transformation of Canada’s health care system into one that is truly worthy of Canadians’ confidence and trust.
Access to care in general, and wait times in particular, continue to be a major concern for Canadians, their health care providers, hospitals and agencies, and governments. Most people can relate a story of how they or a member of their family has had to wait excessively for a health care encounter. Waiting for care is not the exception. It is the norm.
Patients wait to see family physicians. They wait for diagnostic tests. They wait in emergency rooms. They wait to see consultant specialists. They wait for surgeries and procedures, like hip replacements, cataracts, and colonoscopies. They wait to get into hospitals, and, as the ALC (alternate level of care) crisis has shown us, they sometimes wait to get out of hospitals, too.
In 2004, Canada’s first ministers acknowledged this pressing concern when they signed the 2004 Health Accord, an agreement that, among other things, committed a considerable amount of federal money to the wait time reduction effort. The ten-year agreement would “fix health care for a generation”, said then-Prime Minister Paul Martin.
The initial focus for wait time reduction coalesced around five areas: cardiac (bypass surgery in particular), sight restoration (cataract surgery), diagnostic imaging (CT and MRI), cancer care and joint replacement.
Canada’s doctors responded to this exciting challenge by forming the Wait Time Alliance (WTA). Seven national specialty societies, together with the Canadian Medical Association (CMA), banded together and immediately set to work to determine what the medically-acceptable maximum wait times should be for these treatments, procedures and surgeries.
It’s important to understand that the WTA did not use this opportunity to set unreasonable or impossible-to-achieve benchmarks. We know, and accept – as do the vast majority of Canadians – that patients need to wait for some scheduled (non-urgent and non-emergent) treatments. Canadians accept some degree of wait for scheduled medical consultations, tests and procedures as long as they know that their wait will be safe, that it will not be unreasonably long and that their care team will monitor their status throughout the duration of the wait for any change in urgency status. So the WTA did not play politics with this opportunity; rather, WTA member societies defined, after evaluating published evidence and by expert consensus, what the safe and reasonable maximum wait periods should be for a whole host of health care experiences. The intent in developing these wait time benchmarks was threefold: to provide a national standard to which all provinces should aspire as they worked to improve access; to provide a way to compare performance between jurisdictions (provinces/territories or regions), and to allow Canadians to be confident that medical experts, rather than governments, were determining what constituted the maximum medically -acceptable wait. The end result was an array of very sensible documents that laid out state-of-the-art, contemporary wait time benchmarks.
Within a couple of years, the WTA began publishing annual report cards, using provincial governments’ own publicly-reported data. We’ve graded the provinces with letter scores – A to F – based on the percentage of patients treated within the benchmark timeframe. 80% earns the province an A; less than 50% earns them an F. Over the years, as the WTA has grown to 13 specialty society members, 3 specialty society partners, and the CMA, the report card has expanded it’s scope to include many additional consultations, tests, and procedures. In addition, we have featured examples of best practices in wait time management, shed light on the total patient experience (rather than focusing on just one aspect of their wait in what is really more of a journey), and have directed sustained attention to both the ALC issue and on the wait time for referral from family physician to consultant specialists.
The impact of these annual report cards has been astounding. In the months leading up to the release of the reports, officials from provincial Ministries of Health proactively call the WTA office to ensure that we have their most up-to-date information, and to point out areas where they feel they have improved over the prior year. Our annual grading of the provinces’ wait time websites on their user-friendliness and comprehensiveness has led to marked improvement in the quality of these websites over a very short period of time (we have patient panels grade the sites and we report their findings). Excerpts from our reports have been read and the findings debated on the floor of the House of Commons and in nearly every provincial and territorial legislature in the country. The coverage by the press has increased every year; last year’s report card (http://www.waittimealliance.ca/media/2012reportcard/WTA2012-reportcard_e.pdf) had a press reach over over 30 million Canadians. Stories ran for weeks after the report card’s release. As I did interview after interview with reporters from every region in the country, the first question was, inevitably, “So, how did our area do?”
We’ve taken a very deliberately respectful approach to the issue of wait times. We do not want to embarrass governments. We want to inspire them. There is no “blame and shame” – only facts and a fundamental presumption that all the stakeholders want to see improvement. We want to help governments to help improve access to care. One of the most telling moments for me, reassuring me that this approach is the correct one, was an incredible moment of candor from Manitoba Health Minister Theresa Oswald. Upon receiving a not-so-flattering report card for her province last year, including a few F grades, she was quoted in the press as saying, “I’ve been an A-student my whole life, I don’t like getting anything other than A’s.” (http://metronews.ca/news/winnipeg/269301/manitoba-wait-times-getting-nearly-failing-grades/). This refreshing departure from the usual “deflect and dodge” strategy employed by most elected officials demonstrated to us that she respected what we said, she recognized the legitimacy of what we were saying, and she trusted us. We, in turn, felt that we were motivating her to turn those F’s into A’s, and we all want to do whatever we can to help her do just that.
This is what Canadians expect of their elected officials and of their doctors – simply, to lead honestly and to work together. When stakeholders are made into villains, conversations shut down and progress stops. We should evaluate our progress critically, but respectfully.
