Bold choices in health care: It’s time for action

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Health Summit Series: Bold Choices in Health Care

The video features four speakers on screen all the time. Clockwise from top left is host and CMA President Dr. Alika Lafontaine, former BC Premier Christy Clark, political commentator Chantal Hébert and former Nova Scotia Premier Stephen McNeil.

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Opening shot is a slide that says Health Summit Series: Bold Choices in Health Care with an image of a young physician.

Stephen: If we as Canadians don't have a broader conversation about how we're going to access primary care and how it's going to be delivered to us, there is no amount of money. It doesn't matter if if the economy takes off, there is no amount of money to run the healthcare system. That the way it is currently being run.

Next shot is a slide that lists the names of the host and the three panellists.

Alika: We often talk about funding and linked to funding is often this idea about transparency and accountability towards patients, practitioners, and sometimes towards governments when it comes to the way that money is spent for health care services. Is this the right problem to be solving?

Christy: Yes, it is a problem? Who knows who spends who spends money on health care - is it the Feds or the province? They don't agree amongst themselves. I mean, we just saw not long ago, the federal government saying to the Premiers, you know, hey, yeah, but you guys take all our money, and you just put it into jacking up wages for nurses and doctors, which is exactly what Alberta did, by the way, instead of, you know, putting more money into other areas of the health care system. And then the provinces say to the federal government, no, you guys were supposed to pay for 50% of the system. We're supposed to be executing on it. You just don't give us the money, so don't question how we spend it, because each province has different needs, as Alberta did at that time.

Chantal: I think from a patient's perspective - and I translate patients into voters - the main issue would not be transparency and accountability, but timely access. Nobody really cares who's spending money for what, or who's doing what, if, when you need care, you can actually access it.

Stephen: Transparency is not something that anyone had raised with me in my entre time in political office other than they, unless it was some other aspect of our government, it was not about the delivery of health care. Making sure that whatever money is put into the system is about the delivery model and shifting the delivery model, then we can figure out at the bargaining table, how we're going to pay the people who are in the system, and hopefully, we'll have a broader conversation about access to care, and then we can start a conversation about where are we going to get more trained professionals to be in the system.

Alika: Should we disconnect health reform from government? Any progress will be destroyed every four years when a leader tries to get re-elected?

Stephen: It would be great if you could do it but guess what, every four years, people like Christie and I end up going to look for support to be re-elected.

Christy: We will never have profound and fundamental change that we need in the Canadian health care system if we are depending on people who have a four-year time horizon for their annual, their next stockholder’s meeting where they get voted in or voted out from the board of directors, to bet on a huge change that's going to have long-term benefits that are uncertain.

Chantal: I totally agree that best practices should start at the local or regional level and filter up and then provinces to provinces. It can't be a top down someone has this great idea that everyone will have. But I am reminded that I am paid to be live in the real world. And in the real world, it is not happening that governments are going to devolve the reorganization of the healthcare system to non-political actors.

Alika: Is there a way for us to shift from a focus on cost reduction to value?

Christy: We can build different incentives in at the ground floor for people. So, for example, emergency rooms in British Columbia, we did a good experiment a while ago, where we were paying, we would top up the budget of the emergency department in a hospital if the solutions for change that the people working in that space, created and implemented, actually lowered costs, they will get to keep the money that they'd saved and use it for other things. What our experience was, that professionals in the specific areas of hospitals, for example, often know what the savings are that need to be paid. They work in a very unresponsive system, where they can make suggestions for change and they don't happen, most of the time. By giving the professionals in the space the ability to be able to make those things happen and giving them some, not personal financial incentive, but giving their department some incentive, it really brought about a lot of change. A lot of really positive change in terms of wait times, throughput, the patient experience, the whole gamut they saw improved metrics.

Stephen: Christy's idea, you know what I think deserves merit - I wish I’d known you guys were doing that - but that's an interesting concept because it allows the people in the facilities, who are running them and managing the budgets to drive the efficiencies and know how best, and not be fearful that your government is going to just claw back.

Alika: We hear frequent calls for more doctors and nurses, for changing delivery models and for collaborative care models. Collaborative care encompasses health care teams. When will the conversations led by governments become more inclusive of the number of health care professionals, other than doctors and nurses, which can be part of the solution? And I'm going to tack on one more part to this question: In your experience, what other health care workers should be involved in health care teams that we maybe aren't including when we just frame it around doctors and nurses?

Christy: Paramedics could be one. I mean, they're doing that in Ottawa, I think they've got a trial going where ambulance paramedics are helping to provide home care for people, for elderly people, in their homes. So, I would certainly include them in it. We should also think about whether or not firefighters can do some work in emergencies?

Chantal: I think pharmacists come first on the list, by far. And we've seen that over the course of the pandemic. The number of things you can do, dealing with your pharmacist, at least where I live today, compared to even a decade ago, that doesn't even compare. I can solve a lot of problems just by going to my pharmacist now, including getting all those shots that doctors don't need to be delivering anymore.

Stephen: We started a seniors medication review and the Government of Nova Scotia pays for it, where a senior can go in to see a pharmacist that goes through the list of medications they may or may not - that they're on - and look at any interaction with them. That's what they were trained to do. So, we make sure we get their full scope of practice. And I'm also a big believer that social workers need to be part of this conversation, helping with the determinants of health and some of the socio-economic circumstances people find themselves into. What are the supports that we can put around families earlier, before it ends up being a health issue that we're dealing with?

Alika: This is an excellent discussion, but these sessions are frustrating as we want to move to actionables. What can those of us on this webinar do? Where can we start to create change?

Chantal: For individual members who are listening to this, you have some leeway to create some of those changes at your own level, despite the bureaucracy or in sync with the bureaucracy, and ‘thinking out of the box’ is not something that is forbidden by any act of a province or the federal government for one. But two, I'm guessing, finding support across the medical health care practitioners field to call or to bring the governments to realize how bad the situation - and I know that's already happening - is the thing you really can do best for your patients.

Christy: Fundamentally the problem is that Canadians are wedded to the idea that if we don't have exactly the same system we have today, which we all admit is far from perfect, we are going to have the American system, and that is just not true. Talking about that publicly, I think, could make a real difference in opening opportunities for politicians to make some change.

Stephen: You have a powerful, you are a powerful voice in the most important part, and that's in the patient's ear. You are the most powerful voice. No one believes politician. So, we could come up the greatest idea of transformation, but unless your organization is saying, unless other organizations are on the same page, it will be very difficult for government to implement that change. So, my call to action would be strengthen your relationship with your sister organizations, and I would do it provincially and take them into Premiers’ offices, ministers of health, and lay out a consistent plan that's well thought out about what does the new delivery model look like?

Alika: Thank you for the very stimulating discussion. Once again, thank you Christy Clark, thank you Chantal Hébert, thank you Stephen McNeil for a wonderful conversation. So, we’ll switch gears now to another part of our webinar which is a bit of reflection and I’ll just invite Dr. Katharine Smart, CMA past president, and Toni Leamon, CMA’s Patient Voice chair just to join me here in the webinar. Of the interesting perspectives, is there anything that stands out to you?

Toni: So, the first would be accountability. In this conversation, we heard accountability discussed at the federal and provincial level, but ultimately, accountability needs to be at all levels. We all share the responsibility of accountability for health care and health care spending. When we empower patients and essential unpaid caregivers to be part of the decision-making process, as authentic partners, interventions can be better streamlined and tailored to individual needs.

Katharine: Where is there accountability in our system? There’s very little. We do not look at a lot of outcomes in our system nor are they incentivized nor are we necessarily accountable for them. So, if we’re not designing a system that has radical accountability and is outcomes driven and we’re incentivizing people to get those outcomes for patients, I don’t see how we really get significant change. And the other piece I appreciated was some of what Christy brought up around this idea of budgeting. I do think some of what inhibits innovation is the sort of status quo of how things are done. We all know if you don’t spend your money in the budget cycle, you don’t get it back the next year. If you save money, often it’s taken away. So, there’s some of those fundamental bureaucratic changes that we could make now that would really motivate frontline people to say – ok, I’m going to get rewarded for this, there’s something in it for me, I’ve got these ideas and if I can make good changes for my patients, I’m going to have more access to more resources to do more of that. There were many things, but those were the things that really resonated with me. But most importantly, I think, the importance of having the right conversation, and I think it’s really about these issues much more than it’s about dollars right now. 

