Session 1

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Session 1 - Harnessing our collective will to rebuild health care

Dr. Katharine Smart

Good evening, everybody. It's great to see people joining us and joining our room. We've got an exciting evening ahead for you. I'm really excited to be your host tonight for the first session of the CMA health Summit Series. I'm the CMA president, Dr. Katharine smart, and I will be moderating this Twitter space is discussion. In a moment, we will hear from a panel of physicians and patient advocates about how to do health differently in Canada during COVID and beyond. We also want you to be part of the conversation and since there's no chat function in Twitter spaces, we'd encourage listeners to tweet using the hashtag hashtag CMA health summit. Since we're all participating in this virtual meeting for many parts of the country, I would like to acknowledge that we are all situated on many different treaty lands and traditional ancestral and unseeded territories. As such, we pay our respects to the traditional caretakers of these lands, and the firmer commitment to reconciliation, our shared stewardship of the land and our relationships with one another. Tonight, I think we have a very exciting and needed conversation ahead of us. The focus of tonight's discussion is saying our collective will to rebuild health care. We all know that Canada's Health Care System is in a crisis, that primary care is imploding, surgical and diagnostic back are overwhelming. And it may take years and billions of dollars to resolve and that in the meantime, patients and patient care is suffering as a result. At the same time, the pandemic has presented us with a once in a generation opportunity to build a more responsive, innovative, equitable and patient partnered health system. So how do we take advantage of it? Where do we start? And how do we make it a reality? I think these are the big ones in front of us. They don't have simple answers. But I'm confident that the panel we have tonight is going to help us get closer to those answers. So I'd like to introduce our panelists today. We have Dr. Tara Kieran. She is the fidelity Endowed Chair of improvement in innovation and family medicine and Vice Chair quality and innovation in the Department of Family and Community Medicine at the University of Toronto. Through her work as a team based family doctor, Tara Tara seeks to improve the healthcare system to better meet the needs of patients. And I know I have certainly enjoyed following her on Twitter and learning from her so I'm excited to hear what she has to say. Sue Robbins is an amazing healthcare activist, speaker and author, which is amazing. I'm always amazed by people who can box her new book ducks in a row. Healthcare reimagined explores the need to shift from a corporate monitor to a re humanizing of the health system. So it's going to be fantastic to have her insights on tonight. Dr. David Urbach is the head of the department of surgery and interim lead medical executive at Women's College Hospital in Toronto. David also focuses on developing new and better ways of providing surgical services that inform health policy decisions and address the issues of access to care patient safety and health system costs. So it's going to be great to have his his insight since surgical backlogs are one of the credibly pressing needs in our system. Dr. Nell Wyman is president of the indigenous physicians Association of Canada and Deputy Chief Medical Health Officer for the First Nations Health Authority in British Columbia. She's Canada's first female indigenous psychiatrist, and has more than 20 years of clinical experience working with indigenous peoples in both rural reserve and urban settings. And I've had the pleasure of getting to know Dr. Wyman in my work was CMA this year, and I'm very excited to hear her insights tonight. So I'd like to welcome everybody to this space. And I hope that you enjoy our conversation. So I'm going to lead off with a general question to each of our panelists. Tonight, we're here and our topic is time differently about healthcare in Canada. And I'd like to ask each of you, what does differently mean to you? So perhaps I'll start with now, why don't you tell us? What does differently mean to you?

Dr. Nel Weiman

Thanks, Katharine. And it really is a pleasure to be here this evening, and hello to everyone who's listening in? Do you know, I think from my point of view, you know, I can't help but reflect kind of, you know, on what has happened during the pandemic, what has happened to people accessing the healthcare system and what has happened to the providers. So, in order to be brief, and have my other panelists have a chance to speak as well, I think I'll speak to, you know, the the burnout amongst exhaustion amongst physicians that, you know, was confirmed and discussed a lot over the last week or so, with the results of the national physician survey that, you know, we have all been asked to do more with increasingly dwindling resources ourselves in terms of energy and capacity. And so I think we're really going to have to address that. And for indigenous physicians, for example, we're engaged in some work right now developing a framework for physician wellness, and joy and work. And I think just quickly the other thing that has risen to the forefront or at least, we're having more discussions about it is how COVID Unmasked A lot of the inequities in our Healthcare System particularly for people trying to access it. And access doesn't necessarily just mean having health services everywhere you turn, even if you live in a rural or remote place, access also has to do with people being willing to seek services when they are in distress. And we did see during COVID that indigenous First Nations Matey Inuit people were very reluctant to seek care in some instances, because of the fear that of how they would be treated in there. I'm speaking about racism and discrimination. So I've got lots more to say on that. But I think for now, I'll stop and hand over to some of my other panelists.

Dr. Katharine Smart

Thanks. Now, that's a great note to get us started off on in terms of some of the things we really need to be thinking about. Tara, can I go to you next.