Last year, I was privileged, as Chair of the WTA, to present before the Senate of Canada’s Committee on Social Affairs, Science and Technology – the committee charged with examining progress made in Canada since the 2004 Health Accord. (The transcript of the testimony is here: http://www.parl.gc.ca/Content/SEN/Committee/411/soci/49055-e.htm?Language=E&Parl=41&Ses=1&comm_id=47). We advanced the argument that access had not improved as much as it should have because of inadequate accountability for the federal dollars spent, and because the money that was spent did not buy real change. These sentiments were reflected in the committee’s final report (http://www.parl.gc.ca/Content/SEN/Committee/411/soci/rep/rep07mar12-e.pdf).
The WTA (www.waittimealliance.com) is stronger than ever. Our membership continues to grow, and our members are energized by the conviction that we are playing a noble and productive role in the national discussion on access to health care. We will continue to shed light, provide expertise, and lend our hand to all partners and stakeholders. Canadians deserve nothing less than our very best effort.
The trend toward increased specialization and sub-specialization in medicine has led to a number of wonderful advances in the delivery of health care. Patients benefit from the skills of surgeons and procedurists who do high volumes of a small variety of procedures; as well as from the wisdom of experts who have highly specialized experience in the diagnosis and treatment of uncommon diseases. Canadians can be reassured that for pretty much any disease or condition, “x”, there is an “x-ologist” somewhere in the country who will be able to provide state-of-the-art care.
As a cardiac electrophysiologist with a particular interest in inherited heart rhythm diseases, sudden death in the young and cardiac resynchronization therapy, I am one of those sub-specialists who routinely sees patients who have been filtered through 2, 3, or even 4 or more other physicians before they appear in my clinic. I am the “end of the line” – I provide the definitive diagnosis; the definitive therapy. I enjoy my role; I know that our work is important and that we help many patients to lead longer, better lives.
But there is a significant downside to the specialization of medicine – the increased fragmentation of care that has resulted. As we busied ourselves setting up all of this specialized infrastructure (granted, with the best of intentions) we somehow failed to notice that we were building silos of care. It is true that within each silo, there is excellence. But looked at collectively, it is now quite apparent that we have unwittingly contributed to the creation of an “un-system” that is characterized by excellence in episodes of care, but which fails patients’ longitudinal experience by performing inadequately at the transition points. Our un-system also serves to sometimes undervalue the critical, essential, and highly central role of the family physician and the primary care community in general.
Today, we speak of patients navigating the health care system. We speak of the patient journey. Patients are shuffled from venue to venue; provider to provider; consultation to test to procedure to follow-up. It’s complicated, it’s inefficient, it’s costly, and it is a source of great anxiety for patients who find themselves at a vulnerable point in their lives. They don’t want to have to navigate anything. They want our help.
These multiple transition points have created a health care environment that is predisposed to preventable medical error. It is also at these transition points where negative perceptions are spawned, where inefficiencies, waste and excessive wait times are generated and where suboptimal outcomes are born.
Creating a seamless, efficient, error-free patient journey will not be an easy task. Slow progress is being made on the adoption of electronic medical records, medication reconciliation, adherence to guidelines-based care, wait list management and accountability, and (importantly) patient empowerment – putting information and solutions in patients’ hands. All of these efforts are moving us slowly in the right direction.
But these are system-level solutions. What can we, as individual doctors, do better?
My recent work with Health Canada and the CMA on the development of referral pathways has helped me to see where some quick gains can be made at the individual physician level.
It was a fantastic experience. Five family physicians and five cardiologists sat down together and we simply asked the question, “How can we improve the referral process?”
“When I refer a patient, the paper goes into the fax machine and then into the ether. I never know if it’s been received or acted upon. My patient asks me when the appointment will be and I can’t tell them,” said one family doc.
“I got this referral the other day that said, ‘Please see re: HF’”, said one cardiologist. “How can I triage that? Is it urgent? Has the family doc done any testing? What meds are they on? I couldn’t tell from the referral note.”
“My patient got this automated note back saying that they’d see the patient in 6 months,” said another family physician. “Six months! My patient will be dead by then! I tried to call the cardiologists’ office, but couldn’t reach her. Am I supposed to keep chasing her down?”
“I get referrals sometimes that are completely illegible. On one referral, the letterhead listed 9 family doctors and I can’t even tell which one sent the referral!”
“My patient got their appointment with the cardiologist in 2 months, but what can I do in the interim? Isn’t there some way that I can get some early direction? Are there any tests I can arrange or any treatments I could get started on?” said one family physician.
The discussion was rich and peppered with anecdotes about bad referral experiences. Everyone in the room nodded knowingly as each story was told, and excitement started to build as it became apparent that some of the solutions are tantalizingly simple.
A referral pathway for congestive heart failure was developed that day. (http://ccs.ca/advocacy/HF-Pathway_en.pdf). When family physicians and cardiologists all understood where they were failing each other (and therefore, failing their patients), the product took shape quickly.
It’s just a tool. It will certainly help, and I am very pleased to see it being implemented in numerous places across the country. But there are even bigger lessons that came out of this exercise.