Video Transcript

ALIKA LAFONTAINE: As is our practice here at the Canadian Medical Association, here at the second conversation of Bold Conversations, I acknowledge that I'm joining you from the traditional unceded territory of the Anishinaabe Algonquin nation in Ottawa, Ontario. We have more than 800-plus participants who've registered across various traditional territories coast to coast to coast. I'd encourage you to orient yourself to the territory in which your city or town resides. 

Welcome to the second event in our Health Summit Series, "Bold Choices in Health Care." In our first session, we discussed funding and design of health systems, with various themes emerging from our panelists. These included giving providers and patients the ability to shape health outcomes, calling for political courage towards bolder choices, innovating from the ground up, and breaking down barriers between professions. Today, we're building on that conversation and talking about an issue at the heart of an effective and efficient health system-- how we deliver care to patients. 

Our models of care might have worked for patients and providers at some time in the past, but as disparities in access grow, wait times soar, and levels of burnout rise across the system, what we're doing now is, obviously, not working for patients or providers. There are various examples of this, but each of the panel participants felt it important to specifically recognize that children, families, and pediatric care providers are confronting a surge in respiratory illness that's overwhelming community, emergency, and acute care capacity across the country. 

Our hearts and minds are with the patients, families, and providers in the midst of this crisis. A reminder that getting your flu and COVID vaccinations is important, if possible, staying home if sick. Consider masking and being kind to those affected by the pediatric crisis. These are all ways that we can help this crisis from getting worse. 

The core question of, how can we do better in primary, specialty, and surgical care, and what we can learn from existing models of success, is where our focus will be tonight. If you want to follow the conversation or share your thoughts on Twitter, we'll be using the hashtag #CMABoldChoices. Once again, that hashtag is #CMABoldChoices to share highlights from tonight's conversations. 

So we'll start with a 40-minute moderated Q&A with our panelists. That will be followed by a 40-minute question and answer with you, the audience. Questions will be text-based and can be upvoted if you look at the bottom of your screen. There will be a button that says Q&A. You can click on there and follow the directions in order to submit your questions. We ask that everyone help support a respectful, professional, and collaborative discussion tonight. Questions that are discriminatory, defamatory, abusive, or offensive or that violate privacy or confidentiality will not be addressed. 

Now, let me introduce our four panelists. Dr. Brian Goldman is an emergency physician in Toronto and host of the CBC award-winning show, White Coat, Black Art, as well as the weekly health podcast, The Dose. His latest book, The Power of Teamwork, demonstrates how a team-based approach to medicine, combined with the power of kindness, can improve all aspects of the health care system. Welcome, Brian. 

Deb Matthews spent many years in the Ontario Legislature, including minister of health and long-term care. She saw the passage of the Excellent Care for All act in 2010, which strengthened the health care system's accountability to deliver high-quality patient care. Deb is currently a senior fellow at the Dalai Lama School of Public Health in Toronto and consults on health care innovations. Welcome, Deb. 

Dr. Rita McCracken is a family physician in Vancouver and assistant professor in the Department of Family Practice at the University of British Columbia. She's currently studying the family doctor shortage in British Columbia, including looking at how to measure changes in the availability of primary care after new health policy and care delivery models are introduced. Welcome, Rita. 

And finally, to round out our panel, Clare Snyman is a Vancouver-based writer, speaker, advocate, and member of the Canadian Medical Association's patient advisory group, The Patient Voice. Her books, "Two Steps Forward" and "Activate", draw on her personal experience navigating complex systems of care. She continues to advocate around patient agency, safety, and improved access to care, and has contributed to a study with neurosurgeons at Johns Hopkins University on headache disability. Welcome, Claire. 

So with the four of you joining us, we'll dive right into this and our first question for tonight. The status quo is, obviously, not working. We all want good care. But I'll just ask each of the panelists, maybe starting with Clare, what does that look like? What does good care look like? 

CLAIRE SNYMAN: Well, thanks, Alika, for starting with me. That was a curve ball, but it's all good. [LAUGHS] 

So first, I thank you very much for the invite on this important topic, and also for bringing the patient's voice into the fold. The topic of shifting the status quo is very near and dear to my heart as someone who is a frequent face in the health care system, and I hope that our conversation today, we collaboratively, as health care providers and as patients, can really identify some ways to move forward with new models of care and look for ways to move from discussions to enacting decisions and action to make these things happen. 

So when I think of an example of a model that delivers good care, for me, what that means is it means what it might look like and feel like to me as a patient, as well as, actually, what I've heard from others, including our support people, because those are the families and the essential caregivers and care partners that stand by our side. So in this good model of care, it would-- number one, it would meet me where I am. I'm able to receive the right care in the right place at the right time by the right person and in a timely manner. Now, I know that might seem like a hard ask, but we had to be bold today, so I'm going to put it out there. 

And I think this model of care, if it was there, would also be able to take into account equity of care because it would ensure the needs of all the people that it's trying to serve. This good model of care would be patient-partnered. As the CMA Patient Voice, we looked at, what does patient-partnered really mean to us? And for us, it was it's an authentic and equity-informed collaboration between those who make decisions, the patients, as the health care providers, and also the caregivers. And it's really built upon collaborative leadership, communication, situation monitoring, and shared decision-making. 

I think at the end of the day, for me as a patient, a good model of care would offer me seamless care. There's so much that could be supported by a team-based care model. Especially for myself as a complex patient, I come into health care with many facets to my health and my health care. And this would really provide me less silo-hopping, less navigating by myself, and really make it less of a full-time job, hard work, and heavy lift. And I think ultimately not just for myself, but those who provide care for me-- my health care team. 

And one last thing I wanted to add in was, if I were to give you an example of a model of good care, it would have an information-sharing system that is wrapped around it, and thus would provide access to my health care records, my story of my health care, wherever and whenever for myself and my health care team. So there's no rinse and repeat cycle every time I step through into the doors of health care or into that model. 

And so that allows us the space and the time to actually focus on what's really important and what matters to me. It allows me the ability to ask questions. And I think ultimately, it allows the delivery of safe care, quality of care, it allows data to be shared, and also, where is the funding going? Because you have access to all that information. So I suppose that's just my utopia of where a model of good care would sound like, and what it would feel like and look like to me as a patient. 

ALIKA LAFONTAINE: Yeah, thanks for that, Clare. Maybe we can progress through this question just going to Brian, maybe, from your perspective working in emergency rooms and interviewing physicians and patients across the country on various issues. And then, after that, maybe move to Rita. I'd be very interested in what the literature says about what good care is. And Deb, you're probably the only one of us five who have actually been redesigning systems as a decision-maker within the health care system. I imagine that the vision of good care looks very different for you-- or maybe the same, but different challenges. So maybe we start with you, Brian, and then Rita, and then on to Deb. 

BRIAN GOLDMAN: Well, thank you very much, Alika, and I'm really glad that you started with Claire, because I think that good health care responds to the needs of patients. It isn't just given to them, foisted upon them. It's responsive to their needs and, in fact, meets their needs. So it asks them what they need, what they want. 

To what Claire said, I would add that the system is not just a system that delivers medical care but holistic care that pays very close attention to the socioeconomic determinants of health. Instead of just reacting to crises, health crises, we try to move upstream and deal with problems before they become problems by addressing those socioeconomic determinants of health. I would say that from my standpoint as an emergency physician, I see the acute need for good primary care, and I'm really looking forward to what Rita has to say about that. 

There is a huge primary care gap in this country, and I think we can do better. And for me, that would mean fewer patients feeling the need to come to the emergency department because they have nowhere else to go in a timely fashion-- either because they don't have a family doctor, or it's going to take a long time to see them. And so if that were addressed, then I might be more likely to be seeing patients who have true emergencies. 