Dr. Tara Kiran

Yeah. So thanks, again, for having me. And with an amazing panel I built want to build on those comments. Because I would definitely say that differently would mean to me equitable. And that includes really acting on the social determinants of health and having a healthcare system that acts upstream to prevent downstream problems. We we saw during the pandemic that issues like homelessness or precarious housing, Carius, employment, income, race, all of those impacted how well someone was how likely they were to get COVID, how likely they were to get really sick. And although we can address some of those through our healthcare organizations doing a better job at understanding bias and addressing bias, ultimately, I think some of those solutions really do need to be upstream in being able to tackle the social determinants of health and even the structural determinants that determine the social determinants. And by that, I mean racism, capitalism, sexism, etc. I also think a different to me different would mean, integrated health system that's integrated and community based. We saw, you know, in COVID-19, that there, the hospitals were actually pretty well positioned to deal with the crisis that came their way. They have AIPAC professionals working there, who deal with infection prevention and control as their job. They had the resources to redeploy staff as needed, where I think the strain was greater and whether there was less capacity to respond quickly and effectively were in the community based sectors. And those are sectors that have been relatively speaking, underfunded, but are also not integrated with the hospital sector. So you know, can we imagine a future forward where the AIPAC professional, the infectious disease professional at the hospital actually supports the the primary care centers, the home care centers, the long term care centers in being able to enhance their own infection prevention control, and that were working together in a network way? And that were community based, because I think another really tremendous, tremendous innovation and the pandemic or I should say, innovation, because I think we we known this for some time, but something we did, right was, you know, in many areas, was partnering with communities to get vaccinations to where they were needed. That took some time, but ultimately, when it when that was done in cities like Toronto, where I live, but also in First Nations communities. So there's tremendous success in the First Nation communities up in northern Ontario, because they took a community driven community based approach and being able to deliver those health care services. So to me, a better health care system is equitable, integrated, community base. And I'd also add patient centered and creative, but we can get to those in later on in the conversation.

Dr. Katharine Smart

Awesome, thanks for those thoughts. And I love what both of you have said so far. And I particularly love your comments about the importance of looking upstream. Because certainly as a pediatrician, that really resonates with me the need to really be supporting Canadians differently than we often do. Su or T would love to hear your perspective as a patient advocate. What does different look like to you?

Sue Robins

Well, thanks, Katharine. Um, yeah, so I'll be giving a patient and caregiver perspective. And doing healthcare differently to me, I think means looking at the reasons why we do health care to begin with. And I believe that health care at its core is about caring for each other as human beings, and it's about relationships between the caregiver and the care receiver. And I'm just gonna throw this in there, dare I say, I think it's also about love. And we've drifted very far away from what I consider our why. From my patient perspective, we've had a lot of incremental change, but to me, it feels like you're putting a bandaid on in the ICU, and is really not working. There's too much emphasis on what we do programs and services and not enough on the why we are here to begin with. And like I said, I believe that's about caring for each other. And right now, I feel as a patient, that healthcare is really built around the altar of efficiency. You know, I had 12 minutes for my cancer radiation appointment. That's what the radiation tech told me. That's it 12 minutes, nothing more. To get my breast cancer radiation, I had three minutes with my OB, when I when I was pregnant with my last child. You know, we had a cardiac cardiologist sort of dictating or notes when we were still in the room with our little baby with Down syndrome when my son was born 19 years ago, you know, I've had specialists who've had their hand on the door the entire time, they were talking to me, because I knew that they were rushed. And I believe that efficiency causes harm to both the patients and physicians and other clinicians. And that's because patients are not cars to be turned through a car factory, and that physicians are not caught are not factory works. And I'll just close with saying, you know, I have had the good fortune to speak at Grand Rounds, before the pandemic, even all over the world, I was actually in Tasmania, and in Toronto. And the same thing happened to me at these grand rounds in 2019, was that I was talking about kindness and healthcare and things like knocking on the door and introducing yourself and describing what you're going to do before you come in and all these small touches, which are actually a really big deal to patients. But every time I talk, I speak at Grand Rounds, I can see there's somebody agitated in the back, and they're just waiting to ask me a question. And so at the very end of my talk, we open up for questions, and somebody stands up and says, What we don't have time for all these kindnesses. That's what I get told. And if that's the case, and I've heard it over and over and over again, I really feel as if we've lost the plot here with health care in Canada.

Dr. Katharine Smart

Thanks for sharing that too. And I couldn't agree more. And what really struck me as you were talking was, I think, the root cause of so much burnout for the providers in the system, too, is that loss of connection with patients, which is why all of us chose this work to begin with. So I think thank you for reminding us that this is about people. It's about this. It's about connection. And it's not only patients that need that it's also the provider. So I appreciate that perspective. David, what are your thoughts? When we talk about doing healthcare differently in Canada? What does that mean to you?

Dr. David Urbach

It means a few things. And I think what it really means right now is using the this opportunity to address some systemic structural problems in the health system, that have really, really been problematic in Canada for many years, with respect to, you know, provision of surgical procedures, addressing things like access and wait times, and having a system that's really equitable for the population, and accessible to everybody and provides equal opportunities, also to the to the healthcare workforce. There's a lot of discussion now about the surgical backlog about the crisis with people waiting for surgery, the federal government has made a recent announcement of increases to the Canada Health Transfer to try and address this. And I think it's important to remember, when we're talking about a backlog, it's really just an extreme case of a an endemic and systemic problem that we've been grappling with for many years now. I think what's been unmasked to us is the nature of some of these problems, and how much inequity there is built into the system right now, as it exists, we do know that there are some tools available to us that can be really helpful in rebuilding a system that's more sustainable, that's more responsive to the needs of the population, and is more equitable for the population as well as for for the healthcare workforce. So to me, it means not squandering an opportunity to make much needed reforms that will really give us a better and more resilient system as we move forward.

