Canadian Medical Association

Employment vacancies in Canada’s health sector are at an all-time high, leaving many patients across the country unable to get the care they need – and putting untenable pressure on an already exhausted, burned out and demoralized health workforce.

“There’s still a lot of passion among folks attracted to health care,” said CMA President Alika Lafontaine in his opening remarks for CMA’s third Bold Choices event on Feb. 22, “but it’s clear that passion can only take us so far.”

So how do we recruit, train and retain more physicians, nurses and other health workers to a field in crisis? 

To answer that question, Dr. Lafontaine was joined by Indigenous health advocate Dr. Marcia Anderson, registered nurse and podcaster Sara Fung, resident physician Dr. Sarah Hanafi, and Dr. Kevin Smith, who oversees some of the biggest hospitals in the country as President and CEO of the University Health Network.

Here are some key solutions they discussed: 

Reduce the administrative burden of care

“It's not necessarily about throwing more money at something. It's about using resources wisely. Quality care doesn't necessarily have to equate more costs.” – Sara Fung

While increased funding and more seats at medical schools will result in more health professionals for the future, we also need solutions to relieve the pressure on the health professionals at work right now. One common refrain: cut down on unnecessary administrative tasks. As Dr. Hanafi explains, “For a single in-patient encounter I have to open five or six different clinical applications to complete an appointment.” 

A better approach, says Dr. Smith, could be exception documentation: “If you know that most of your patients are in a post-acute surgical world requiring one or two home care visits, why would we spend more time than the visit entails in documentation? … If things are going well, you can do some very quick check-offs; if things aren’t going well, then we all want more detail.”

Strengthen primary care

“We need to think about how we wrap the services of the entire system around primary care providers as well as the patient.” – Dr. Kevin Smith

According to a survey released by Angus Reid in 2022, almost one in five Canadians do not have access to a family doctor. Without reliable access to primary care, there is more pressure on the acute care system – from urgent care clinics to emergency departments – for medical attention.

To change that equation, more family doctors are needed – and more must be done to make primary care practice attractive to medical learners. “We continue to lag on pay equity for family physicians,” says Dr. Hanafi, and to reflect both their foundational role and the increase in care complexity that they face.

Fung agrees. “We are very hospital-centric when it comes to our health care system,” she says, and hospital-based work typically pays more as a result. If we want health professionals to take on primary care, work to full scope of practice in teams or see patients in different settings, we need to show that we value these roles. 

Support providers’ mental health

“It’s really important to prioritize mental health supports. There's still so much stigma in health care, especially amongst health care providers, for having any mental health struggles.” – Sara Fung 

The 2021 National Physician Health Survey revealed a profession in distress, with 6 out of 10 respondents reporting deteriorating mental health and 8 out of 10 reporting bullying, harassment, intimidation, and/or microaggressions in the workplace. 

Yet as Fung points out, health workers “don’t really have any supports when it comes to dealing with these challenging situations.” 

Feeling helpless to change a negative work culture – let alone a broken system – is itself a risk for health professionals. “When we’re exposed to stressful situations, and either we perpetuate them, can’t prevent them, or witness events that really contradict our own values and beliefs – this can cause a lot of distress,” says Dr. Hanafi.

Negative experiences among health workers usually indicate poor patient experiences as well. “If we don't treat our colleagues with respect and our colleagues are experiencing racial microaggressions from us, then patients are too. That’s how power relationships operate,” says Dr. Anderson. 

Data shows that improving health care culture benefits everyone. 

Empower health workers to drive change 

"It’s incredibly important that all health care professionals feel safe, and actually are safe, sharing their professional, evidence-based (perspectives) around important policy choices.” – Dr. Marcia Anderson 

The people who make up our health system must be empowered to participate in its transformation. “We have a lot of emphasis now on training around advocacy, equity and justice, but unfortunately our institutional cultures do not value that,” says Dr. Hanafi.

As a nurse, says Fung, “I was taught to care for patients, advocate for patients only. I didn't realize I could advocate for myself or my profession or even the health care system in general.” 

Advocacy is as important outside of health care settings as within them, says Dr. Anderson. “There’s a role for all of us to participate in democracy,” she says, “(to) focus on the governments that get elected, the types of decisions that they make, and the accountability and transparency they have around health care system funding, investments and the outcomes that it creates for the population.”

The challenges of the health system and the health workforce are complex. But panelists emphasized that we’re at a critical turning point. The pandemic made it clear that health care affects all of us. “There's a sense that we're all in this together,” says Dr. Anderson, so there's national attention.”

“We really have to look at the current crisis as equally urgent [as the pandemic] in order to find the courage to move towards real action.” — Dr. Sarah Hanafi

Likewise, says Dr. Smith: “We see the problems more acutely than ever before, but they're in the light and I see that as entirely positive. I don't think we have easy solutions. (But) in the past I think we wouldn't have actually looked for those solutions or have been brave enough to admit that there were problems.”

You can watch the full session:

Video Transcript 

ALIKA LAFONTAINE: Good evening. Tawnshi, malo e lelei. Welcome to all of our virtual participants and panelists tonight. I'm pleased to join you from Treaty 8 territory in the homelands of the Metis in Northern Alberta. I'm grateful to work, live, and learn on the traditional territory of Duncan's first nation, Horse Lake first nation, Sturgeon Lake Cree Nation, and region 6 of the Metis Nation of Alberta. 

Since we're participating in this virtual meeting from different parts of the country, I'd like to acknowledge all of the many treaty lands and unceded territories from which all the participants join on. I encourage you to contemplate especially with events of the past week, how we all live on native land, and the role that that has in the ways that we work and engage as Canadians. 

I'd like to welcome you all to the third event in our Health Summit Series, Bold Choices in Health Care. After our two previous sessions on health funding and care delivery models, tonight we're finally turning our focus to the health workforce. It's an open secret that Canada is facing a desperate shortage of healthcare workers, and that's directly impacting access to care. 

Employment vacancies in the health sector are at an all-time high. And this is leaving many patients across the country unable to get the care that they need in a timely manner. At the same time, care providers are exhausted, burned out, and demoralized like never before, many working in untenable conditions for much too long. 

I participated in a session with medical learners recently in advance of tonight's conversation. And I have a lot of optimism based on the themes that I heard. There's still a lot of passion for these folks who get attracted to healthcare. But it's clear that passion can only take us so far in today's environment and why sustaining the health workforce is so important. 

So the question is, how do we move forward? How do we attract, train, and retain more physicians, nurses, and other health workers to a field in crisis? How do we create a system that prioritizes the people within it, those receiving care, and those delivering it? And how do we support those leading us within these healthcare systems to make more impactful decisions? That's what we'll be exploring tonight. 

If you'd like to follow tonight's conversation on Twitter and other social platforms, we'll be using the hashtag #CMABoldChoices to share highlights. We'll be starting with a 40-minute moderated question and answer with our panelists followed by a 40-minute question and answer with you, our audience. 

Questions will be text-based and can be upvoted. If you look at the bottom of your bar, there should be a question option within the selections. Please input your question. And based on the upvotes, we will answer those that are most upvoted first and work our way through the list. 

We ask everyone to support a respectful, professional, and collaborative discussion tonight. A reminder that questions that are discriminatory, defamatory, abusive, or offensive, or that violate privacy or confidentiality will not be addressed. And now let me introduce our four esteemed panelists. 

Our first panelist Dr. Marcia Anderson practices internal medicine and public health and serves as a medical officer of health with Indigenous Services Canada for the Manitoba region. She is the current vice dean of Indigenous health, social justice, and anti-racism at the University of Manitoba. 

And she serves as chair of the Indigenous Health Network of the Association of Faculties of Medicine of Canada and is on the National Consortium for Indigenous Medical Education. She's also a past president of the Indigenous Physicians Association of Canada. 

Ms. Sara Fung is a registered nurse who spent eight years in maternal child health at Toronto's Mount Sinai Hospital. Now, in nursing leadership, she has served as a clinical nurse specialist and professional practice specialist. 

She is the co-founder and co-host of The Gritty Nurse podcast and an advocate for anti-racism, health equity, mental health, and improved working conditions for nurses. I was on her podcast in the past, and she is a very sharp mind and has her hand on the pulse of what's going on for the frontline. 