We need a seamless electronic health record, as Claire has already mentioned. And I think that all of us who work in health care, whatever kind of health care provider we are, we need to function in a team-based model. And that's one of the things I'm going to be talking about it again and again. I think that a lot of us talk teams, but we really don't understand what it means to be on a team. 

I'm happy to talk about that later, but what I'm talking about is the sum-- the team is greater than the sum of the individual members on the team, that there's a greater sense of exhilaration, ecstasy, working together, that there's less stress on us because I don't have to come up with all the answers. I'm working in a team, which means that other people are providing information that's helpful to me, and I'm providing information that's helpful to them. And when we're working in a team, it means that I'm working seamlessly from the referral by the nurse practitioner or the family physician and on to the specialty service to whom I'm referring from the emergency department, so that we're all working together. We're all working for the benefit of the patient. We've defined our goals together. Those are some of the things that I think we need to see to make things better in health care. 

ALIKA LAFONTAINE: Yeah, Rita? 

RITA MCCRACKEN: Yeah, it might come as no surprise that there is actually not a systematic review that answers the question, how do we fix health care in Canada? But there are a lot of clues in the academic literature. And hands down, one of the most important things is that we think about building a system that consists of not health care heroes, but health care humans. 

And I think we've seen through the pandemic, and through this last really terrible pediatric respiratory illness crisis, just what happens when we put too much emphasis on single individuals to be everything. This shows up really loudly and clearly in primary care, where we've done a lot of talking in Canada about team-based care in primary care and very little action. There are some really notable examples-- for example, community health centers, which have been around in Canada for over 60 years, and are rooted in a community, led by a community, and have a true team-based performance-- also show great outcomes for patients but just haven't been able to get traction within the system. 

I have a lot of ideas about why that is from what I've seen in the literature and from my experience as a physician working in an environment here in British Columbia where we're trying out a lot of new things because the shortage just keeps getting worse, and worse, and worse. But I think that idea that if we just are focusing on trying to support the heroes versus building an environment where humans can work together, that that really is where we're going to start seeing some longer-term solutions. 

ALIKA LAFONTAINE: Deb? 

DEB MATTHEWS: That is such a big question. I'm going to just give it a bit of a stab. And I apologize, I'm having some technical issues, so bear with me, please. I think Claire said it absolutely right. Patients need the right care, and that means evidence-based care. 

We do a lot in medicine that isn't evidence-based. We need to give people the right care at the right time. And that means if things are going to get worse, we've got to deal with it up front. Let's deal with issues early so people get the care at the right time, the right place. 

We need to invest in options for people outside of acute care hospitals so that we can free up hospital beds for people who need that acute care and provide the support people need to get into the next phase of their care, whether that be in a rehab situation or at home. But we need to invest outside the acute care hospitals. And the right provider-- we need to really focus on working to get everyone working at their full scope. And team-based care, one of the things that team-based care can do is free up doctors to deal with people who need to see doctors and have other health care professionals deal with people who would be better served, perhaps, by a social worker, or by a physiotherapist, or whatever. 

So right care, right time, right place, right provider, and I think we need a much bigger focus on the social determinants of health. It makes no sense to me that we are OK paying for an amputation for someone who hasn't had proper foot care, but we somehow don't find it in our budgets to actually prevent that amputation. So we need to focus on social determinants of health. 

It's pretty lopsided. Doctors can order thousands of dollars of tests and procedures, but they have to really bend a lot of rules to get people a healthy diet. So that's a start. I think we could all go on for far more than the 90 minutes of this seminar on this, so-- 

ALIKA LAFONTAINE: [LAUGHS] Yeah, no, I really appreciate how the four of you have been framing that. I'm going to go through one more time and maybe just modify the question a little bit. So Claire, I've read your books, and your experience and realization of taking a position as a manager of your own care, helping yourself navigate, and now teaching other patients how to navigate, we often, as doctors, talk about-- and I think in discussions with government, we often frame different models of care as different ways of getting paid-- fee-for-service, alternative relationship plan, capitation, and stuff like that-- words that the average Canadian doesn't really understand or comes across. 

When you go into different places to access care, or you talk about persons that you support going through the system, does it feel different when you move from place to place? Do you pick up on when it seems like someone is working under one sort of system versus another? And related to that, is there a type of system that you kind of lean towards based on your own personal experience? 

CLAIRE SNYMAN: That's a really good question. And I think things have definitely changed pre-COVID and post-COVID, I think because of the stress that the health care system has gone through. I think if I look at the continuum of care through which I myself as a patient go, for example, my family physician, who I see on a very regular basis and who I've been in the practice-- which I'm very grateful for-- for over 16 years, I'm able to be in that space, have the time to connect. It may not be-- it's not a long time, but at least I have the time to connect, ask the questions, feel I have the time to ask the questions where I'm able to. 

However, when I step out of that space and I am referred to a specialist or referred, down the pipeline of continuum of care, even though I consider myself to be an activated patient, my sense of control over what that looks like changes completely because it is no longer my point of reference. I no longer have control and visibility over when I'm going to get in to the specialist, when I'm going to see my call, or get my call for my MRI, or my CT scan, or-- [VOICE ECHOING] Sorry, a bit of buffering there. 

And that, for me, creates a lot of uncertainty. That is a challenge for me, but I know as an activated patient, I always need to follow up. I need to phone in as soon as I know my referral has gone in. But that's not something that everybody knows to do. 

So when I'm chatting to people who I know are referred to a specialist, I'm always like, make sure you call a week after your referral has gone in to find out what their wait list time is like. Be put on a waitlist. If it's a year, keep on going. Keep it in your diary. If you've had blood tests, follow up on those results because it might just go into an abyss. 

If I step into the ED, I know what it looked like two or three years ago pre-COVID. But now, I know even trying to access going into the ED is a very different domain. This is a challenge for me. I have asthma, which is highly flared. So if you see me coughing in the side or going offscreen, that's because I'm trying to navigate my medications on the side here. But I know that's, for me, my main visits to the ED. 

And so what that means for me is I want to go there, but I'm navigating, what does that look like for me? When I know I need to go there, I need to go there, but what does that look like for me? So I think, Alika, in a nutshell, I think it's hard for patients sometimes to know how and when to navigate. And I think that's why the fragmentation, and sometimes not the visibility of how to navigate and not seeing what that looks like can cause a lot of uncertainty. 

ALIKA LAFONTAINE: Yeah, and Brian, why don't you jump in here? 

BRIAN GOLDMAN: Thanks, Alika. And what Claire is talking about-- and she's mentioned so many things, and I know we want to get into talking about fragmentation because that's such an important topic. But she talked about not having enough time. That lack of-- that time pressure that is pervasive in health care is something we need to address, because it doesn't serve people who work in health care and it doesn't serve patients and families. That time pressure leads to poor care, and it's something that can be addressed. And there are many ways that it can be addressed. 

The other things that I think that need to be addressed that have a direct bearing on time are stress in the system and scarcity. And there are ways of addressing all of them, but all of them add up to the sense of time pressure, the sense that you've only got a small aliquot of time because that's all the time we have because we're in such a hurry. We've got to run from patient, to patient, to patient. 

We have to build time back into the system. And there are ways to do that. And we can talk about those. 

ALIKA LAFONTAINE: Thanks for that, Brian. I'll throw it over to Rita and Deb just for any thoughts you might have. You might be on mute, Deb. Think you might still be on mute. 

RITA MCCRACKEN: I'll just offer a thought while Deb is unmuting. And I think that that idea-- I love the idea that we are empowering patients like Claire to hold their story and to be their own manager and their own advocate. And yet, at the same time, it's asking a lot of patients. And so there needs to be-- we need to meet and have a reasonable measure of what a patient can do and what the system should be doing for them, because otherwise, we see people who don't have the same resources that Claire has access to be able to navigate the system. And so we need to make sure that we are building in mechanisms to empower patients from the place that they are coming from. 

ALIKA LAFONTAINE: And Deb, did you have anything to add, or-- OK, still really on mute? [LAUGHS] Maybe we'll jump to Claire. 