Dr. Katharine Smart

Thank you, David. And I think that's so true. We're sort of at this juncture in time where we need to really capitalize on this moment and make sure that we can move forward with a system that's actually going to be there and able to medians. So we've heard lots of great opening thoughts from our panelists. And I'm not going to move into the next question to sort of explore those issues a bit deeper, I'd love to hear from each of you, you know, you've described sort of what you see your bit of the future, some of the fundamental ideas and values that underlie it. What do you see are the building blocks to create a more responsive, innovative and patient centered and patient partnered health system? I'm going to start with you this time, Sue.

Sue Robins

Sure, okay. The building blocks. Okay. So I just want to build on about what David said about system change. And, you know, I really believe there's two levels of change, there's system change. And there's also what we can do as individuals to make things better in our everyday lives. And, in fact, the ducks in a row is about that about what we can do what is in within within our power within our serenity prayer, but what's in our control and what's not as far as changing healthcare. So I have some very practical suggestions about what I believe from my perspective. I worked in patient engagement for many years, as well as being a breast cancer patient and also the mum of the child with Down syndrome, as I said, and my very practical sister Questions are these there's three of them. The first one is thinking of healthcare environments as healing spaces, not spaces that cause trauma to people. And, you know, you'd mentioned about creativity, I think leaning on the arts and the humanities is a really great way to start that, you know, I think about things like very practical, again, soft music in the waiting rooms turn off CNN and the TV, you know, leaning on the visual arts, and having spaces for storytelling. In fact, the last Children's Hospital I worked in, we started a book club, and we met with families together with staff to discuss the book that we were reading about health care. So really thinking about healthcare as being healing, I think that would be a reframing as opposed to traumatic, which I believe that it is, or it has been for me, right now. The second thing is, is to create safe spaces for feedback. And this to me, I get really stuck on this as a thorn. In my side, I don't think that those folks higher up in administration are open to honest feedback from either patients, or people, clinicians, people who work for patients. And I think if we opened ourselves up to the experience of health care, and what it's like to work in health care, and also to be cared for in health care, and that includes the good, the bad and the ugly, then I think that's where change would actually happen. And that hasn't happened so far. Like I, you know, anytime I've had some constructive feedback, I get shut down as being, you know, minimized or I get called hysterical or, you know, people just really want me to go away. But one point I really want to make is that patients have lots of really great ideas, especially for those of us who are invested in the healthcare system. And what's interesting about creating safe spaces for feedback, and for people to share their stories. There's an organization called care opinion in the UK, and they're also in Australia. And what that is, is a online system where people can share stories about their experiences of healthcare. And they've told me that 60 to 70% of those stories that are shared are actually good positive stories, which I think I wish there was a mechanism for us patients to be able to say thank you, especially now during COVID, to the healthcare professionals that look after us. And then the 40 to 30 to 40% of stories that might more negative or what I like to say is constructive feedback. I think that that's how we get quality improvement is when things go wrong. So, you know, that's my second point. And my third point is, you know, I hope we get to talk about patient engagement, because we talked about patient centered care, I know is in the title. But really, engagement is about outreach. And it means going out to the people and doing things together. I think and beyond the boardroom. And like Tara had mentioned, going out to communities defining what's important to them, is something that I think would really rechange reframe healthcare as we see it today and enough of the ivory tower stuff about people making decisions for us. So far removed with what real life is like both a point of care in the hospital and our communities.

Dr. Katharine Smart

Love all those ideas. So you thank you so much. And I think your point is well taken that we have to when we say we want feedback, we have to mean it. And we have to be open to what people have to say. And we have to think of real authentic ways to partner with patients and hear their voices, not just pay lip service to it. Tara, you have lots of ideas. I know, tell us what do you see as the building blocks?