Dr. Sarah Hanafi is a fifth-year resident physician and chief resident in psychiatry at McGill University. She has been an engaged leader throughout her training with several professional associations and continues to serve on the public policy committee of the Canadian Psychiatric Association. Through these leadership roles locally and nationally, she hopes to contribute to healthier policies and more inclusive communities. 

And finally, Dr. Kevin Smith. Dr. Smith oversees Canada's largest academic health sciences center and is one of the country's top research hospitals as president-- and is one of the country's top research hospitals as he serves in the role of president and CEO of the University Health Network. 

During his career, he has overseen the investment of $7 billion in research infrastructure and has been a pioneer in advancing integrated care models spanning the continuum of health and social services. Welcome to the four of you, and thank you for joining us. 

To create a better health system, we need to know what we want the system to achieve. This is what we do know right now. Patients want access to care in a timely manner and high quality. Providers want to have time to provide quality care while working in environments where they can thrive. Governments want high-impact and quality results while managing costs. 

We're struggling to do any of these priorities well right now in most health systems across Canada. So our first question to our panel-- and I'll split this into three parts. Are these the right priorities? How do we triage them against each other? And how is this different from what we're doing right now? Maybe we can ask Sarah H to start us off as we make our way through the panelists. Sarah. 

SARAH HANAFI: Yes. So I think I first want to thank the CMA for organizing this event and also thank all the attendees for taking the time to join us this evening. And I think just to maybe preface my answers, I'll situate myself a little bit. I grew up in Alberta. I did my medical school there. 

Here, doing my residency in Quebec, I've had longitudinal experiences working in Nunavik and Cree territory. And being in Montreal, I've also had the experience of spending years on a waitlist for family physicians. So I name this background because I think these experiences have allowed me to compare two fairly different health systems. And it really informs some of the perspectives I might share tonight. 

But I think that the priorities can be thought of in terms of what do we need for patients, what do we need for providers, and these things are often complementary. So for patients, it's caring for them as old persons within their communities, respecting their dignity, and really prioritizing equity for all Canadians. 

I think that's something that has to be primordial. Our system is only as good as its ability to care for our most vulnerable and marginalized. And I think of many populations. As an example, those experiencing homelessness, Indigenous populations, we need to measure excellence by the care that those who are the most marginalized are receiving. 

When I think of providers, it really comes down to a work environment that's going to respect the humanity of providers and allow them to, I think, be their whole selves. And that translates to work conditions that respect the basic needs for agency, that allow for safety, whether psychological or physical in our institutions, and that preserve our moral fiber. 

And I think a concept that is very key right now is moral injury. This is something that's plaguing our healthcare providers. So when we're exposed to stressful situations and either we perpetuate them, can't prevent them, or witness events that really contradict our own values and beliefs, this can cause a lot of distress, increase the risk for poor mental health, and can contribute to this sense that providers are maybe being betrayed by leadership. 

And right now I'm studying for my real college exam. And I'm learning about all the evidence-based things or revising them. And unfortunately, many of them are actually things that my patients don't have access to like psychotherapy, like paying for certain meds, or a hospital bed that they're actually spending a week waiting on a stretcher in the ER. 

And so these are things that occur daily. And it's very hard when we have to reconcile our knowledge, our passion for caring with our feelings of helplessness and having to apologize on behalf of the system that we represent. 

When I think of the government, I hope that the government looks to prioritize meaningful engagement with stakeholders, especially those whose voices have been least present in current decision-making processes, and really that they see stakeholders as equal partners in the decision-making processes. So that's how I see priorities right now. 

ALIKA LAFONTAINE: Yeah. Thanks for that answer. Maybe we can go to Sara F next, and then we'll go to Marcia, and then Kevin to close us all. 

SARA FUNG: Yeah. I think that there are lots of different priorities that we talk about, and they don't have to be mutually exclusive. So we don't have to think of providing high-quality care as something that necessarily costs more. It's just really about providing timely care, about being able to do for patients what we are trained to do and what they're expecting. 

So in terms of the quality, I think that's the piece that often gets overlooked. So, yes, we do want to provide the care, but we need to provide it in a way that's meaningful for patients and also is meaningful for the healthcare providers. 

So in terms of nursing, so my approach is that when nurses feel like they're one person looking after 30 patients, there's no quality of care that's being delivered. And ultimately, that is going to impact the patient. And when I think of cost, the government's always talking about costs. 

It's really just not necessarily about throwing more money at something. It's about using resources wisely. So quality care doesn't necessarily have to equate more costs. But that's what we are led to believe. So in terms of what's most important, I think they're all equally important. 

But I also want to bring some attention to privatization of healthcare, which is something that's of great concern to me. I'm very proud of the fact that we do have universal healthcare. As a Canadian, I know this is something that other countries look to us because they want to get to where we are. 

And I'm concerned about the slippery slope that we're going down in terms of privatizing some healthcare services. And really, I just think that this really hurts the people that are the most vulnerable. So the unhoused, people of color, new immigrants, they are not able to access the care that they need. And we know that these individuals are going to need care the most. So that's of the main concern to me. 

And I think that really, the other thing I just wanted to bring up is just having a more integrated healthcare system. So these most vulnerable groups are very prone to falling through the cracks, so to speak. And if we can prioritize high-quality care, I think that's something that we really need to look at a bit more closely. 

ALIKA LAFONTAINE: Thanks for that. Marcia. 

MARCIA ANDERSON: Yeah. Thank you for having me. And I just want to build on or add to the comments that my colleagues, both named Sarah, have made already. I also wouldn't see those priorities as in competition. And I think it's a really important moment to reflect on the fact that there is a lot of work that has to happen all at the same time but doesn't all have to be done by the same people. 

And maybe that is one of the ways that it becomes not about being in competition because there are many leaders who are stepping forward and wanting to be part of the solution who recognize that our status quo is intolerable and is not serving anybody particularly well. 

And so we can capitalize on this opportunity to have many emerging, newer, junior, mid-career leaders stepping forward and working towards creating systems that meet their needs and the needs of the future workforce as well. 

I think those are all important priorities. But I've been in practice for 15 years now. Actually, it goes by pretty fast. And I think I would reflect that there was not a time in my training when I would have anticipated the state of the healthcare system today. 

A pandemic, you can kind of anticipate. We had SARS when I was a resident. That was a bit of a foreshadow. Had H1N1 shortly after I started practicing. And then the scale of COVID-19, of course, significantly beyond both. So those things are actually kind of predictable. We've dealt with them in the past. But the health workforce situation right now is not something that I really anticipated. 

And one additional thing I want to bring in here because I think it is, in my opinion, probably the highest priority and underlies each of those three priorities is re-establishing trust. There's been a significant amount of trust that's been broken by all parties in the system. 

Sarah H mentioned the moral injury. I do think about moral injury. And I had heard this term in a talk of institutional betrayal. And in COVID probably more than any other time-- although I'm a public health doc who works in harm reduction. So this is maybe a bit more common in my work. 

But feeling like we're working against our government partners at time instead of for a shared purpose or with a shared goal. And I'm not saying that that's absolutely true, and they might see that differently. But I know that I certainly felt that at time. And I know that I'm not alone in feeling like that at time. 

And often, the way that that gets transmitted to people who are working in hospitals or in wards or in public health are through medical leaders. And so that can result in that secondary level of lack of trust between the health workforce and health leaders or health administrators. 

And I also want to note that for patients or people accessing the system, providers often become the recipient of the mistrust. And in part, we've earned it in the past when we talk about systemic racism in healthcare, for example, or homophobia or transphobia in healthcare. 

We too have contributed to these problems and continue to uphold them. So we have earned some of that mistrust ourselves. But we also bear the weight of the mistrust of the Canadian public right now when it comes to how the healthcare system is serving them. 

And so when I think about the priorities and the three that were mentioned up front, I think about how important it is for us to first try to reestablish some trust that we are rowing in the same direction and that we actually have a shared goal of a well-publicly-funded, universally accessible healthcare system that seeks to deliver equitable high-quality care to everyone who accesses it. 

ALIKA LAFONTAINE: Thanks for that, Marcia. Kevin. 