Our discussions that day allowed a common understanding that in turn led to a harnessing of the power of professionalism. Collegiality goes a long way, and there is nothing like face-to-face communication to facilitate this.
Canada’s primary care/community-based care physicians are increasingly isolated from the consultant/hospital-based community, and this has served to perpetuate and reinforce the silos.
Every doctor can help to reverse this trend by embracing the power of professionalism and collegiality. We should foster personal relationships and friendships with other doctors in our communities. Every consultant should examine his/her practice and fix simple issues like acknowledgment of receipt of the referral, and by being readily available to referring docs for questions and advice. Every family physician can work to enhance their referral notes with pertinent information that allows the consultant to triage effectively and so duplicate testing can be avoided. Finally, we can all ensure that patients are kept in the loop along the way, so they don’t feel abandoned or uncertain while waiting for their visit with the consultant specialist.
All of this is achievable and it doesn’t have to cost a cent. Patients’ confidence in us will increase when we show that we understand and are interested in the integration of our contribution to their care with their overall journey.
Every physician can make a difference. I strongly believe in the capacity of Canada’s physicians to provide meaningful solutions. Let’s embrace these professional principles as a key component of our path forward.
When I talk to my colleagues who are in training – medical students and residents – and ask them what their most pressing concerns are, the health human resources issue is always at or very near the top of the list.
It is no longer uncommon for doctors finishing their residencies to find themselves without a job. Many more are underemployed; doing locums or part time work wherever they can find it.
Particularly hard hit are newly-graduated physicians in highly specialized fields that require expensive hospital resources - cardiac surgery, orthopedics, nephrology, and otolaryngology, to name a few. This is not surprising given that hospitals across the country are cash-strapped, Ministries of Health and regional authorities are holding the line on funded volumes of expensive procedures, resources are being increasingly diverted to community-based care and chronic disease management, and we are now graduating people who entered training at a time when we were increasing the number of training positions to deal with a critical shortfall of doctors.
Embedded in this latter point is the irony that the solution to our HHR problem that was enacted 10 years ago has become one of the key sources of our HHR woes today.
New physicians in these specialty areas are casualties of the chronic and repetitive boom-and-bust cycle of physician supply that inevitably results from the fact that Canada has no effective national health human resources (HHR) strategy.
The story is much more complex than this, of course. While some specialty areas now seem to have more physician supply than positions available, other areas – family medicine, general internal medicine, psychiatry, pathology, pediatrics and geriatrics come to mind – are undersubscribed and positions sit empty.
There are other complexities, too. The roles of our other health professional colleagues are changing just as ours are. Nurses, nurse practitioners, physician assistants and others are increasingly working with us in teams and with expanded scopes of practice; fundamentally transforming the Canadian HHR landscape. The economic downturn that began in 2008 not only put a cap on resources available to us to do our jobs but also led to many older physicians choosing to delay their retirement – further exacerbating the supply-demand mismatch. The always-controversial issue of physician remuneration also plays into this critically; it is no coincidence that the undersupplied specialty areas are also the least well-paid.
Technology changes have thrown HHR planning a curve ball as well. Few imagined, 10 years ago, the explosion of minimally-invasive procedures that are replacing many traditional surgeries, or that it would take only a fraction of the time that it did previously to perform cataract surgery. Physicians and their skillsets must adapt, but this will be increasingly difficult as the pace of technological change continues to accelerate.
Some provinces have made sincere attempts to address this issue before. In Ontario, a very thoughtful report entitled “Shaping Ontario’s Physician Workforce” was published in 2001 after having been commissioned by then-Minister of Health Elizabeth Witmer. Other provinces have developed their own strategies as well.
The fundamental flaw in any provincial strategy, of course, is that individual provinces have little control over the specialist mix available to them. Trainees typically move around the country during their training and are also highly mobile upon graduation. Ontario, for example, might decide that they need more family medicine training positions to address a shortage of family physicians, but this may be less effective than it could be if they all then leave to work in Alberta when they graduate.
There are many stakeholders, many competing interests, many resource limitations, and even more unanswered questions. The solutions won’t come easily and they won’t come tomorrow. However, it is important for us to acknowledge that our failure to address this is both underserving a public that deserves better and leaving a cohort of highly-trained medical professionals (whose training was taxpayer-subsidized) demoralized and marginalized.
Better and earlier career counselling for medical students and residents, along with increased flexibility to move to a different specialty are two ideas with merit that have been discussed and lauded by many. Progress on these ideas would be an excellent start.
But even more fundamentally, we must assemble the courage to develop a pan-Canadian approach to this problem – one that brings all the relevant stakeholders to the table with a mandate to create, implement and oversee a new process. The group must be enabled and empowered to make a greater number of smaller changes over time, rather than big, sweeping changes every ten years. They must be resourced with information and data about training programs, practice trends, political environments, demographics, areas of inequity and health economics so that they can be timely and nimble with their recommendations. Finally, the group must have a mandate to communicate with and provide information and assistance to training programs, hospitals, regional authorities, Ministries of Health and health care trainees themselves.
Good solutions come from good process and good data. Let’s get started.