Dr. Tara Kiran

Thanks, Katharine. I mean, I think I'd like to focus on two building blocks. And, and the first is really building off what Steve said. And that building block is patient partnership, and patient partnership, not just in a clinical encounter, but patient partnership to help us redesign the system. Because I totally agree with what Sue said. And I will say that working with patients has really helped me transform how I look at things, and has revealed to me my own blind spots, and often has led to new and creative ideas that I would never have come up with on my own. Sometimes they're actually obvious ideas that I'm like, Why didn't I come up with that on my own. But in any case, they're ideas that we hadn't come up with, and we weren't planning on executing, but that sometimes are simple, sometimes are complex and make make a difference. And, and so I'm speaking here from you know, when we started back in 2014, to doing a patient experience survey at our family health team to then lots of experiences I've had working with patients around focus groups or patient engagement days or even doing a province wide consultation around with patients. And I've learned so much from that. And I honestly feel that there's one thing I would go back and do differently around this pandemic that I felt I would have control over it would be to really fight to actually have built a Citizens Council during COVID where we could actually ask ordinary people who live in Ontario or Canada, what they thought at various stages and how they would value the trade offs. Because I don't think ordinary people really have that opportunity to engage in dialogue with decision makers to help inform those policies. And so that's just so that I think is a very key building block and thank you super articulating it so clearly. The second thing block is going to be no surprise coming from me. And that is, of course, I think a strong primary care system. So we know that health systems that have strong primary care systems have better outcomes, they have more equitable outcomes. And they actually also have lower costs. And and, and so you know, my dream is that every patient in Canada, every person living in Canada should have a family doctor or other primary care provider. And I don't think this is just a pipe dream, I don't think this is something that is unattainable. I really think we could make it happen if we if we focus on it. And also if we compromise, because I think there are trade offs that that we might need to make to make it a reality, I do think it would take some investment. So I think we, we need to make Family Medicine continue to be attractive to family doctors, and, and, and other primary care professionals. And that means, for example, changing the way we pay doctors, so it's not paper service. So we're not tied to time and the way that's to describe and to expanding team based care. Studies have shown that team based care produces better outcomes. We've just published a study that showed that, you know, teams, patients that will take take care from a team, they seem to help lower emergency department use and then those that weren't. So we know that that we also know that those things, changing the way we're paid as doctors and introducing teams is something that new doctors really want in order to be able to enter the profession. And it's something that doctors who are currently in the profession want to alleviate and address some of that burnout that we've been talking about as well. I do think that ideally, though, you know, those investments come with some trade offs, perhaps with physicians from an accountability perspective. So we need to be more accountable, I think to our communities, and the geographic neighborhoods in which our practices are based, and start to make more of a commitment that we're going to take on unattached patients, for example. And you know, to start, we probably have to be really mindful taking an equitable approach so that we're not just taking any unattached patient or the first comes through the door. But perhaps there's, you know, while we still don't have the capacity, we would desire when the capacity is more limited. Let's start by taking those who are most at need, you know, let's prioritize attachment for, for example, indigenous populations and black populations, population, people who are struggling with opioid addiction, people who we know, have, have a high need for healthcare potentially, or are at greater risk for health, worse health outcomes. So how can we prioritize those people to have access to a family doctor, I think we can do it and there creative ways. And some of my colleagues have already started to do that. So that those are the two things that I would focus on to start patient partnership and redesigning our healthcare system, and strong primary care.

Dr. Katharine Smart

Love it totally agree. So important, and certainly something that we have been trying to talk about a lot, as well as that need to really reimagine that primary care system in this country so that Canadians have access to the front door of the health care system. It's so critical and concerning where we're headed. And I think we're going to hear more from you on that topic shortly. But David, I'd like to go over to you now, what do you see are the building blocks that you'd like to see?

Dr. David Urbach

So I think I'd like to build a little bit on what Tara was just describing, with respect to working in teams and abroad are integration across the system, because I think that really applies to the way that we deliver surgical services as well. One of the problems right now is the the lack of coordination and the the siloed, and highly independent nature of how it of surgeons work and Canadian hospitals and how surgeries organized and I think there's tremendous opportunity for greater participation within the health system of surgical care providers. So that, you know, for example, we could be more coordinated into teams, you know, sharing the care of patients, we could have single entry models where pay, there's a central intake, or as a single queue for patients who enter a system so that wait times for surgery are more equitable, without as much variation as we see from region to region and hospital to hospital. Overall, these have a lot of benefits to the population and improved satisfaction with care as well as confidence in the health system. So I see that as a huge opportunity for system innovation, when it comes to how we organize surgical care. The other area that people often talk about is greater investment in the system, you know, greater funding or ability to increase the supply. It's important to realize right now, although, obviously, we need to provide as much surgical care as possible to address the issue of backlog. We do have some limits, primarily right now. We're really stressed with respect to Health Human Resources, skilled nurses and hospitals, and nice to test surgeons. Well, we really don't have that much capacity to really To increase the amount of services, we provide eight points. And I think, right now we really have to focus on what we can do to better coordinate and streamline the movement of patients across the system to be able to enhance access with the resources that we have.

Dr. Katharine Smart

Thanks, David, I'm hearing some definite themes emerge, I think from everyone a lot working as teams be more efficient with what we have looking for those potentially easy wins just by reorganizing how we do things and that importance of, of patient ideas and centering some of this on what they see. Because sometimes the solutions might be more obvious than them than they are to us. Now, I'd love to hear your perspective, what I think are some of the critical building blocks that we need to be thinking about as we reimagine the health system.

Dr. Nel Weiman

Yes, thanks, Katharine. I think my comments actually, I think, are very much aligned with what people have already mentioned. Here in British Columbia, which is where I'm situated, and I do work for the First Nations Health Authority, you know, even prior to the pandemic, there was a lot of effort that went into using cultural the, the ideas and actions associated with cultural safety and cultural humility, hardwiring those into the health system, this leads to health transformation. And and people have mentioned, you know, the, the concepts related to cultural safety already. But, you know, it is an outcome that's based on respectful engagement that recognizes and strives to address power imbalances inherent in the health system. So we hear that, you know, when people have mentioned patient centered care, for example, and cultural humility of the providers is, you know, that we all undergo a process of self reflection to understand personal and systemic biases, and to develop and maintain respectful processes and relationships based on mutual trust. So those concepts, I think, as lay a foundation for First of all, providing better care, increasing access, but in the benefit that everyone is it's it's a better system overall. And it manages to reach out to some of those communities and populations that have been underserved to date the some of the communities that Tara mentioned. So I'm using this in the in the, in the context, because of the work I do with First Nations, but it's really applicable to all and you know, here in British Columbia, for example, we are working on the finishing touches to developing a provincial standard, a partnership between the organization I work for and health standards organization that lays out the different domains that are required to increase cultural safety as part of different health organizations and health systems. And their you know, people I'm sure have heard of the different reports that have come out of BC during the pandemic as well, including the in plain sight report, which found that racism is widespread in the health system here in BC. So the other thing that I would mention, when we're talking about team based care and expanding different models of care, I would, I would say, from, you know, a First Nations lens from an indigenous lens, being able to work in what we call a too wide using a too wide seeing approach. So recognizing the value of Western medical systems and ways of being recognising the importance and value of indigenous knowledge and ways of being and, and that's not to say that every indigenous patient is going to want to see traditional healing or ceremony as part of their health care. But up until now, it has been really difficult for indigenous patients to access that in many instances, and that I think, you know, being able to provide work in those two systems in different settings, I know this is happening in other places across the country, not just in British Columbia CAMH, for example, in downtown Toronto, that provides better patient care, in this instance, to indigenous patients, but for other intersectionalities other groups, there are similar models that could be that could be used. So I think cultural safety in the system, cultural humility of healthcare providers prevent provides a really good background or foundation for moving transforming healthcare in Canada.