KEVIN SMITH: Thanks very much. My colleagues have said much of what I'd reinforce although perhaps I'll dwell on a slightly different theme. And it's the theme of civility, respect, and dignity both for patients, providers, and funders. 

I have yet to meet a politician or policymaker who actually gets up every day to not try to improve the healthcare system just as we do. It is a very challenging world where we are increasingly faced with demand that outstrip supply, be that in work hours or available health human resources or back to the simple issues of what we're able to fund from the public purse. 

And we get to a point where we also recognize what my colleagues have talked about-- population health, health of those most equity-deserving groups that oftentimes as we consume more and more in the illness system, we are bleeding away from housing, food security, road safety, and many other health-producing endeavors as opposed to illness care. 

So I'm very concerned as I look at the current environment. And perhaps it's the world of Twitter and social media. But a time of civility where we actually debated ideas about what we wanted from our healthcare system in a personally respectful way seems more elusive than ever. 

And I think if we don't recommit to the civility, respect, and dignity that we show each other, be that working within the system, working with policymakers, working with patients and their advocates, then I fear that actually, the environment will become even less desirable for those young people who are thinking about it as a career. 

ALIKA LAFONTAINE: Thanks for that, Kevin. So lots in there, lots of different ideas that have come out. I'm going to lean in a little bit with the panelists just with one part of that question again. I'm a big believer that we get the systems that we design. And the more resources we pour into an area, the more of the output we get. 

I think that's one of the reasons why the CMA has repeatedly said you can't just continue to pour money into a broken system. So we've obviously arrived here. Like Marcia said, it's not really working for anyone. So what have we been focusing in on the past? Are we still focusing on that? And how do we need to shift where we focus? 

Just acknowledging that these are all important priorities. Maybe I can start off with Sara F. I've listened to The Gritty Nurse podcast. You guys have talked a bit about nursing struggles, particularly some of the legislation that's come in that was very challenging for nurses and their negotiating posture. Can you share with us a little bit of your thoughts around that? 

SARA FUNG: Yeah. I think it's been an extremely challenging time for nurses. And the public isn't always aware of the struggles that we face. So in terms of what was happening during the pandemic, we first dealt with being unable to access PPE. We dealt with legislation that capped our wages. 

And sometimes the public might think that it's about the money. But ultimately, it's about the respect that we deserve. So having working through the pandemic and being called healthcare heroes, but really, we're not seeing any tangible improvement in our working conditions. 

And with more and more nurses leaving the profession, it only serves to make the situation more challenging for those who choose to stay. So I think there's a huge issue with that. And I think just in general, the healthcare system seems to be centered around hospital-based care where I think we really need to go back to basics and put more resources and energy into primary care. 

So when you have patients that don't have a home base, they don't have a primary care provider. It makes it very challenging for them to seek the care that they need and be able to access the resources that they need to be able to achieve optimal healthcare status. So that's where nurses are at. 

And just the amount of violence that nurses have gone through is really, really a lot. So they've been subjected to verbal, physical abuse. We don't really have any supports when it comes to dealing with these challenging situations. I'm sure other healthcare professionals would agree. 

And so it's just made for a very challenging situation. And I think, unfortunately, the state of nursing the way it is, I don't know if we've quite hit the bottom yet. So there is still a long way to go and lots of improvements to be made. 

ALIKA LAFONTAINE: Yeah. Maybe we can go to you next, Marcia. I mean, you're in the midst of a medical school trying to be a part of stabilizing and fixing some of these problems. What's your thoughts? 

MARCIA ANDERSON: I want to pick up on that point because it is, I think, usually concerning that we're training future healthcare providers in today's environment because when I think about medical school curriculum-- and I'm sure this translates to other health professional curricula as well-- we don't just think about what's taught in the classroom or the stated objectives or what gets on the exam. 

It's everything in the environment that the medical student experiences. And in the journey of a medical learner, most of that is actually in the clinical learning environment right now. And when we think about, to pick up on Sara's point, where they spend most of the time, that too is mostly in the acute care system, mostly in urban centers, mostly in tertiary care centers, although not extensively, and there are some different models and more distributed education out there. 

And so I do find it particularly concerning from that medical education perspective of how much are today's medical students going to have to unlearn as we try to transform the system to where we want it to be right now but also to note that it would be much easier for a medical student to unlearn what we've taught them so far than it is for someone who's been in practice for 15, 20, or 30 years, and doesn't really want to change. 

I do think metrics are important. And I'm someone who loves data, I will say. And one of the examples that I often think about is where has the focus been at least locally here. There was a ton of focus on patient flow and how patients move through hospitals to decrease the times on those stretcher beds in the emergency room or in the hallways and all the different points along the way. 

But what we didn't often hear about was those quality measures along the way. Was there differences in how long Indigenous patients waited on stretchers compared to non-Indigenous patients? Were people getting their investigations at equitable times or their prescriptions according to guidelines and, again, disaggregated by important sociodemographic factors? 

And why do I mention this in tie to the medical education environment is because when we're not measuring that and focusing on that, we are still teaching medical students about what's important in healthcare that we provide. And healthcare is clearly more about-- it's about more than just that throughput too. 

And so I certainly would like to see that we have a data environment that is aligned with community-defined relevant metrics of quality so our learners are immersed in an environment where it's that team-based approach to providing quality care. 

And then similarly, I think lots of us realize we have to focus more on generalism and, like Sara said, on care outside of hospitals. And so ensuring that those same approaches are taken to those other environments and having learners spending more time in those environments also. 

ALIKA LAFONTAINE: Thanks for that, Marcia. We'll move to Kevin. 

KEVIN SMITH: Yeah. Thanks, Alika. I'm going to make just a slight friendly amendment to your opening statement that I think we have the system we incent oftentimes. And increasingly, I think if we are-- to Marcia's comments, if we're going to change the incentives, then we have the capacity to think about changing the outcomes. 

And I completely agree with you about data and meaningful data, particularly for groups that have historically not been well-served by the population. The first 10 years of my career was as a medical educator at McMaster, and they were wonderful days. 

One of the remarkable things I think I sadly learned was what we do remarkably well in undergraduate medical education, we often undo in postgraduate education where students and those of you who are closer to that part of your lifecycle than I can validate or disagree with that. 

But I think undergraduate medical education has done a-- or nursing education or other health professions does an extremely good job. And then people get dropped into the clinical environment where, unfortunately, the behaviors, rules, regulations, and historical practice patterns immediately get rewarded or disincented either economically or behaviorally. 

And I completely agree if we want to change how we behave and we want to change the outcomes of what our patients experience and create a truly high-quality work life, we really need to go back and think about what are the kind of reward systems, not only economic and academic centers that would include promotion and tenure, in other environments, including the opportunity for leadership roles and opportunities, but really revisiting do we look like the communities we serve, do we respond to the communities we serve, and are we evaluated by the communities we serve so that that data is not only available to us. 

I look at some of the things we're a bit frightened to do in healthcare. We're frightened often to tell our patients what they can expect on their care journey. But no one's a better quality assurance expert than the patient. If you actually tell them in your process of care, this is what you can expect if we drop the ball, if that doesn't occur, being fallible is a very important ingredient in being collegial. 

And back to Sara Fung's comments, I think, in nursing, where we've clearly dropped the ball dramatically, is a quality of nursing work life that allows nurses to exert some autonomy and voice into the kind of work they want to do, the tools that they need to be successful at it, and the kind of ratio to patients that will allow them to ply the craft and art that they've trained for so well. Thank you. 

ALIKA LAFONTAINE: Thanks, Kevin. Sarah H. 

SARAH HANAFI: Yeah. I would echo a lot of what has been said. Just to, I think, piggyback off of Kevin's point about what we maybe undo as people go through training, we have a lot of emphasis now on training about advocacy, equity, and justice. 

But unfortunately, actually, our institutional cultures do not value that. What do we need to do differently? I think currently, we value providers just as professionals or people who come in and maybe have some kind of clinical role. And we fail to value them as entire people or persons. 

And so once we enter our institutions, we're shown that when you do take on these roles, when you do try to speak truth to power, it's not valued. It's penalized. And this is actually a loss, I think, to our institutions because our providers come from diverse backgrounds hopefully and increasingly more representative of our communities and can be a vital connection to some of these communities, particularly those that are underserved or structurally marginalized. 