CLAIRE SNYMAN: Yeah, Rita, thanks for bringing that up. I think that's actually vitally important, because everybody has a different level of the way they are able to support themselves within health care, a level of health literacy. And even though you may be educated to grade 12, but once you jump into a health care system, it doesn't matter where you're coming from. It's a completely foreign environment, and the way people are talking and so forth-- the fragmentation and siloing of it. So how can we not just support patients, but also families and caregivers, coming into that siloed environment, and helping them work their way through that, I think, is really integral. 

So I think that when we look to new models of care delivery, how can we actually support and give agency? So not just empower-- because there's a power differential-- but actually give agency to patients, families, and caregivers to actually support them through this process? 

ALIKA LAFONTAINE: Would you like to-- 

DEB MATTHEWS: Yes, can you hear me now? 

ALIKA LAFONTAINE: I can, I can. 

DEB MATTHEWS: OK, thank you very much. I have to say, I'm feeling like we know what needs to happen, and we've been talking about it for a long time, but we need to be bold. Then, the fact that you've called this series "Bold Choices," it's bold choices, but it's also bold action. 

We need to take action. And I'll tell you why I feel so urgently that we need to take action, is that I sense that people are losing confidence in our uniquely Canadian health care system. I'm starting to see pay your way to the front of the line care being offered. 

There's a company, a company where you can get to the front of the line on hip replacement surgery, but it costs you $28,000, and the trick is you have to go to a different province. They figured out a workaround in the Canada Health Act so that they can actually provide two-tier care. That's taking resources out of our public system and benefiting only those who can afford that kind of care. So we are on the brink. I'm worried that if we don't actually take action that people can see the improvements in health care, we are going to lose our precious single-payer system. 

ALIKA LAFONTAINE: Yeah, that's very wise counsel there, Deb. I'm going to throw it back to Rita just for a second. Obviously, the stresses that we're talking about, they existed before COVID. They've maybe shifted a little bit because of COVID. What are areas that you're seeing the barriers to practicing the ways that Claire talks about, and each of you are talking about-- that feeling of coming into a care environment and getting a good enough level of care that you maintain your confidence that the system can give you what you need? What are those barriers that you're seeing right now, and how have those shifted over the past couple of years as demand has gotten much more acute? 

RITA MCCRACKEN: Well, I think one of the important conversations for us to have is how much of a barrier physicians have been to real change in the system. Physicians have a history of going on strike when they don't get their own way. That's happened several times in various parts of Canada. And the world has changed since 1962 when Tommy Douglas started the conversation about Medicare. 

And we are not the only people who can provide great health care. I think all the other speakers have mentioned this already-- that there are really important other team members who absolutely need to be involved in this exchange. But very often, when a crisis happens, it's physicians and governments sitting down behind closed doors. 

And I think that is a bold choice that we could be making-- to not have those conversations behind closed doors anymore, and making sure that we have all the right people at the tables-- the other care providers, caregiver and patient voices, and community members. Health care belongs in your own community. 

I work in a very large family practice in East Vancouver, and I have an area of expertise in HIV. And right now, I have patients who travel over 500 kilometers to come and see me because they can't find another family doctor who will take on a patient with HIV. And it just-- this is bananas. This is completely bananas. We absolutely need to be taking a look at, let's get our care organized for 2022. And that means not just doctors having the conversation. 

ALIKA LAFONTAINE: Yeah, we're going to throw it to Brian for comment. 

BRIAN GOLDMAN: Yeah, there's a couple of things I want to say about that. I don't disagree with anything that Rita is saying. I think we do need a new model. But I do want to take a moment to defend family physicians. 

For instance, I've spent some time recently in British Columbia. I had a great conversation, spent some time with Dr. Chris Applewhite, who's the family physician on Salt Spring Island. He was a physical therapist, and then, in mid-career, he decided he wanted to become a family physician. And he did. 

And the tagline for the show that we did on White Coat, Black Art was "Salt Spring Island-- a great place to raise your kids. A terrible place to practice longitudinal family medicine." He described the situation being, basically, having lack of resources, having patients who can't get a timely MRI, who can't get timely access to cancer care-- and I we've heard about that thanks to a series of articles in The Globe and Mail-- and being buried in paperwork. That, where he's spending hours after he's finished his clinic for the day, he's not with his family, his kids might be enjoying themselves, but he's buried in paperwork. That's all unpaid. 

Now, I know, of course, there's a new primary care agreement, and I think everybody's going to be watching that experiment in British Columbia-- other provinces, particularly. So the system-- I don't think the system serves family physicians particularly well. I would advocate for a completely different system, one that is team-based from the start. But it's very hard to just magically transform of that by snapping your fingers. 

You're going to have a whole cohort of practitioners who are well-versed in the current system and are going to find it difficult to just switch. I think there'd be all kinds of organizational logistical headaches doing it. What I would favor is saying that graduates beyond a certain year, from a certain year and younger, you're going to be functioning in a team-based model, the kind of model that I'm sure Rita is going to be talking about shortly-- a community health clinic type of model. A multidisciplinary kind of model where, starting in first year professional college, professional school, every allied health professional would be studying together so that they can begin to see what it's like to function together on a team. The currency, the unit of function, would be a team. And then, they would move out into the community when they graduate. 

And they would serve a geographic area. They wouldn't be cherry-picking. They wouldn't be picking and choosing patients. They would serve a geographic area, a neighborhood, in the same way that a school serves the residents, the children of the residents who live in that particular neighborhood. But that's a massive transformation, and you've got to deal with the here and now in the meantime. 

ALIKA LAFONTAINE: Yeah, I'm going to ask Claire and Deb just to consider the next question. I mean, I think as providers, we often see the problem a little bit differently. There's always two sides to any value exchange. We have to worry about the patient experience, but then we also have to worry about workers and their experience. 

And I think the pendulum has definitely swung back and forth. We only cared about persons who worked in the system for a very long time, ignoring patient needs, and the pendulum swung the other way as well towards maybe ignoring some of the struggles that health care workers are going through in their environments. As someone who's navigated many systems, Claire, and Deb, as somebody who's tried to redesign many systems and arrive at that place of value exchange but that works for both sides, what's your thoughts based on what you've heard from Rita and Brian so far? Maybe we'll start with you, Claire, and then we'll go to Deb. 

CLAIRE SNYMAN: I'm 100% on board with what has been said. I think some really good comments have been brought up a lot of what I've been sort of nodding my head over and I've actually thought about before. And I think what I'd like to just bring up is actually, if I thought about-- I mean, we're talking about bold choices today, and one of the things that came up with COVID-- and I'd love to, how do we look back to what happened during COVID, and take some of those learnings and some of those things that happened with knee-jerk and happened. And we're like, wow, we've been asking for this for years! As a patient, we have been asking for other ways of delivering care to us for a long time. And suddenly, virtual health came up because of the pandemic and the reality of having to deliver care to individuals other than in-person. 

Obviously, now, we need to ensure that we have options for patients in-person. Virtual health is another opportunity. I see my GP in person, but I know that if I need a script, I'm probably just going to do a phone call, too, which is great. But how can we really take some of those amazing opportunities that push through some of those barriers that are just continuous in a lot of the health care system-- that we put our heads against the wall and just keep on hitting them against the wall? And I see that as a patient. 

I wonder why some of these policies and some of these structures are in place, and why they can't just be moved a bit quicker out the way, which is what happened during COVID. And can we look back to some of the learnings, and some of the amazing structures, collaborations, and groups that were put in place, to push forward and say, why don't we take this forward? Why don't we do this again and use that learning to move forward? 

ALIKA LAFONTAINE: Thanks for that, Claire. Deb, can we go to you? 

DEB MATTHEWS: Yeah, I think we have to be really careful that we actually let patients lead us in health care reform. I think we often do the token, include a patient voice, where what we really need to do is listen very, very closely to patients in, probably, a much more formal way than we do now and have the patients lead the providers so that providers actually understand they're working for patients. That's, A, who's paying for the system-- it's the public that pays for the system-- and it's the patients that really should have a lot more say in how we provide care. 

And virtual care is a really good example. Patients like it a lot because it saves them having to go to the doctor. We just heard about patients going 500 kilometers to see their doctor, when they could do it virtually. But in Ontario, they've just rolled back the fees for virtual care, which is contrary to the direction that we should be going. We should be encouraging virtual care because it's better for patients. 