Dr. Katharine Smart

Thank you know, for highlighting that it's so important. And again, I think something that we just keep learning more about it and how critical it is to create a safe space for patients. And as you touched on an opening, actually having them want to access the health care system and having it be a place where they they feel safe is so important. We've been talking I think quite a bit about primary care. And I'd like to dive a little bit deeper into that issue, because it's such a critical problem right now, you know, as people have outlined tonight, we know that primary care forms the foundation are the backbone of our health care system. It's the front door into the health care system. You know, as Tara said, a high functioning primary care system is better for patients. improves people's lives makes people's lives longer higher quality and cuts called health care system. Yet we also know we're facing this huge crisis in primary care, I think a huge variety of reasons. But the reality of that is that all, you know, over 5 million Canadians don't have access to a family doctor. And we're expecting that to get worse, not better if something doesn't change. Also, our recent national health survey showed that almost half of doctors are planning on cutting back their clinical hours in the next two years. So it's it's concerning? You know, Tara, I know that your research really focuses on quality improvement and innovation in family medicine. And you you've already alluded to some ideas you have around the fact that we should have that goal of getting every Canadian, a family doctor, do you think it's achievable? So tell us more about that. What are you doing to innovate in this space? How do we get doctors practicing longitudinal Family Medicine, what can we do to get things back on track?

Dr. Tara Kiran

Yeah, such important questions. And, you know, I want to start just by building on what you said Katharine, about that the problem is just going to get worse right now. So I think, fortunately, some of the research that we've done ourselves here in Ontario has shown that the proportion of family doctors who stopped working was much higher in the first six months of a pandemic than it was for the 10 years prior to that. So that data to me suggests that, you know, many doctors went into early retirement. At the same time with then surveys of family doctors in Toronto and found that nearly one in five physicians, family doctors in Toronto have an active practice, are thinking that they may close their practice in the next five years. So yeah, really concerning that, we already have a workforce shortage and things may be getting tighter. So I do think that we need to place pieces to stabilize our workshop force and make Family Medicine attractive to the people who are in it now and to new graduates. And the noticing, as I was saying earlier, I think that that involves payment reform. And it's great to see that advancing, for example, here in Ontario, and as well, in British Columbia, there are some pilots that seem like they need to be expanded. There are other pilots elsewhere as well. But we really need to move away from fee for service more towards blended payments and payments that encourage also care of people with complex who have medical complexity, because that's been a weakness in Ontario for some time. And then, you know, working in teams, so I work with a pharmacist, a social worker, a dietitian, nurses, these are all part of the my amazing team, in my practice, which is a family health team. And I feel lucky to do so every day. And so that's, that really transforms how I can deliver care. You know, I'm many, many years from medical school, but I can still keep some of the latest new medications, including new medications to treat COVID, because I have a pharmacist who is in the office beside me who I can consult and who can give me advice around starting these kinds of new medications. When a patient is struggling with depression, I have a social worker who I can turn to to ask, you know, what are some, you know, resources that might support them? Or can you see them for a short time for a limited amount of time to kind of get them stabilized? So So, and then, you know, the nurses are absolutely indispensable. So for, for example, when people we were managing a lot of people with COVID, as vocations our nurses ran a whole COVID care at home program, where they would check in with with, with folks and I know many of my colleagues practice it practice in settings that don't have those resources. And that's not fair to them. And it's certainly not fair to their patients, we need to expand this kind of team based model, which works which provides joint work and better patient outcomes across the country. I also think that there's ways in which we can really lean into creativity and collaboration and learning from what's worked right in different settings. And so I'm most familiar with the innovations occurring in Ontario, but I want to just draw attention to a couple of colleagues who have been doing amazing work. So Jonathan Fitzsimons, and Renfrew County, for example, has been doing incredible work collaborating with paramedics to deliver primary care in an underserved rural area and then trialing Virtual Family Health Team as a way to deliver care to unattached patients as well. So using creative solutions, to try and meet a very challenging problem. Another person whose work I'd like to highlight is TFM, Doctor TFM, a close colleague of mine who that se trata family health team. She's worked with colleagues in the East End to join to put together a family practice network. And these, this family practice network was really instrumental in COVID. And being able to deliver vaccinations and in long term care in their area. They were one of the first to be able to, to actually complete all the vaccinations and long term care in their neighborhood to take care of patients in retirement homes, to step up during port when it came to testing and some of the priority neighborhoods in Toronto as well. So that network of doctors was stronger than any of the single doctor practices on their own and And how can we learn from these kinds of innovations? I think we can I think we can start to move towards more network models where we support each other to care for our communities. And that's the kind of innovation I'd like to see coming out of the pandemic.