And so I think that's something that we need to do differently. And I think the other part that we absolutely need to do differently-- and it's been touched on a bit-- but we need to invest heavily in public health and preventive approaches. And I think more than ever, we need a Health in All Policies mindset. 

Health is not the acute care we get at a hospital. We're failing if that's where we're providing care. We need Health in All Policies. We should be actually mitigating things before it arrives to the point that someone is in an inpatient setting or in an ER setting getting care. So those are hopefully things that I think we can do differently going forward. 

ALIKA LAFONTAINE: Yeah. Thanks for all those comments. I don't know whether it's-- so, Marcia, you've been in practice for 15. I've been in practice for 12. Sara F, I know you've been practicing for a very long time as a nurse. Kevin, you've been around forever in different health systems. And, Sarah H, I mean, in fifth year, I mean, you're going into your ninth year of medical education. 

So we've all been in our different places for a long time. And I don't want this to come across as a good-old-days comment. But did the health system work in the past? What is it that shifted? 

Did it never work and only work for certain people and then changes in the world or changes within the profession or what patients needed shifted? Why do things feel broken right now? And were they ever fixed in the past? Maybe we'll start with Marcia. 

MARCIA ANDERSON: Yeah. And I think it's a really important point because for sure, our healthcare system has never worked well for everybody in this country. And this has been mentioned in the past, but we all know that absolutely, Indigenous peoples have been, by policy choices, underserved, whether we're talking about upstream determinants like adequate housing and education and employment opportunities or the actual healthcare that's provided in Indigenous communities, be they rural, remote, or urban. 

And often people make the mistake of assuming that because one is urban that they have better access to healthcare. And there's actually no data that shows that that is true. And that has to do with how racism and colonization impacts us in more boundaryless ways than the healthcare system serves us. 

And those same gaps definitely experienced by Black people, other people of color along income gradients, people who are inadequately or not housed at all, certainly by gender and gender diversity. And so there's lots of people who have actually never been served well by the healthcare system and have not had their full right to the highest attainable standard of health and everything that is included in that respect. 

And I think that's a really important point because, in the WHO's analysis or description of the right to the highest attainable standard of health, one of the key principles is that you have to center those who are furthest behind first. 

So we know that right now everyone in Canada will be impacted by the state of the health workforce. But same ocean, different boats. And so even now when the healthcare system is significantly under stress, who is being hurt the most by that or being least well-served will follow those same historic patterns. 

And if we were to center the needs of these populations first, the system would get stronger for everybody. And I can't remember who said it before, but delivering better-quality, more equitable care actually has the potential to save money, not necessarily cost more money. 

So what do I think is different? I think that for one thing-- I think there was a sense that some people were served better before. And so they were willing to ignore the people who were not being served well, whether that's in decision-making or allocation or whatever. 

And, again, our data systems promote this in its, quote-unquote, "colorblind ways." And so like the early days of COVID, now there's a sense that we're all in this together even though we're not being impacted the same. But there's a sense that we're all in this together. And so there's national attention on this. And so I think we can use that as an opportunity in terms of whom we center in our plans to respond. 

The other thing that I think has happened that's been really fascinating and a huge benefit of the increasing diversity of the workforce is the increasing number of studies around how things like racism and sexual harassment impact the workforce too. 

And I think we all know if we don't treat our colleagues with respect and our colleagues are experiencing racial microaggressions from us that patients are too. That's how power relationships operate. 

So we have an opportunity to intervene and measure how racism is impacting our health workforce as an indicator that it will then improve for patients as well. So I think we have new evidence and data as one of the benefits of how the health workforce has changed that gives us an opportunity to respond in a different way. 

ALIKA LAFONTAINE: Yeah. Thanks for that, Marcia. Any of the other panelists want to jump in? 

KEVIN SMITH: I'd like to maybe speak on the wildly positive side of this although Dr. Lafontaine's comments about my being around forever has made me feel absolutely ancient. The other reality, look at our discussion tonight. Most of the topics we talked about would never have been touched on historically. 

Most of the panels who would have been speaking this evening would not look like the panels that are speaking tonight. Most of the topics we're talking about wouldn't have been touched on in a CMA meeting. So while I think all of our cultural structures are very different than they were 10, 15, 20, 25 years ago, that people are much more vocal, are very clear about their dissatisfaction, I think that can sometimes translate into the system is worse. 

I look at where I work and the patients that we look after. And UHN, while it, of course, operates hospitals, it also operates home care, long-term care, hospice care, you name it. Now we're opening Canada's first social housing environment in the spring with prescribable housing. Very excited about that. That would not have even been on the agenda of our board and our clinicians 15 years ago. 

So I absolutely understand that people perhaps feel more dejected than ever. But when I look at the reality of the kind of issues that we're facing, the way in that we're openly talking about the challenges of the system and those who are most poorly served, the issues being brought forward around quality of work life, the work life of learners, I'm actually very encouraged. 

It's frustrating. We see the problems more acutely than ever before. But they're in the light, and I see that as entirely positive. I don't think we have easy solutions. In the past, I think we wouldn't have actually looked for those solutions or have been brave enough to admit that they're problems. So I'm going to be wildly optimistic. The good old days weren't so good. They were just old. 

ALIKA LAFONTAINE: Yeah. Thanks for that, Kevin. Sarah H. 

SARAH HANAFI: Yeah. If I had to think about what might be different-- and I only have nine years here to compare at this level-- but I think the one thing that I think has been different or perhaps was better previously was really that access to primary care and primary care that was longitudinal and relationship-based. 

My sense now is that, well, there might be changes in the metrics of access whoever is attached to primary care provider perhaps that the actual nature of that care is more rushed because of the increasing pressures for those working in the primary care setting that it might involve less preventive care and might actually have less of that context of a patient's social setting, their family setting, something that I think was perhaps more present in the past when I think there was less pressure on our primary care setting. So that would be something that I'd see as different for sure. 


SARA FUNG: This is a really great discussion. I think about when I started nursing, which was 15 years ago. And I think the one thing that has really come up in the last 10 years, I would say, is the rise of social media. So all of the advocacy work I do, the podcasting, none of that would be possible, I don't think, without social media. 

And just knowing that I have a voice and that I can use it is something that's very empowering to me because as a nurse, I was never taught to advocate for anyone except my patients. And maybe it's the same in other healthcare disciplines as well. 

I was taught to care for patients, advocate for patients only. I didn't realize I could advocate for myself or my profession or even the healthcare system in general. So that's a real shift, I think, that I've gone through. 

And just in the past few years, COVID has really just pulled back the veil on underlying issues that have been present for years, if not decades. So things like short staffing have been an issue since the beginning of time in my profession. 

It's just that now people are willing to give us a seat at the table and hear what we have to say. And it's up to us to rise to the occasion and be able to talk to everybody about what the issues are so it's just not contained within our industry, that other people know about it and can help us when we need it. 

ALIKA LAFONTAINE: Thanks for that. Go back to Kevin. 

KEVIN SMITH: I just should have mentioned this one, but I look at the population of patients that we serve in hospitals as an example. They would not have been alive 15 years ago. We are looking after people with comorbidities, complexities, and illnesses. 

Cancer has become a disease of chronicity. So very, very different population of patients served as well. That's wonderful for patients so long as that's their choice. But it's also very challenging for providers as we continue to struggle and look at how do we continue to meet the needs and address end-of-life care in an increasingly death-phobic world. 

ALIKA LAFONTAINE: Thanks for that. Marcia. 

MARCIA ANDERSON: Yeah. I just wanted to note that both can be true. We can be making progress in some ways and also not seeing the outcomes or be making progress fast enough. And I often think about one of the statements from Stamped from the Beginning, which is Ibram X. Kendi's book on the history of racism in the United States, where he talks about there being a dual and dueling forces of racism and anti-racism. 

And so progress isn't linear. And when I think about what are our actual indicators showing, the most recent First Nations Health Status Report in Manitoba showed everyone's life expectancy got better. But for First Nations people, it was so much less that the gaps in health actually widened. 

Every gap in health actually widened for First Nations people compared to other people in Manitoba. We have these massive gaps. And so just to keep in mind that even where there's progress, the progress isn't happening at the same rate. And so that also is not equitable or just. And so, yeah, I agree with Kevin's statements. 