ALIKA LAFONTAINE: Yeah, this is a wonderful discussion so far. I'm going to just take a bit of a turn, and we're going to move towards some of the questions submitted by participants attending. Just a reminder to people, if you'd like to submit a question, just go to the bottom bar of your screen, click on Question and Answer, and submit a question. 

We will go through in the order that people get upvoted. So if you have a question that you like, or you'd like to support your own question, make sure to press that number 5, and we'll go in rank order as we go through. If it's simply a comment, we'll just read out the comment, and then we'll move on to the next question. 

So just to each one of the four participants, just as we're asking these questions, I'd really ask you to try and weave in thoughts around these two questions as well-- how can we support new models of care delivery, and, when you're looking at what has to change about people's behaviors and expectations about how the system works, whether patients or providers, what types of things will have to change? For example, we often have this solo practitioner model when we think about primary care, shifting that into whatever comes next. 

So our first question comes from Lee Green. There's extensive literature on teamwork in many fields, including medicine and good measures of it. The fact that we don't do it well suggests that there are perverse incentives militate militating against it. For example, the system is ideally designed to get the results it gets. 

What are those perverse incentives, and how do we fix them? So what are some incentives maybe taking us in the wrong direction? And maybe we'll start with Deb first. 

DEB MATTHEWS: Yeah, I mean, what comes to mind very quickly-- and I think it's absolutely right that you get the outcomes that you incent. Whether you intend to or not, you're getting the outcomes you incent. So I think one serious issue we have in Ontario, at least-- and, I suspect, other places as well-- complex patients are not patients that doctors want to take on because the compensation isn't enough more than it would be for somebody who is an infrequent user of health care. 

So I think we need to really look at who's not getting served because of the compensation, and we need to fix that. I'm not saying we need to spend more, but I think we need to rebalance that, because the incentives are getting in the way of everybody getting access to care they need. 

ALIKA LAFONTAINE: Sure. And I'll just ask the panelists, if you have a comment on any audience-driven questions, if you can just raise your hand. Otherwise, I'll go through the questions, and go forward. So Brian? You're just on mute. 

BRIAN GOLDMAN: Thanks. I think there's some culture factors and there's some systemic factors that tend to not favor team-based care. So one of them is the time pressure that I was talking about. Everybody feels as if they're under a lot of pressure, and when they're under stress and they're under pressure, then they tend to revert to their more primitive instincts, which is to coalesce around your in-group and to quickly identify outgroups who are people who don't understand the way we think. And that's what leads to siloed behavior. And it gets reinforced by the culture. 

I think that there's a hierarchy, an unwritten hierarchy, for instance, in hospital care. And I know that we're not just talking about hospital care-- that specialists tend to be more influential than primary care physicians and nurses, and primary care physicians are more influential than nurses, et cetera, et cetera. There is in medicine-- I'm not going to talk about the culture of nurses, but I will talk about the culture in medicine-- there is an "I alone" mentality, the idea that I'm trained, when I'm graduated, when I have oral examinations, people aren't helping me answer the questions. I must answer them alone. And there is a kind of a cultural belief that if I don't have all the answers, then why am I here? And we need to overcome that. 

No question, I learned late in my career as an emergency physician that when I function in a team, I do better. I'm a much better emergency physician when I'm surrounded by students, learners, residents, nurses, nurse practitioners, physician assistants, and allied health professionals. But and then, there's simply a lack of experience with teamwork. A lot of us talk teamwork, but we don't actually understand what it means to have team cognition, for instance. Rita? 

RITA MCCRACKEN: Yeah, I'll just add to that by and large, especially with regards to primary care, the total sum of our transformation is to talk about physician remuneration in new ways. And so it's completely targeted at individual doctors. So of course we're not getting team care. Of course we're not getting access for different patient groups. 

And I think the other thing, building on what Dr. Goldman just said, is that we have this belief, as within our profession, that what I do is right. And so this idea of a continual improvement loop versus just picking the right next step, we're constantly looking for quick fixes or, for a family doctor, a problem I can solve in 12 and 1/2 minutes and then document it very quickly. 

And if there was a quick fix to the mess that we are in, we are smart. We're a great nation. We would have figured it out right now. These are complex, wicked problems, and we need a transparent lens to look at what we are doing and a sense that it's OK to try something, and make a mistake, and readjust. And I think we really need to be thinking about that in how we educate and how we support each other. 

ALIKA LAFONTAINE: Yeah, thanks for that. So Claire, this question often gets asked to providers, so I'm actually going to ask it to you instead, just to lead off this conversation. So this is from Greg Manning. 

Our health care system, unfortunately, funds and incentivizes procedures rather than primary care. So I'm thinking by "procedures," he means things like taking out lumps or bumps in family physician offices, or taking out a gallbladder in the hospital, or things like that. What changes need to be made at a system level to shift focus and value onto primary care provision? And I imagine you've had a lot of experiences, seeing how this gets applied in your context. 

CLAIRE SNYMAN: Wow, that's a really good question. I think for me, I always believe that primary care is the foundational pillar of the health care system, and then it flows from there. I think showing value is essential to be able to, obviously, fund that area. And by doing that, I think, honestly, if you were to ask me as a patient and say to me, where would you-- if I was given $100 and asked, where would you fund, where would you split that money, for me, a lot of it would go to my primary care. 

And I'll tell you why. It's because that, for me, is preventative. It is making sure that my general health care, my everyday health care, my chronic health care conditions are supported. They are maintained on a daily basis so that I don't have to go to the ED, that I am referred to my specialist when I need it. But that specialist should be the 10% of the time. My family physician and my family doctor is the 80% of the time. The rest of it makes up the 20% of the time. 

But I think in the health care system that we have, we become so that-- well, we have been so acute care-focused that we have not done the funding in the way that-- or the understanding, even from the public perspective if you are not a patient or a loved one is not a patient, that we see acute care as being the be-all and end-all of the health care system. And so primary health care, community care, is not being given the focus and the love that it really needs to be given. 

So if I had $100, that's where I would spend it. No, no thanks to anybody else, but that is where my care happens. It happens in the community, the majority of it. 

DEB MATTHEWS: Can I jump in, Akila? 

ALIKA LAFONTAINE: Yeah, go ahead. 

DEB MATTHEWS: If you don't mind, I just want to comment on one thing that Claire has talked about. And I completely agree that primary care is where everything starts. But one of the big challenges for primary care physicians is how difficult it is to get referrals for their patients. They spend way too much time trying to get a referral, and that is a waste of time for those primary care physicians and other providers. 

We need to move, in my opinion, to a single waiting list. So if you need a hip replacement, can't we just have one list that we'll refer you? Obviously, geographically specific and so on, but that we can relieve a lot of the burden. And we can speed up wait times, I'm told, by 20% just by doing that. So why don't we just do that? 

I think we need to set ourselves a goal of having single referral lists by procedure. I think within a few years, it's totally reasonable to say that we have those lists set up and people are comfortable with them. 

ALIKA LAFONTAINE: Yeah, thanks for that. So I'm just going to read what looks like a comment from Jonny VanAird. Claire's describing relationship-centered care rather than patient-centered care, dynamic and multi-dimensional, not two-dimensional. That's the way to go, Claire. Thank you. 

So thanks for that, Johnny. I've read your writings on relationship-centered care. So we'll move on to the next question, which is from Johnny as well. 

Physicians have to define their role, now more than ever, or others might do it for us. That means giving up some of our power, becoming interdependent-- so talking about teams, enlarging our view to the bigger picture, not just acute or primary care looking at it in silos, rather than independent of the whole system, while keeping our autonomy to treat and advocate for our patients and their needs based on evidence. And then, there's a couple of questions here. So how do you approach that redefinition of the role, and not getting trapped within those silos? And maybe we'll start off with you, Rita. 

RITA MCCRACKEN: OK. 