Dr. Katharine Smart

Thanks for highlighting those examples. And again, I think we're just noticing a lot of themes that we're caring for each other, you know, this idea of team, working with other like minded people feeling supported to care for patient sharing, sharing that that work, to make sure that patients are getting what they they needed. And finding that joy again, in this work, which I think takes us back to what Sue said at the beginning, which is that medicine should be about connection and kindness and finding the finding that with each other.

Sue Robins

I Katharine, Can I just jump in really quick. I'm just thinking about primary care. You know, when we're talking about team, I always have this hope I was saying about the reimagine healthcare world, but that we're not only talking about professionals that we think about patients being on that team, too. I think that that's really, really important. And I was just thinking when Nell was speaking, you know, she was talking about choice and giving people choice as far as what type of medicine they want to access. And a lot of people ask me about patients, they say, though I don't represent patients, I only represent myself, but they say what do patients want? And my answer is always It depends. And how do you find out what patients want? And the answer to that is ask them. So when terror terrorist talking about all the different team models, and I came from Alberta, which had, I don't know if it still does, but it did have, at the time, a very strong primary care network model. And I think having that choice, when you enter primary care to go to a social worker, or an NP or a pharmacist, I think that's something that patients would embrace as well. And also have, you know, choices of urgent care centers and places are open a bit later. So we don't always end up in emergency. And, and no, the choice I think works both for you as the professionals and for us patients, because we're not alike. None of us are alike. So there is no one answer for everybody.

Dr. Katharine Smart

Yeah, so true. Totally agree with that. And I think that's a great perspective. And you're absolutely right, I think we need when we think about what we mean by team, we need to be thinking about patients and their plays on the teams with us collaborating 100%. So, Tara, I know you work in Toronto, and you're talking about colleagues, Ontario, I live in in the north in the Yukon. And we know that there's, you know, other challenges for sure, reaching remote and rural communities. And I know that one of the really exciting things I think we've seen out of British Columbia, and the First Nations Health Authority is their work with some more remote and rural First Nations communities. And we've saw, again, a ton of innovation and important models of care that were created there to make sure that patients, First Nations patients in BC were able to access care. So now, I was hoping you could tell us a bit about your experience working at the First Nations Health Authority during the pandemic, when what the rest of the country can learn from your health authority, and the way it was able to guard and champion the health and wellness of indigenous people in British Columbia.

Dr. Nel Weiman

Yeah, thanks, Katharine. I think you know, one of the one of the things that happened at the very beginning of the pandemic was we realized that people would need to, you know, would need to be in touch with health services and access them, even while many communities are located in rural remote and very isolated settings, in some cases, some communities or only fly in. And so very quickly, a virtual service was set up, which was the virtual doctor of the day program. And for the first time, some people had access to primary care that they didn't before. And of course, the the service was grounded in cultural safety and cultural humility. And we found that people you know, who hadn't access for the variety of reasons that I've talked about, and others have talked about earlier, was you know, there was really good uptake. And then almost quickly after that, we realized, the other thing to remember is that British Columbia has actually been living through two public health emergencies. One is the COVID pandemic, and one is the toxic drug poisoning crisis. And in many ways, First Nations communities have been disproportionately impacted by both. So there was another virtual service that was set up the virtual psychiatry and substance use service where people could see either psychiatrists and or addiction medicine specialist. And the two of those two virtual services worked together in a complementary fashion. So if you are unattached, for example, to a primary care provider and wanted to be seen during the psychiatry service as an example, you could quickly be seen by the doctor of the day and then referred on to see the specialist so that was something that will that was stood up, it quickly reached capacity. But and we're looking to expand and it will be one of our legacy pieces as the you know, as the pandemic sort of, hopefully at some point starts to wind down. And then I guess the other thing you know, that was I mentioned, I think it was Tara mentioned, it was just creativity, you know, being able, even in the midst of being very stressed, and everybody working very long hours, like the vaccination rollout, for example was, you know, extremely successful here in British Columbia because people used creativity as a way to deliver vaccines and one creativity, one creative way was, we took a whole of community approach, whereas the rest of the province was allocating the nation by age group, we strongly advocates for a whole of community. So communities were 18 and older to start with were vaccinated. So those are just some quick examples. But I think what I really want to stress, I think, for us, as physicians is that need to, you know, even though we're kind of overworked, and we're feeling we're feeling stressed out, we're feeling overwhelmed. But there's always been that space, that motivation, that drive to continue to advocate for our patients and, and be creative in doing so and looking for the solutions. And that will differ, of course, across the different provinces and territories from coast to coast to coast.