And I appreciate the folks who are represented on the panel today and on the different perspectives. But, yeah, I think where we've seen maybe some process progress, we've not yet seen outcome progress. That would be, I don't think, showable by data in an equitable way. 

ALIKA LAFONTAINE: Thanks for that, Marcia. So just a reminder to participants, we are keeping an eye on the questions that are being submitted. There's about 21 so far. We will start with the questions that have the most upvotes. 

So if you do have a question that you'd like asked or if you'd like to have your own question asked, then I encourage you to get those upvotes in. Feel free to ask more than one question as well. I really encourage those to come in. 

We're going to shift towards those questions in about six or seven minutes. But I'm going to shift gears. And we've talked a lot about defining the problem, which, I think, is where a lot of solutions lie, but maybe shift into talking a bit about what are some solutions that can actually be applied. 

So a question to the panel. Maybe I can start with Kevin this time. What do you think is needed now in the short term to stabilize the workforce? And that can include everything from training to retaining and attracting health providers that just seem very scarce right now. 

KEVIN SMITH: Well, as I learned from a number of my nursing colleagues first talk about retention before about attraction. You have a skilled workforce. How do you keep them there? I think, unquestionably, we have to listen loudly to what's making the quality of work life, particularly of nurses but across the disciplines and across those who support the disciplines, better than it has been of late. 

I think the other piece of this that continues to plague us is a lack of implementation of full scope of practice for all professions. And, again, looking at where scope of practice can actually benefit quality of work life as well as quality of care and caring. 

Similarly, I think when we look at other systems in the world and look at extenders, we know that we cannot educate or immigrate our way out of the shortage of healthcare providers-- physicians, nurses, and others. We unquestionably will have to think about different models of care, different extenders of care, the application of technology. 

You got digital health and distance support monitoring systems that actually support patients and providers. And wrapping care increasingly not only around the patient as we've always, I think, tried to do but wrapping support around the providers. 

Particularly, we've talked about primary care tonight a great deal. Why is primary care not as attractive as a comprehensive discipline for lifelong care, relationship-based care management? And obviously, we need to think about how do we wrap the services of the entire system around the primary care providers as well as the patient. Those would be a few thoughts for me. 

ALIKA LAFONTAINE: Yeah. Thanks for that, Kevin. Maybe we can go to Sarah H next. 

SARAH HANAFI: Yeah. I think I'll preface my answer by saying that the things that I'll mention are things that, I think, can be done in the short term if we have the necessary political and administrative well. We saw from the pandemic that when there's a crisis, we're able to move mountains to transform our system through virtual care whereas before, it faced dragging feet. 

And I think we really have to look at the current crisis as equally urgent in order to find the courage to move towards real action. So I think the first-- and this is really primordial, but we need healthy and humane training and work conditions that really respects the dignity of our providers. 

I'm here in Quebec, and my nursing colleagues for years now have faced forced overtime. And we just can't expect providers to remain in a system that doesn't show respect for their need for modicum of agency. So I think that's number one. 

A second piece that I think can be a quick win or quickly at least actionable is remuneration that does reflect the value of different providers. I'll speak from the perspective of medicine, but we continue to lack and pay equity for family physicians that reflects their foundational role, the increasing care complexity that they face, and the mounting administrative load. 

I do think we need the material resources to do our work. It might be surprising to some jurisdictions. But in some places in Canada, that is still a basic challenge that we face in our day-to-day work, ensuring you have reliable access to an office, a computer, drinking water. These are things that still lack in some of our institutions. 

And I think we have to go beyond this narrative of exceptionalism within healthcare that we shouldn't be complaining or asking for our needs because these are things that do contribute day to day to some of our stressors and workplace dissatisfaction and inefficiency. 

Digital tools, I think, really have to be invested in and prioritized. They can do wonders to improve our workflow and reduce our administrative loads. Right now, for a single patient encounter, I have to open five to six different clinical applications just to complete one appointment. 

I trained in Alberta. And that care is, I think, a fabulous model and one that is certainly, I think, a great example for us to look at across the country. But this is something that we have the tools to do it. We should be doing it now. And we've waited too long to put some of these tools into place. 

And I think it tags well into this concept of making evidence-based decisions because, through digital tools, we can actually get some of these quality metrics quickly. We can automate some of this and look at really key care indicators. 

And then finally, I think, in the short term, we really have to change the language and culture between governments and providers. We have to speak and act in ways where governments are demonstrating that they value providers, that we're seen as equal partners rather than sometimes vilifying us or actually using us to score political points. And I think that change has to come now. 

ALIKA LAFONTAINE: Thanks for that. Maybe we'll go to Marcia and then Sara F, and then we'll transition into audience questions. Marcia. 

MARCIA ANDERSON: Sure. I think I'm going to be really brief on this one. I'm very interested in Sara F's thoughts as well. I think one of the immediate things I would prioritize would be to look at our funding models in particular for primary care and really to see all the ways we might be able to move away from fee-for-service practice and into team-based funding to enhance primary care access availability and quality. And so I just want to throw that one out there, and then I'll throw it over to Sara. 

SARA FUNG: Well, I think since this one was directed to me, I'll address that first. So for nurse practitioners, especially those in primary care, they don't work on a fee-for-service model. It's a salary. It's an hourly rate. So I think that the way that nurse practitioners deliver care in the primary care setting is very different than how family physicians provide that care. 

And I've seen the difference firsthand. I've had a nurse practitioner. I've had a family doctor. I think there are benefits to each. But certainly, in terms of supporting those that need the most care and continuity of care, it is helpful to not have fee-for-service. 

I just want to go back to some of the other points in terms of what I think would help in the short term from a nursing perspective. If you ask any nurse, they're really looking for safe patient ratios. They just want to be able to deliver the care that they know they need to deliver in the way that they can deliver it. 

And if there could even be a way to have legislation to enforce that, I think that would be hugely impactful in not only retaining but bringing back the nurses that have left the bedside, that have left the profession entirely. It would be really important to prioritize mental health supports. 

So there's still so much stigma in healthcare, especially amongst healthcare providers for having any mental health struggles. And sometimes it's seen as not being able to practice safely if you have a mental health issue. I think also, like I said before, more support for abuse encountered on the job, whether that be verbal or physical abuse. That continues to happen time and time again. 

And there's just no staffing. There's short staffing when it comes to hospital security as well. So I think that's one other thing. And just lastly, I wanted to mention from a nursing perspective, more flexible scheduling, more support for working parents. 

I'm not sure if anyone has ever found daycare that can support shift work, but that's certainly a challenge for a lot of parents in being able to stay in the workforce. So those are some of the issues that I've seen. 

ALIKA LAFONTAINE: Thanks for that, Sara. So we're now going to transition into questions from the audience. We have 31 so far. I'm sure there will be a lot more that are coming through. Just for the panelists, I will assign the question each of you just to make sure that we rotate around and everyone gets a chance to comment on different things. 

I'm hoping I match them well. But if you don't feel that way, I'll apologize in advance. I really encourage folks within the audience to continue to submit those questions. We'll try and get through as much as possible. 

So I'll start off with a question from Joel Bradley. And I will direct this towards Marcia if that's all right. Do we know how many physicians we need per capita, factoring in aging? I think we don't have enough currently. I don't see we have enough in the pipeline. I really think it is unethical to recruit them from other countries. We need to decrease the demand for healthcare. 

Lots of questions packed into there. Maybe we'll start with Marcia. And then if other folks want to jump in, if you can just raise your hands. Otherwise, I'll move to the next question. 

MARCIA ANDERSON: Yeah. The quick answer is, no, we don't actually know the answer to that. And we don't know it for any health professional really, not just for physicians. There are some who would argue that what we have is primarily a distribution problem and not a numbers problem. 

I think more likely, at this phase, it's both. We don't have sufficient physicians or health professionals. And we don't have a distribution that matches where the population lives and the healthcare that they need. 

We are seeing many provinces make announcements about increasing the number of seats of health professions. In Manitoba, for example, we've had increased seats in respiratory therapy, nursing, physician assistant program, and in both the medical student class and more recently, also the PGME spots. 

I think we have to understand that increasing seats produces more health professionals but not in the immediate short term depending on the program. I think the quickest turnaround might be about two years depending on the specific program and for a specialist physician. 