ALIKA LAFONTAINE: I'm giving you the softball questions. [LAUGHS] 

RITA MCCRACKEN: Right, thank you. How do we do that? I think many of us have it in us to become team players if we're not already team players. I think most people go to medical school with that idea that they're going to work together, rather than be a single, solo hero. And then, further to what Dr. Goldman was saying about that, we've got a group of providers right now who have a way of working, and we have had a tremendous level of incredible care throughout the country with those people with their current attitudes. 

But times are changing. And so I think that offering structured places where new ways of being a professional physician can happen. And not in-- here's one tip. If you ever feel the urge to say, for example, oh, it's the millennials' fault that we have the family doctor shortage, or it's women's fault that we have the family doctor shortage, just stop it and don't do that. Because we need to be thinking about how we're going to recreate a new environment. 

We have a lot to learn from women in the field, and we have a lot to learn from our new graduates who are joining us. They have new and fresh ways of doing things. And some of my more recent research that I've been involved with shows that, in fact, that it's not true. None of none of those tropes that we dance out to have some intergenerational blame are ending up to be true. So I think that we as individuals need to open our minds, and we need to be able to create places where new ways of being a physician can actually happen. 

ALIKA LAFONTAINE: Yeah, thanks for that, Rita. Brian? 

BRIAN GOLDMAN: The primary care physicians that I've spoken to, certainly if you look at family medicine, it is to some extent splintering off into specialties-- sports medicine, hospitalist, palliative care, et cetera, et cetera, emergency medicine. And in those domains, it's fairly self-explanatory. There, family physicians are redefining themselves by the specialties and subspecialties in which they practice. 

I think that longitudinal care is what's in need of a redefinition. And some of the characteristics of longitudinal care-- chronic disease management, being able to meet the needs of increasingly complex patients. So increased training in geriatrics, increased training in complex care, and navigation-- being able to get additional training in navigation, and having a reliable system that can meet the needs of-- the navigation needs of primary care physicians. 

All of that, and take away their paperwork. They're getting buried in paperwork right now. And what they need to have is a system that's a lot more nimble, that doesn't demand that family physicians become bean counters, become the documenters of the system, and having to fill out forms again and again. 

And there are many, many examples, but one of them is having to re-consult, send another referral every six months or every year, depending on what province you practice, simply just to suit the system because that's a form of accountability that the system demands, when it's clear that the patient will require-- will be managed by the family physician, but will require occasional assistance of a specialist from time to time. 

ALIKA LAFONTAINE: Yeah, thank you, Brian. Claire? 

CLAIRE SNYMAN: Yeah, just wanted to add a different point of view here from myself as a patient with a couple of chronic conditions, and how I see my family physician and the role and the scope with how she assists me, is that there's also other-- and we've spoken about the team-based care, but sometimes, outside of family physician office hours, I'm a little bit stuck. So I'm like, oh, I need to do this, what do I do? 

But my pharmacy just up the road is amazing. And I know them all by name. They know me by name. And sometimes I'm like, oh, I really need to ask them a question. I need some help with my medications. There is a band of team members that I think a lot of public and patients are not including, or maybe are not just fully aware of how important they really are and can be utilized and wrapped around into their care. 

My pharmacist is integral in my management of my health and health care. And how can that be wrapped into, whether it's a team-based care model, or just into the physician's referral basis out? Because everybody has their individual area of expertise, and so I think that's really important. For me, just understanding what the different elements of the health care system and the team members, I think, is really important. And I think if we look for being bold, from a policy maker perspective, is what does that scope of practice look like into different areas of the health care system? 

And, what does that mean to patients? If you were to ask me what matters to me, I think that's where you're going to start really bringing the interesting bits up. I know Deb has alluded to that several times, and thank you, Deb, for bringing that up. Bringing the voices of those who are living this day-to-day-- the patients, the families and caregivers, to the table-- I think that's where you're going to get some nuggets of wisdom. 

ALIKA LAFONTAINE: Yeah, thanks for that, Claire. Maybe I'll ask the next question starting with Deb. This is from Oras Retallack. The patient and family voice can be so much more useful, helpful, and productive if there is a significant drive to improve health literacy. Is there any move to improve health literacy in the planning and/or thinking? And just a comment that until that happens, it's going to be difficult to develop real patient partnerships. So just that question to you, Deb, about-- 

DEB MATTHEWS: Yeah, I think I would actually disagree with the premise of the question. I think patients know what they need. They don't know specifically what procedure, or what medication, or what. But they know what they need in terms of responsiveness of the health care system. 

I think it's just so important to listen to patients. I also think it's just as important-- or almost just as important-- to listen to frontline workers. And when I mean "frontline workers," I'm talking about PSWs. I'm talking about people who have as much touch with the patient as-- have more touch with the patient than others who are higher up the pecking order that Brian talked about. 

I think there's a great example of St. Joe's Health Care in Hamilton, where they completely redesigned post-acute care for thoracic patients, thoracic surgery patients. And that's now being spread around the province. But it was premised on listening to those home care workers who visited patients after their surgery and connecting them to-- it's a fascinating, a fascinating success story. But it was driven by those PSWs who visited people in their own homes after surgery. 

ALIKA LAFONTAINE: Yeah, that's excellent. That's a great answer. Claire? 

CLAIRE SNYMAN: Yeah, Deb, that's actually, really, a comment on bringing the patient, the voice of those receiving care, and also those who are providing care to the table. As a patient with multiple conditions on two sides of a coin, it's myself as a patient, but those supporting me-- which is my family-- but the health care team. And so it's really essential that the health care team is part of anything going forward, really. 

What did I want to say? Now I'm at a blank. Oh, yes, health literacy, thank you. I actually think that health literacy should be taught from an early age. 

And the reason that I say this is because otherwise, the first time you step into the health care system, sometimes you don't even know if you're allowed to ask questions, what that looks like. And I think from a patient care provider perspective, wouldn't that be great if I knew as a patient, hey, I should actually write down a few questions before I head in about this? Make it a much better, more effective, more even playing field relationship. 

And I think "relationship" is the term here-- a two-way street between the person receiving care and the person providing care. But often, people don't even know that, yeah, you should actually ask questions when you go in. You should think about it before you go in and be a little bit prepared about what you're doing. 

And I think that's what health literacy is all about. It's having an understanding of what your condition, your health care is, and being able to then articulate that in the conversation no matter where you are. So I would love to see that in some matter of form. I talk to my son about that a lot of the time, about what that looks like for him to have an agency in his own health and health care, because that's really important to me as a mum. 

ALIKA LAFONTAINE: Yeah, thank you for that. And I'll direct the next question to Brian. Anataub asks, could we have a session looking at other countries' successful health care systems? So what other countries do you think provide care in a way that we could aspire to? 

BRIAN GOLDMAN: I think that there are a number of OECD nations that have a higher-- certainly a higher proportion of family physicians, primary care providers, compared to Canada. And I would look to Scandinavian countries. I'm interested in the model in the Netherlands because they have an intriguing system called the Buurtzorg model. 

And it's a model that delivers home care, and instead of it being provided by private agencies, it's provided by groups of 12 providers, mainly nurses, and they are assigned to a neighborhood. And they're given a budget, and they work, and they provide-- they work it through. They decide who needs what in their neighborhood in terms of home care. And I'm wondering if that kind of a system could be adapted to, for instance, primary care-- we could have that kind of a model instead. 

There are opponents to the Buurtzorg model, but it's something that I know health care policy analysts were interested in implementing in Canada. And there was a time when it was good to go, but the COVID crisis seemed to put it on hold. And that's something I'd be interested in looking at. 

ALIKA LAFONTAINE: All right, Deb? 

DEB MATTHEWS: Yeah, I wanted to make a comment about this because I think it's really important. I think Canadians think we have the best health care system in the world. We are very jealously protective of it. But the Commonwealth Foundation does really good research. Out of the top 11, 11 wealthy countries, 11 OECD countries, Canada ranked number 10, and we're not even a close 10 out of 11. 

We always compare ourselves to the States, and we shouldn't. We really should look at other countries that have much better-performing systems with less money than we do. And I think they have a real focus on social determinants of health, is one of the things that makes make their health care system a lot better. 

So I think our providers are fantastic-- our doctors, our nurses, our health care professionals are fantastic. It's not their fault. It's the system's fault. And the system needs to reform. 