Dr. Katharine Smart

Thank you Now for those examples. And again, I just think it's amazing to see how people were able to pivot in a crisis to leverage different tools to actually improve access to care, which is amazing, right? Because we were worried about that, how are we going to reach people, and you've actually been able to find a model that improved care beyond what communities had experience before? And then how do we keep moving that forward. So it's amazing to see, like you said, just that creativity, and that importance of seeing communities and their unique needs and listening to what they want, which has been telling us about a minute pivot a bit away from primary care now and back to something we talked about a bit at the beginning. We know in addition to the crisis in primary care, probably one of the other biggest pain points in the current system is the backlog issue. We did report at CMA last fall and estimated that we were going to need a minimum of $1.3 billion in funding to clear that backlog across only eight medical procedures. So we knew that was really the tip of the iceberg. And that was before the fourth and fifth waves of COVID that increase backlogs er, and we know that the main backlogs are imaging and surgery. And we know that these delays have had an incredible impact on people's quality of life. And there's a lot of suffering. You know, David, you're a surgeon, you're the head of the Department of Surgery at a large hospital. And you've talked a little bit about you have some ideas about what we could be doing about love to hear more from you about what are some innovative approaches to improve capacity, and reduce this growing backlog and these rarely critical, important surgical procedures.

Dr. David Urbach

So I think some of the technological innovations that we've seen over the last few years have been really helpful in addressing some of these problems. You know, in particular, use of, you know, for example, outpatient surgery for common surgical procedures. You know, total joint replacement, which historically had always been an inpatient procedure with a few days in hospital has been transformed into essentially an outpatient procedure for hip and knee replacement. A lot of surgical procedures can now be done on an outpatient basis, which really helps improve efficiency decreases dependence on hospital beds, which obviously become very, very scarce. So these types of technological innovations have been really helpful. And I think it's a trend I'd like to see continued, which is innovations that, you know, in the past, it seemed like a lot of innovation just really increased cost and complexity. But now we're seeing innovations for sustainability and for efficiency within the health system that I think is going to be really important. So those types of innovations are really helpful for improving our capacity to do surgical procedures. There's probably also some work we can do on the demand side, we do know that in addition to this huge backlog of patients who are currently waiting for diagnostic imaging, testing and procedures, surgery, you know, a lot of those are for urgent and critical procedures. But we do know that a lot of people are waiting for tests or procedures that they may not necessarily need. If we can do a better job at improving our appropriateness to make sure that the patients on the waitlist are really those patients who truly need the the tests or the procedures that they're waiting for, will obviously reduce the wait times for everybody within the health system.

Dr. Katharine Smart

That's such an important point, I think about that accountability and how we're using resources and making sure that they're being used effectively. So that there is more access to people and and I think that's, you know, one of the things we've been talking about is the need to have more of a data driven healthcare system. And I think what you're talking about would, you know, is just one more example of how data could improve the way we utilize our resources if we're able to track and monitor the appropriateness of diagnostic imaging, testings, referrals, surgeries that patients have to make sure that we're optimizing those outcomes. So I'd love to hear from Your perspective, like as a patient, what do you think we could be doing to reduce wait times when you're hearing this conversation? What springs to mind for you?

Sue Robins

Well, I'm currently waiting for a mammogram. And I've been waiting for six months. And I still haven't received my appointment from the Cancer Agency. And I did have breast cancer before. So it's a little bit distressing, in the waiting, and I wanted to talk about the data, because I'm a data person, but the stories behind that, and I used to work at a children's hospital that had an Autism Clinic, and there was a very long wait list for the families to come in with their kids to get diagnosed, to have the assessment to get diagnosed with autism. And I would talk to many, many of those families in that waiting, and how distressing it is to wait. And in fact, the time between I went to my family doctor, you know, with a lump in my breast to when I finally got my breast biopsy was three months. And I have to say that that waiting was purgatory, it was awful. It was like the worst thing, thing, you know, once you're finally off that waitlist, and they're doing something, I think mentally that's a lot better for patients. So I've always wondered about weightless, if anyone has ever talked about the experience of either being on a waitlist or waiting to get on a waitlist, which is there's this pre waitlist thing that happens to right, while we're waiting for a referral to a specialist, and how we are caring for people while they're waiting. I think, you know, in the absence, like David said, you know, there's certain capacity for Oh, ours and surgeons and and if we reached that, particularly with that staffing crisis, is there a way for us to be caring for people while they wait, so that they don't experience so much in the waiting. And I think, you know, people like peer support workers and social workers could really, you know, nursing navigators, those types of people could probably step in and make your job this positions a bit easier, because we're not quite as distraught by the time we get to you, right, within the waiting. So, you know, as we talk about these kinds of hard things, these database things, I just hope that we can always think about the experience and the story and what goes along with it and talk about those things together.

Dr. Katharine Smart

I think those are great points. And I think, you know, the other thing it touches on I think is how much we've normalized waiting in our health care system. Right? We've, we've taken waiting for all these things as you as you outlined and kind of made it an expected part of the experience rather than asking those questions about could this look different? And I absolutely agree with you. And I see that certainly with my patients. Just the stress and anxiety that people experience when they're waiting, particularly as you said, or maybe not experiencing care in that period can be really impactful.

