Bold Choices: ‘We're saying things out loud that we didn't say before’

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.