Like Sarah's told us, she's writing her Royal College exams now after nine years. So the time lag can be significant from when we increase seats, which is why we have to try to anticipate demand a bit better. 

I will also note we can't just factor in aging because age is not the sole determinant of good or poor health, as we know. We also have to look at the other demographics of the population and the policy choices that distribute income, housing, or those other factors that result in population health gaps. 

So we do have to look at some of those different factors as well when we're trying to estimate what the need for different types of health professionals are. The last point there around it being unethical to recruit from other countries, there are international statements on this to discourage recruitment from countries that are also experiencing health workforce shortages, which is many. 

And so there are some different options. We do have some Canadians who have trained abroad or moved abroad. So that might be reasonable. We can focus on health professionals who are already in the country and have had very difficult pathways to licensure. 

So improving the ease for entering the workforce for folks who are already here would be a couple of things that we could look at that wouldn't necessarily displace our problems with the health workforce to another country. 

ALIKA LAFONTAINE: Excellent, Marcia. Sarah H. 

SARAH HANAFI: Yeah. I just wanted to add that I think from a trainee's perspective, this is also vital information because trainees, whether it's medical students, residents, are having to make decisions about career planning without actually knowing what are their real populational needs, what is the workforce going to look like, where am I going to have job prospects when unfortunately, it does lead to a situation where there is a mismatch between what people plan for in their training and then what kinds of opportunities they have access to. 

And so I think this is another part of how do we improve this process for trainees and also ensure that there is a match that will produce better satisfaction in the workplace. 

ALIKA LAFONTAINE: Yeah. Thanks for that. I think I can't ask Kevin for his input since he's taken off. But he'll be back soon, I'm sure. We'll move on to the next question from Mark Bilodeau. Why not make a better and more extensive use of adjunct healthcare providers and physician extenders, such as nurse practitioners and physician assistants? Maybe we could start with Sara F. 

SARA FUNG: I think that's a great idea. So using nurse practitioners to their full scope is absolutely something that should be explored. There are a few nurse-practitioner-led clinics. So primary care centers that are led just by nurse practitioners. 

And traditionally, there's been funding for them in remote settings. I think that there is a huge opportunity here to explore more nurse-practitioner-led clinics in urban settings. And this would really offset some of the demand on family physicians. So absolutely, I think this is something that should be explored. 

And we also need to let nurses know that this is a viable career option. So if we just look south of the border, there are so many more nurse practitioners per capita in the US than there are in Canada because we just don't use nurse practitioners to their full scope. 

So I think that's something we should be looking at. And even for the public to know what nurse practitioners do. So many people aren't even aware that you can receive your primary care needs from a nurse practitioner. So it's something that definitely should be explored a bit more. And I think there should be more of a push towards this. 

ALIKA LAFONTAINE: Thanks for that, Sara. Any comments from any of the other panelists? OK. We'll move on. Oh, sorry, go ahead. 

MARCIA ANDERSON: Sorry. I was slow to raise my hand there. I was just going to note that that has to be tied into what we fund. I think we have often had a situation in Canada where we have trained more NPs and PAs than we can hire because they did not have salaried positions to move into. 

So, again, as we're starting to see increasing enrollment in spots, we also have to make sure there are well-funded suitable positions for people to move into as part of our funding and care models. 

ALIKA LAFONTAINE: Yeah, that's a great point. Thanks for that, Marcia. We'll move on to the next question from Michelle Desilets. Many healthcare workers lament the amount of time and energy they spend on items they don't consider to be of value-- sick notes, insurance forms, excessive hospital documentation, et cetera. 

Has the CMA or any other influential body considered pushing for legislation around this, creating laws preventing employers from requiring frivolous sick notes, regulating how insurance plans are administered, trimming down the excessive duplicate charting required of nurses to allow more patient care? 

So I'll just answer real quick. Reducing administrative load is one of the priorities of the CMA. We have quite a few things that are going on in this area. And we have been lobbying with stakeholders to help move this forward. 

I'll also note that somebody has to do this work. And so it may not be direct clinical care, but someone does have to fill out insurance forms. Someone does have to order toilet paper. Someone has to keep the consumables and rest the system going. Maybe I can direct us towards Kevin. I'm sure this is something that you might be confronted with. 

KEVIN SMITH: Yeah, it's a very regular discussion, especially when you put in new technology systems. And at the end of the day, we're all looking at how do we make life simpler. Remember when we started with the paperless office? My office feels like it's been more paper than it's ever been in my history. And technology hasn't been the be-all and end-all that we hoped. 

So, again, I think part of it goes back to what's the minimum requirement. And as you've pointed out, there are some documentation issues that need to be done. But I also wonder whether we can't go back with funders and providers and talk about areas where we actually can just put a plug-in. 

So I'll just give you an example. If you know that most of your patients who are in a post-acute surgical world require one or two home care visits, why would we spend more time than the visit entails and documentation? 

If that same patient perhaps requires intensive home care therapy because of a complication or a wound injury or an infection, by all means, think about better documentation. But I would vote for exemption documentation or exception documentation. 

If things are going well, we can do some very quick checkoffs. If things aren't going well, then we all want more detailed information there. So the multidisciplinary care team can play a role in that. Unfortunately, we followed a bit of the medical legal model of the United States around the world unfortunately where we probably over-worry about documentation as opposed to comprehensive clinical practice. 

ALIKA LAFONTAINE: Thanks for that. Any comments from the other panel members? All right. 

SARA FUNG: I don't think there's a-- sorry. I don't think there's a short solution to this because I used to sit on several EMR documentation committees. And part of the problem with a lot of these systems is that they were not developed by frontline clinicians. 

So when we talk about multiple documentation of the same information, it's almost as though the system was developed, and it was set in stone, and then we went back and asked for input from frontline providers. And at that point, it is very expensive, if not very difficult, to change, I guess, the layout of certain systems. 

So I don't know if there's an easy solution. I just know from a patient perspective, it's very difficult when there isn't one-- there's not one chart and there's so much photocopying and CDs going around. It's just very fragmented. 

ALIKA LAFONTAINE: Thanks for that. So we'll maybe combine the next two comments from Johnny and Elkie because they both seem to be touching on a similar theme. So I'll read both. So from Johnny, we continue to make short-term investments in curing disease. The paradigm has to shift. We need to invest in health, the long-term solution. 

Would distancing government from the health system by one or two arms lengths help us to make the right decisions? And should we talk about the health system rather than the healthcare system? 

And then from Elkie, we need to change the way we practice altogether. Important changes are taking place in medical education pivoting towards a wellness model. We need to apply this wellness model to all of society by prioritizing wellness. So maybe I can open up that question to Sarah H. 

SARAH HANAFI: Yeah. I appreciate the question. I think it's a big question in that right now even just to get our governments to collaborate at provincial and federal levels that we're entrenched in this concept of traditional roles. 

So even when it comes to making, I think, an incremental change to how we are engaged on this issue, it's difficult to imagine that governments would allow for us to completely, I think, remove their involvement in this process is hard. I think it's a big stretch. 

Do I think it would provide greater stability? Certainly. Once again, I'm speaking from Quebec. Quebec were quick to institute reforms with each successive government sometimes that completely overhaul things in the system before we maybe had the opportunity to actually understand what the impacts would be. 

And the unfortunate part of that is that people end up having change fatigue. And so I think it would be beneficial if we had some kind of structure that would allow for a longer-term planning and governance model. 

I don't know what that would look like or what would help us get there as a country. I think there are structural challenges that we face in that regard. But certainly, I think it would allow us to really work towards the long-term vision that we need to be striving for right now. 

To the second part about a wellness model, I think that comes back once again to what are we incentivizing. So if we just focus on a system where health means you see a doctor, maybe you see a nurse, and you see them often in acute care settings, well, then we're not working towards a wellness model. 

I'll draw quickly on an example here locally. But back in the '70s, Quebec instituted what was called CLSCs. It's a long French acronym that I'll spare you. But the principle there was that in their community, patients or just citizens could come to a center. They would be received by someone to just understand what are they coming for, what do they need. 