ALIKA LAFONTAINE: Yeah, thank you for that. Just to the panelists, we've broken more than 100 questions and comments. That's usually a good sign of an engaged audience. [LAUGHS] So we'll continue on with the questions. Rita, you had a comment? 

RITA MCCRACKEN: Yeah, I just wanted to build on that. I get asked this a lot. So which country should we model our system after? 

And again, there is not a systematic review that we can turn to. There's not one system that we can just transfer here. But as Deb and Brian have mentioned, I think there are some really interesting elements that we could be bringing forward. 

Particularly when we look at those OECD countries, one unifying theme that we see throughout, especially, the primary care is this focus on clinics versus physicians. So where you are looking at clinics in a community that are serving, like, a public school system. And so that is something that is quite dramatically different than what we have here in Canada and, I think, deserves some really close conversation. 

For years, we've been saying we can't do that. And I think we really need to be asking ourselves, why Not and, how do we make it happen? 

ALIKA LAFONTAINE: Yeah, thanks for that. So we'll move on to the next question from Rob Robson. And I'll maybe start with Claire for this question. 

At the present time, every province in Canada has legislation which severely limits the ability of patients to learn the details of the care they receive. And then I'll just move a bit further down, just because it's a long question. Without easy access to this information, how is it possible for patients to be truly integrated into teams dedicated to providing safe quality care? And then, there's a question about legislation that needs to be changed, which you can comment on, or we can wait for the other panelists. 

But your thoughts around this, Claire? Do you agree with that? What's your personal experience with that? What's the experience of persons that you've worked with and help navigate the system? 

CLAIRE SNYMAN: Yes, it is hard to try and get access to my medical information. I wish I could take my binders which sit in my cupboard over there. I have one binder this big, and then I have another three binders, which have copies of all my medical records, my MRIs, doctor's reports, because I firmly believe it is in my best interest to have copies of all, basically, my medical story. Because sometimes I've been to medical appointments, and they're like, oh, I didn't get the information from this doctor or this doctor. And I'm like, oh, that's no good. So I take it along with me. 

And 100% agree that it is not easy, and/or if somebody requests the information, there are sometimes barriers that are put up against that, even though if you're in British Columbia, you are able to access and ask for your information. But sometimes there is a fee to do so. And there's sometimes a reluctance to give your information. 

And/or if I ask my MRI copy, a CD, at MRI imaging, it comes to me on a CD-- which, obviously, is a problem because my computer no longer has a CD drive. I think we need to really look at if we are going to bring the patient, family, and caregiver into the fold of a true relationship which is going to have benefits for the entire continuum of care. We need to look at, how do we make that information unfettered so I can access it whenever I need to? 

And it's not just my lab results, which I can get. That is actually the only thing that I can get. And I apologize. I cannot see my vaccination status and my doctor's visits, but I can see nothing inside there. I need to actually be able to see what happened inside there. 

I have a brain injury, so I have short-term and I have long-term memory loss. So let me tell you, I can't remember. I have to keep separate notes on every single thing that happened. Wouldn't it be great if I could access that information? 

And also, it helps my health care team as well. It just helps that whole information-sharing wraparound. So I think we need to look at what can happen from a legislation perspective. I know that there's often this issue of privacy that comes up, but I think if we need to move forward, we need to address that in a timely manner and ask what matters to the people who it's affecting, such as myself as a patient, and families and caregivers. 

ALIKA LAFONTAINE: Yeah, thanks for that, Claire. I'll switch gears and move to another question. But I think for Robert Lester, your question I'm actually going to share for the very end. Maybe we'll have that as a capstone question. I'll read it now just to have the panelists put some thoughts into it. 

We have about 12 minutes left in our conversation before needing to wrap up. It's been a really great conversation so far. But for Robert, many great ideas, but respectfully, many of these ideas have been talked about for decades, perhaps using different terms. What are the barriers that stop us from moving from talk to effective implementation? 

So just hold that question, panelists. We'll end with that one, and we'll move on to Declan. I promise we'll get back to you, Robert. And maybe I can direct this to Rita. 

The vision of a patient medical home for everyone is very strong. How do we ensure that everyone at all levels keeps this vision at the forefront when making decisions about changes in the health care system? It seems that if this is the North Star of where we all need to go, not many who impact the system are looking at it. How does that change? And so that does assume that the medical home is your North Star, Rita. So maybe-- 

RITA MCCRACKEN: [LAUGHS] I had not reflected today about where my North Star is. But the concept of the patient medical home, which is a place-- usually a physical place-- where a patient can go and be known and get the right care at the right time, is certainly-- it's an entirely reasonable place for us to start, particularly for primary care. We know this to be true for almost every hospital in Canada, where you can show up at the door and whatever you need, you're going to get access to in a reasonable time in regular times. 

We've seen some real significant stresses over the last few weeks and, arguably, over the last three years with COVID. But I think, again, we need to make sure that the conversation is staying focused on what the health system is supposed to do, not who it employs and how much we pay them. So what is that system supposed to do? It is supposed to give patients access to the right care at the right time. And that's where the conversations need to be focused on our solutions. 

ALIKA LAFONTAINE: Yeah, thank you, Rita. So I think we might have time for one more question before that capstone question. And I'll actually ask all participants just to weigh in on this one because it's an important question. This is from Shahnaz Abani. The vulnerable who need the most are least able to navigate the present health care system to be able to access it, sometimes because of lack of technology, poverty, mental illness, et cetera. How can we bring care to this group of the populace? And maybe we can start with Brian, and then maybe go to Deb, Claire, and then Rita? 

BRIAN GOLDMAN: You know, Alika, when I visited Japan for when I was doing research for my book, The Power of Kindness, one of the things they talked about in that country is that they do a really good job of providing care for the, say, 5% of the population who are the most vulnerable and who have the least means. And a country can simply-- or a province can make a decision that that's where they're going to direct resources primarily, and perhaps leave it to the middle class to pay a greater share of the health care cost to be able to-- and the well-off-- to be able to support a health care system. 

I don't think it's difficult to do, and I think, as has been-- as was embedded in that capstone question, a lot of these solutions are decades old. We have them. We can certainly provide more resources for people who require complex care. We can provide a better place for them to be looked after so that they don't have to come to the emergency department. We just have to put our minds to it, and it can be done and put the resources into it. If we're a kind and caring society, I don't see how we would not do it. 

ALIKA LAFONTAINE: Thank you, Deb? 

DEB MATTHEWS: I completely agree with Brian. We know what we need to do. We just need to do it and do more of it. 

There's good work that's happening. There's good outreach happening from some of the community health centers. I'm thinking of The Oaks in Ottawa, which is a terrific place for men who have struggled with alcoholism, and it's a terrific project. I don't know, Brian, if you've covered it, but you should. It's fantastic. 

But there are great models, but there, we don't do enough of it. And we need to do more of that street work. And it's not just the right thing to do, but it's also the smart thing to do. Because the better care we can provide for people who are in the margins, the less it will cost the system. So whether you're looking at it from the financial perspective or from the moral perspective, it's a winner. We need to rebalance our spending so that we can spend more reaching out to the people who have the greatest barriers. 

ALIKA LAFONTAINE: Claire? 

CLAIRE SNYMAN: Yeah, I think such an important question. And I think COVID has really broken open in these areas of individuals who might fall into the vulnerable things, like lack of technology, poverty, mental illness. Just individuals who might not be as heard-of as we were in the past. 

And I think some of the areas that I would think of is, how do we bring care to them? Well, we want to find out what matters to them in bringing and delivering care to those individuals and to those communities. It might be engaging with them directly, but sometimes this might be a little bit-- it might be challenging, just to are we able to engage with those individuals in a safe space? But are we able to reach out to organizations that might be engaging with those individuals and find out what matters to them directly? 

If I were to look, actually, I think what's really important as well is, how do we actually support the non-medical and social needs that actually can improve and impact well-being of individuals as well? Not just an individual patient who has a medical condition, but there's a lot of other things that impact me outside of my diagnosis and my conditions. 