And based on that conversation, which is like a triage conversation, they could maybe meet a social worker, maybe meet a nutritionist. Maybe they'll see a psychotherapist. Maybe a family physician or a nurse. And so this, I think, demedicalizes people's problems but also helps do more of that preventive and wellness work that we need to be focusing on. 

And it's community-based. So if you are caring for people in their own community and you have an understanding of the school system and what kinds of challenges they face or which community-based organizations offer different kinds of services or what's the socioeconomic situation, then you're better able to help people. 

And I've had the opportunity to work as a consultant in these CLSCs. And when these centers are well-resourced and being implemented in their full scope, they do tremendous work. And we're able to actually prevent a lot of people from having to meet, in my case, a psychiatrist, in some cases, a family physician or other specialists. So I think certainly, we have to work towards a wellness model. But I think it means that we actually have to invest and value things other than just medical care. 

ALIKA LAFONTAINE: Thanks for that. We'll go to Kevin, and then we'll go to Marcia. 

KEVIN SMITH: Echoing Sarah's comments, I think the other piece of this is wellness models are not always medical models. So obviously, we really need to think about who are people who can bring wellness paradigms to the table, how will patient-inspired groups, patient-lived experience inform that. 

We know that patients who are engaged in the process of care often in a group setting end up a much more highly satisfied patient or a client, whether that's in wellness or in chronic disease management. 

To John's question, I also think that it isn't or. I think when people are ill, they actually do want rapid access to medical intervention. And they want good access to preventive care, public health, and better health maintenance. So I don't actually see very many people actually saying, I want to trade one off for the other. I actually want to look at the continuum. 

The last piece of this one, I think, is when I look at places where government is further removed, sadly, the example probably most common to us is the United States. I think it becomes a more challenging environment to actually have a dialogue around more marginalized populations and equity-deserving groups. 

Without that political lens, without that political accountability, when it becomes purely a third-party insurance discussion, in my view, we lose a great deal. When we can bring that back to a population-based discussion in which we ask and hold governments to account and ourselves to account, then in my experience, we've had a more successful, albeit at times frustrating, experience. 

The other piece, I think we can't always put the blame on government. Governments respond to what Canadians want. And I always leave debates with a bit of disappointment when I think about leaders debates provincially or federally how little despite the fact that we spend about 30% to 40% or more of provincial budgets on healthcare, virtually, every political debate is almost absent to discussion about the healthcare system citizens expect and providers wish to offer. 

ALIKA LAFONTAINE: Thanks for that, Kevin. Marcia. 

MARCIA ANDERSON: Yeah. just to reinforce a comment Sarah made earlier around a Health in All Policies approach, I think that underlies shifting to more of a wellness focus, most of that going back to Senator Keon's report. 

25% of the population's health is determined by the healthcare system and 50% by access to income, food, housing, education, employment, and things like that. Improving the health of the population and closing gaps is another really key factor in sustaining our publicly funded healthcare system. 

And so I think for sure, obviously, there is always a competing tension between the funding the healthcare system itself takes and where to reallocate resources to decrease the percentage of the provincial budget that the healthcare system takes. 

So it's not a quick or an easy answer, but absolutely, we need to do that in order to improve the health of the population and have a more sustainable healthcare system. One of the professors I had when I did my MPH at Hopkins in the mid-2000s was Vincente Navarro. 

And what I loved about his work was his focus on political economy and health. And so there is a whole area of research and study around what type of policy decisions result in healthier populations and looking at the amount of years a country has, left-leaning or right-leaning governments. We'll leave further discussion of what that means to a different time. 

But that correlates with the population's health and their health outcomes. And so I think for sure there's a role for patient voice in the healthcare system. And there's also a role for all of us to participate in democracy. 

So we can debate how far removed healthcare organizations should be from government, but we also can focus on the governments that get elected and the types of decisions that they make and the accountability and transparency they have around the healthcare system funding, investments, and the outcomes that it creates to the population. 

And I think it's incredibly important that all health professionals feel safe and actually are safe in sharing their professional and evidence-based decisions around important policy choices when it comes to election cycles. 

ALIKA LAFONTAINE: Thanks for that, Marcia. Sara F. 

SARA FUNG: Yeah. I just wanted to go back to one comment that Kevin made earlier, which was that the government does what the public wants. So I think the government does need to do a better job at seeking out these opinions because a lot of times, the heaviest users of healthcare are those patients that don't have a voice and they're marginalized. 

So listening to the person that is the loudest, the squeaky wheel doesn't often yield the best information. So I think that's really important. Another point I wanted to touch on is that, yes, we are very hospital-centric when it comes to our healthcare system. So putting more funding and resources into things like home care. 

So I have worked in home care in the past. And I can tell you this is where patients want to receive their care. This is where they want to be. So not only would it be more cost-effective, it would result in a better patient experience. And this goes for many different types of healthcare as well. So if we can be more creative with how we look at it. 

I think the other thing to note is that jobs in hospitals do pay more at the end of the day. So if we can incentivize people to look for other healthcare settings that are of value, I think that would be a great idea as well. 

ALIKA LAFONTAINE: Yeah. Go ahead, Kevin. I think you're on mute. 

KEVIN SMITH: I want to-- sorry about that. I want to totally agree with Sara on the home care piece that when we talk to patients consistently, it is the points of transition and care where they and their providers have the greatest frustration. And every patient we talk to constantly says, my greatest desire is to go home with functionality. 

The challenge that I think we also have to overcome are these continued silos that we really do need to turn the care experience on its side from the points of transition between pre-primary care to primary care, primary care to specialty care, specialty care to hospital-based admission, hospital to either home or long-term care or complex care or whatever. 

Every time patients move and we talk to them about that, they tell us their greatest frustration are those transition points where, where they depart gives them one piece of advice or information about what's going to happen next. 

Then if they're received by the next piece of a system, they're often told, well, that's not what's going to happen at all. And we constantly undermine the confidence that our patients have in a system because we actually aren't a system. We continue to be a number of separately funded silos. 

ALIKA LAFONTAINE: Thanks for that. So we are running a bit short of time. We'll keep things going for the next few minutes. So we'll probably get through, I hope, a couple more questions, maybe three. The next one is from Don Wilson. I'm just going to modify this just a little bit just to make it a bit more team-member-inclusive. 

The disappearance of journalism has resulted in a lot of diminished access to healthcare, especially in rural areas. The fragmentation of healthcare providers into ever more specialized silos is not serving a large proportion of the Canadian population. 

I would love to see more support for rural medicine as an actual specialty area along with the necessary supports for them to train and practice and hopefully reduce reliance on transfers to urban centers. Is this something that CMA membership would advocate for? Maybe we can go to Sara F to answer this first. 

SARA FUNG: Yeah. I think that-- I mean, in healthcare in Canada, we say that healthcare should be accessible and equitable. But the truth is if you live in a rural setting, you are disadvantaged. In my experience, I've looked after patients that have come from the far north. 

And because I used to work in labor and delivery, they often would have to leave their communities weeks before their due date. And they'd be completely isolated having to give birth in a large urban center because that was all that was available to them. 

So if we can somehow bring healthcare to the patients, I think that would be of value, but also putting incentives in place for healthcare workers to want to go to these areas. I think it's a difficult issue. But certainly, we need to look at more creative solutions. It can't just be that if you live in a remote setting that you're not receiving the care that you deserve. 

ALIKA LAFONTAINE: Thanks for that. Sarah H. 

SARAH HANAFI: Yeah. I think this is a really important question and one that actually-- it starts in the training environments. So when trainees are being educated in settings where rural primary care providers are being valued, that imprints on trainees early on. 

I did my med school at the University of Alberta. And we actually had an opportunity if we wanted to where we could do a full year of our clerkship, which is our first pure clinical year. We could do a full longitudinal year in a rural family setting. 

And I had many classmates who chose to do that and ended up applying to rural family medicine. And in my year, my graduating year, the rural family medicine spots were actually more competitive than urban family medicine. So I think that's a model that was successful. 

It also means when we look at admissions, we take people who are representative of these communities. And so when we have admission spots that are dedicated to people who are from these settings, there's a greater likelihood that they will end up wanting to return and serve these communities. 

Even when it comes to postgraduate education, in my own program, we have an opportunity for those who want to train longitudinally in underserved Indigenous communities. So in our case, it's Nunavik and Cree territory. 

And for many of us who have that opportunity, some decide to work full-time in those settings, or they decide to do some part-time work serving those communities, or it changes the way that they serve these patients who end up being transferred down south. So I think it really does-- it has to start in training. It has to start with who we bring into our training programs and then where we're training our students. 

ALIKA LAFONTAINE: Thanks for that. Marcia. 

MARCIA ANDERSON: Yeah. I just want to add a few additional thoughts to that. First of all, I completely agree with the comment from Don and the observation and would strongly support more generalism, more consideration of rural and remote health practice as a specialized field with adequate supports. 

In Ongomiizwin Health Services, we've certainly seen a major shift away from health professionals who stay in the community full-time to physicians who practice part-time in urban areas and part-time in more remote areas. We see this as highly beneficial in terms of the diversity of the practice they get and some of the additional experiences. 

So, for example, if they're doing hospitalist shifts in an urban ICU, for example, and how that strengthens the emergency care available, I'll note that there are a few things that make that more possible. It requires some infrastructure support like the availability of accommodations, housing, vehicles, Wi-Fi so people can stay connected to family, and to entertainment in this setting. 

It requires strong networks of communication so that even with physicians or health professionals who are not in a full-time practice, it still feels continuous to the person or the people receiving care because there's enough regularity in how often that they come. 

I think there can be enhanced virtual supports to generalists who are practicing in rural and remote areas as well. But I think what we have seen locally here in Ongomiizwin Health Services is that desire for more flexibility in what that practice can look like. 

And the other thing that I'll note is our docs, in general, aren't responsible for finding their own locums when they need to take time off. We do that centrally. And I know that's a huge burden to rural health professionals if they are responsible for finding their own coverage not just for vacations but for parental leave or for an ailing parent or educational leave or things like that. 

So looking at how, as networks of regional health authorities or service delivery organizations or academic institutions, we can help support that and take some of the weight off, I think, will help us not just recruit but retain people over the longer term. 

ALIKA LAFONTAINE: Thanks, Marcia. Kevin. 

KEVIN SMITH: There is an amazing international literature on how to attract and retain people in rural health. And unfortunately, we are often not mindful of going back to the literature on this. I want to urge Dr. Lafontaine to give the CMA even more work. 

This may be an area where actually pulling that comprehensive literature together and talking about what makes it attractive. We know that up until people's children are about the age of five or six, it can be a very attractive environment. And then do they have access to the kinds of services and access to initiatives that their kids want to participate in? As you mentioned earlier, do they have technology access? 

I personally believe that digital health offers us a remarkably different opportunity than we've ever had in the past as we think about rural and remote health. And then last but certainly not least, the good work that's being done around medical education, health professional education in those settings to actually demonstrate what kind of quality of life rural medicine can offer, which obviously can be remarkable. 

ALIKA LAFONTAINE: Thanks for that, Kevin. Sarah H. 

SARAH HANAFI: Yeah. Very quickly, I just wanted to add that I think the other piece of this is it comes down once again to equity. And so if we're actually-- if we're actually looking to improve the quality of life for people living in these settings, then they also become more attractive places for healthcare providers to settle and remain for their own lives and families. 

So we think of accommodations, access to Wi-Fi. These are things that are often woefully lacking in Indigenous communities. And so I think these things go hand in hand. And if we advocate for one, then it might actually be feasible to retain healthcare providers in those settings. 

ALIKA LAFONTAINE: So we'll be able to fit in one longer question and then probably one quick question. We do have a hard stop at 8:30 Eastern Time. But the last question from viewers is going to be from Adnan Khan. 

Are there any considerations to utilize current international medical graduates, physicians, and surgeons who are already integrated into Canadian healthcare and serving as clinical assistants? And maybe I'll ask Kevin this question. 

KEVIN SMITH: Let me start actually with nursing, if I might, because we've just actually hired 40 internationally educated nurses where I work after going through a program that I'm working with the College of Nurses and others. 

So I think the answer, obviously, is absolutely yes. The challenge of IMGs, particularly in terms of licensure and evaluation and the amount of time and availability of spots, is perhaps more challenging than ever. 

My own personal view is that we need to think about how can large academic health science centers, faculties of medicine and nursing and colleges actually work with clinical environments to say we're going to take a significant number of IMGs in nursing and medicine and beyond. 

We're going to put them in a clinical setting. And we're jointly going to assess that their clinical skills, knowledge, ability is up to the standard of care that we expect and deserve. I see many colleges being quite anxious and quite nervous about licensure without traditional documentation. 

I think once we think about graduated licensure or a licensure that operates in an environment where there is mentorship and buddying, we could dramatically expand the number of IMGs and IENs that Canada could attract and retain. 

Just at the moment, in our own shortage of providers where I work, we've looked around the world. There are significant numbers of nurses, for example, in refugee camps. That just seems unconscionable to so many of us. What a wonderful opportunity to bring skilled colleagues to Canada and remove them from often war zones and worse. 

So I think this is a very important direction. But, again, it does require the alignment of Immigration Canada, the colleges by province, another opportunity for a shoutout to national licensure, which would make a huge difference on this one as well. But the solutions are there if we want to attract them. 

ALIKA LAFONTAINE: Thanks for that, Kevin. We'll let Sara F have the final word on this, and then we'll move to the last question of tonight. 

SARA FUNG: Yeah. It's really great to hear that they've been able to streamline the process for internationally educated nurses because I've been working with some who have spent years actually trying to get licensed in Ontario, and it's a real struggle. 

I always say that we have the most educated PSW workforce anywhere. I've worked with PSWs that actually have medical degrees from back home. And they can't practice as anything except PSWs. So it's a huge untapped resource. And I think it's a great thing, I suppose, that the pandemic has paved the way for this accelerated process. So it's really great. I think there's obviously more that can be done, but it's a great start so far. 

ALIKA LAFONTAINE: Thank you, Sara F. So final question of tonight before we wrap things up. This will just be a quick answer. Sorry, it's purposely structured in a way that you probably won't be able to give a satisfactory answer. 

But for stabilizing the healthcare workforce, what would you prioritize first? And you can only pick one. We all recognize that there's lots of really amazing things that all have to be done at the same time. Maybe we can start with Sarah H. 

SARAH HANAFI: Yeah. For me, I think it goes back to investing in the foundation. And it means, right now at least, investing in the primary care setting and investing in team-based care in that setting. 

ALIKA LAFONTAINE: Thanks. Marcia. 

MARCIA ANDERSON: If there were any way to get rid of mandatory overtime for nurses, that would be my first vote. 


KEVIN SMITH: Yeah. I think the tools that clinicians have asked for to provide high-quality care, including adequate number of colleagues and extenders. 


SARA FUNG: I think taking care of the workers is most important. So taking care of them so they can ultimately take care of the patients. 

ALIKA LAFONTAINE: Thanks for that. So in behalf of the CMA and all of those who've attended tonight, thank you so much to Marcia. Thank you, Sara F. Thank you, Sarah H. Thank you, Kevin. I really appreciate your expertise, your insight, especially your vulnerability. This isn't an easy conversation always to have. And we brought up a lot of really, really important points. 

To everyone that's attending tonight, we'll be sending you a post-event survey shortly. So please let us know what you thought of tonight's event. We've covered a lot of ground over these three Bold Choices sessions. We know that there's a lot more to tackle. This is just the beginning of delving into a lot of these conversations. 

We also hope that you'll join us in August for the CMA's annual Health Summit. This will be the first year in a few years that we'll be having both in-person and online attendance. So if all things line up, we're hoping to see you in Ottawa next year. 

We'll focus on what healthcare should be and the bold solutions needed to get us there. And I really encourage you to attend online or in person. We'll bring you more details in coming months. 

Let's keep these conversations going. I am Dr. Alika Lafontaine, president of the Canadian Medical Association. And I really encourage all of you who are involved in this discussion to keep advocating. Your advocacy is making a difference, I think, in how healthcare is evolving. Thank you. 

Missed our previous Bold Choices sessions on funding and models and care? Check out the highlights here. 

“We know that there's a lot more to tackle. This is just the beginning of delving into a lot of these conversations.” — Dr. Alika Lafontaine

Join us in August for our annual Health Summit to continue these important discussions on the future of health care. 

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