So I know in Canada, there's a lot of work that's being done on social prescribing, and I think those are areas that could be looked into to really support individuals outside of medical conditions and look at social determinants of health, and what does that look like? So I'd like to see that explored in more detail, and actually engaging directly with those individuals or through organizations to understand what matters to them. 

ALIKA LAFONTAINE: Thanks. We'll go Rita, and then we'll go back to you, Brian. 

RITA MCCRACKEN: Yeah, thanks, Claire, for the adding on there. I think we need to acknowledge that poverty, racism, and colonialism are real, and they have created massive gaps in access to many of the services that other Canadians take for granted. And we have a health care system that just routinely reinforces those things. And we need to be breaking that down. 

And I think if we were to start putting a focus on every patient having access to the right care, at the right time, and the right place, that that would be a real mind-bender, a paradigm shift for us to think about. We used to create special schools for kids who were blind or kids who had severe physical disabilities, and now they're integrated, largely, into other schools. And we would think it pretty appalling if we were going to tuck them away in a little gated facility. 

And yet, that's what we have done for health care, largely, is we've created special places for these people who are having extra challenges. And I think that we just really need to crack open, what's the basis on which we're seeing these people who are having these extra challenges, and start designing a system that's going to take care of everybody. 

ALIKA LAFONTAINE: Right. 

BRIAN GOLDMAN: If you're looking for one solution that could easily be adapted, I would look to the model that's going on right now in County of Renfrew. 

CLAIRE SNYMAN: Yeah. 

BRIAN GOLDMAN: Where they had a problem during the beginning of the pandemic. A very sparsely populated part of Northeastern Ontario-- the Ottawa Valley, Algonquin Park, Deep River, Chalk River, and not enough primary care providers in a sparsely-populated part of Northeastern Ontario in which 20,000-- about 1 in 5-- people don't have access to primary care. 

They developed a system, and the need of the system-- the primary need that was identified-- was to try and avoid the inevitable transfer of patients to the emergency department of people who didn't have access to walk-in clinics, didn't have access to public transit, but needed medical care. They developed a system with a toll-free number. You called the toll-free number. You spoke to a triage person who would guide you to a nurse practitioner or a family physician. 

They would speak to you either virtually or by phone. If you could make it to the office, fine. If you couldn't and you needed a house call, they dispatched a community paramedic. 

The community paramedics are regarded as the shiny object of the system, but in fact, the glue is teamwork. It's that you have all of these allied health professionals working together in a team with a centralized record. They're talking to each other, and they're servicing the needs of the clients. 

You could easily adapt that kind of a model to vulnerable patients. What you might have to do is add a layer where you could reach patients who might have who might not have a cell phone, who might not have an address, who might have precarious housing. So you'd have to find a way of reaching them, but public health has been doing that for decades. 

ALIKA LAFONTAINE: Thanks for that. So for our final question, we'll just go around the panel. Maybe we can start again with Claire, and then we'll go to Deb, Rita, and then end with Brian. It's the question about moving us from talk to effective implementation. So I think this is really a call to action. 

So I'll ask if you can condense your answer into something chunkable-- maybe one top priority or barrier that you think we should focus on-- and we'll move throughout the panel. Go ahead, Claire. 

CLAIRE SNYMAN: OK, so this is a really important one, I think, and I really like the topic of going, moving from discussions to decisions. And it's hard for me to pinpoint one, but it's really important that we don't just discuss. We need to-- action. Because I know I'm tired, as a patient, of just being more stories, and I just want something to be resolved. 

I think for anything to really be resolved, if I were to put it on my Christmas wish list, it would be that a group of diverse patients, families, and caregivers, and also those providing care, were sitting at a table with federal and provincial ministers to actually have a discussion. Because I think that is what has been missing. I think we need to have some sense of urgency around future discussions, and I think we need to be able to put the voices of those receiving care and providing care right at the table right at the get go. Because I feel if we don't have the input of those-- especially from my side, those receiving care, and diversity is absolutely key-- and form a collaborative body on, how do we actually move this forward, and not just another discussion, but actually driving forward to change and action, we will be sitting having this discussion later into next year, and the following year, and the following year. 

ALIKA LAFONTAINE: Yeah. 

DEB MATTHEWS: Are you asking me? 

ALIKA LAFONTAINE: Yeah, sorry, Deb, yeah. 

DEB MATTHEWS: Sorry. So I think this is really important. I think we need to-- and Claire has gathered the people together, but we need to do some backcasting. We need to say, what does the system-- what should the system look like in five years, in 10 years, in 15 years, in 20 years, and work backwards to actually, step-by-step, follow that path, develop that roadmap. 

So I would start with three parts of the care. The first one would be primary care. How do we move to a team-based model? And I would say I think within five years, all primary care should be team-based care. But let's figure out what we have to do to get there. 

The second thing I would really focus on is elder care. I think we're doing a terrible job providing care for our elders. And I see it, if I were creating where we want to go, I would have much more home-based care, community care. I would have much smaller homes, rather than big long-term care homes that are filled but institutional. But I would look at a whole elder care strategy. We need to implement that now. 

And the third area I would really focus on is homelessness. We know how to end homelessness. We can do it, and we just have to implement those steps that would actually eliminate chronic homelessness. And I think we should set a target to do that within five years. It's doable. We just have to do it. 

ALIKA LAFONTAINE: Rita? 

RITA MCCRACKEN: Yeah, we need-- we have great examples of things we should be doing. One that I think we should coordinate immediately is get some combined provincial and federal funding to establish community health centers across Canada. Let's make it a model that is easy to pop up. And we can get expertise on team-building and leadership from various sources, and we can slowly build up that infrastructure. But we absolutely need some dedicated funding for this to happen and for it to happen in a way that is going to target communities that are most in need. 

ALIKA LAFONTAINE: And Brian? 

BRIAN GOLDMAN: I agree with everything that I've heard. And I would add I think if you want to be able to design a health care system that will meet the needs of Canadians not just next year, or five years, 10 years, 20 years, 30 years down the road, then we have to de-emphasize the role of politicians and try to create a structure that would endure beyond the election cycle, that would consist of wise people that we trust. 

And there are other countries that have done that. In Sweden, they have the Wise List of pharmaceutical drugs that are paid for by the system. We can adapt that system and make it evidence-based, and take the best of other countries, and implement them here. But we can't do it if health care can be changed-- if you can centralize health care with one government, and then regionalize it with the next government, and go back again. We have to get beyond election cycles if we're going to get this on a good footing. 

ALIKA LAFONTAINE: Yeah, thank you. So there were 130 questions and comments that were submitted. I think that really speaks to the discussion and how much it made people think, and reflect, and want to get involved. There were some questions about what happens to this conversation and questions and comments that were not answered. I just want to assure participants that we do read through each and every one of those, the comments that we have during this panel, and what we hear from you continues to help shape Canadian Medical Association policy and the advocacy that we do in behalf of patients and physicians across the country. 

So in behalf of the Canadian Medical Association and the participants who've viewed this session, thank you so much to the four of you. It was wonderful to chat with Claire Syman, Rita McCracken, Deb Matthews, and Brian Goldman. I personally learned a lot. It reinforced a lot of the conversations that I've been having since becoming CMA president. 

And just like Claire said-- and I'll leave it with your words, since you also had the opening word today-- we have to make sure we don't just get back into these conversations again. And so that really is the end goal of having these conversations. So thank you so much to the panelists for participating tonight. 

So thank you all for taking the time to join us today. We're in the final planning for the next Bold Choice session for February 22. We'll be sharing more details in the new year for how to register. We'll also be sending you a post-event survey shortly. 

So please let us know what you thought of tonight's event. You can also provide additional information or reinforce the questions that you might have asked that weren't able to be answered tonight. I really look forward to continuing this conversation. I personally have a strong belief that if we ask the right questions, we'll get to different answers. And I think that I've heard during this panel-- and I hope that you heard as well-- we're saying some things out loud that we didn't say before, and that's a really positive sign for the change that I think is coming. You have a great night, and thank you. 

View 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. 

ALIKA LAFONTAINE: Yeah. Sara F. 

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. 

ALIKA LAFONTAINE: Kevin. 

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

ALIKA LAFONTAINE: And Sara F. 

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.