Sue Robins

Yeah, even even the term backlog like that return that reminds me of like a sewage backup, like hope that we can remember that there's people behind the numbers, like that's one of the things I've despaired about so much with the pandemic, is that I feel like our public health officials have totally dehumanized, you know, people have gotten sick and died from COVID. And what's really important to me, as we start, you know, remembering there are people behind the numbers who have families. And, you know, always talking about both right, the numbers are important, but also the story pieces important to

Dr. Katharine Smart

know, I absolutely agree with you. And I think there is nothing more powerful than that stories. And I think they're very compelling. And they're an important part of, like you said, moving past just just the numbers to really understanding the human the very real and human impact of these issues. So we've got about six minutes left in this discussion, and was just announced today that the federal budget is going to be tabled on April 7. So we've heard today about lots of potential areas that we want to see focus on that we think need to change. So I'd like to just ask each of you to close out with what you're hoping to see in the budget, and what needs to be in there from your perspective to address the future of healthcare. So why don't we start with talk, Tara?

Dr. Tara Kiran

Katharine, there's always so much that I think we all want to see in the budget. I mean, maybe I'll just start by saying that I I am hopeful for that we will make progress on national dental care and PharmaCare program. That's been a long time coming and will really help to improve the health of so many low income Canadians. I know that the details right now are a little vague, especially on the pharma care. And so I do hope that there are more details that will see this forward in the next short while. But building on that I thought Andre Picard had a terrific op ed in the globe that I read this morning, that just really helped, you know, talked about how we need to step back and think about you know, what, what is Medicare about and what should be covered in Medicare, and for so long, it's been, you know, focused on physician and hospital services. And so it's great to see the dental care and the home care, but sorry, the dental care and the PharmaCare. But of course, what the pandemic and pre pandemic reports have highlighted is, you know, we need to also bring in long term care and home care better into our system and mental health care, mental health care. have, you know, there have been some great innovations during the pandemic just or great new services, I should say, during the pandemic, that have allowed people to access that virtually I think those kinds of things need to be expanded to have greater public access and a structured way. I think some, you know, work we've done around home, transitions from hospital to home has really shone a light for me on how patients and caregivers, they think the non priority for improving that transition would be better quality and more accessible home care. And then, of course, I don't think I need to tell anyone who's listening about why we do invest better in long term care. So I think we need to really take a look at these other sectors. And I'd like to see more of that in the budget upcoming.

Dr. Katharine Smart

Yeah, totally agree. Absolutely. And like you say, when we say universal health care, we really need to define what we need mean by Universal and and I think that list that you offered is much more comprehensive than what our system currently offers Canadians. Now, what would you like to see?

Dr. Nel Weiman

Well, I think in addition to what Tara has mentioned, I think the one thing I would like to see is an expansion of services that offer, you know, both Western medical services and for indigenous people, you know, indigenous forms of healing ceremony, cultures healing, you know, there are models of this across the country. But I would like to see funding for the expansion of those services.

Dr. Katharine Smart

Thank you. Yeah. So, so needed. And I certainly see that in my work in the Yukon and that something our communities, they're asking for, David, your surgeon, what do you want to see in the budget,

Dr. David Urbach

I'm just most worried about the degree of federal investment in, in health care, I think it's really important to make sure that it doesn't wane much more, because I do worry about the provinces, ability to be able to provide comprehensive services that address the principles of the Canada Health Act. And with the declining share of provincial expenditures that's covered through the Canada Health Transfer. I think we become at risk without continued and increased federal investment in health care. And I think that's the most important thing I would look for from the federal government.

Dr. Katharine Smart

Absolutely, that's critical. We know that dollars have stagnated, and they're sent to decline as a percentage cost. So stabilizing investments in our system will be key. So I want you the last word, what matters to you in this federal budget?

Sue Robins

Boy, I'm hardly an economist. I've got a degree in Shakespeare. But anyways, let me give you a sense, from my bias perspective, I have a son with a disability. Well, dental and PharmaCare is very important to us, I just paid his dental bill a couple of days ago, and that would be great to have help with that for disabled people. But I think what we're really missing is some sort of disability benefits that's universal for folks who are disabled across Canada. So it's not just so piecemeal, province to province species benefit amount is extremely low compared to other provinces, considering our cost of living, especially since there's going to be a lot of people with long COVID that are going to be flooding into the system fairly soon, and who are unable to work and who need that support as far as a disability benefit. And I know, it's something our organizations have been lobbying for. But I gotta tell you, you know, you talk about equity and inclusion, disability tends to come last. And so I wanted to make sure that I mentioned it, my son certainly doesn't get nearly enough money for him to be able to live on and get $400 a month for rent, which in Vancouver area is ridiculous. So there's that. And then my other two things is, if I had a magic wand, and I'm doing real blue sky thinking, and I know this is not going to show up in the but I wish nationally there was some mandate that there had to be engagement with patients, not just at the hospital level, but at all levels in health care, including community health care, including public health. I wish this was more of a mandated thing like it is in some of the Australian health regions and in the NHS in the UK. And also, I think we're counting the wrong things as far as funding, really, we count like efficiencies and acuity and length of stay and all that type of thing. And what I wish that we counted were feedback mechanisms, like the patient experience, and what the experience is like in health care. I wish that that was somehow tied to funding because I think that's the only way the patient experience is going to actually improve. So those are the three things that disability benefit, mandate engagement of patients, and also some sort of mandatory feedback mechanisms for patients.

Dr. Katharine Smart

All fantastic ideas. Well, we're out of time unfortunately, feel like we could carry on this conversation for a long time. There's so much knowledge in this group of panelists and, and so much to be done in the healthcare system. But I really want to thank each of the four of you for your time tonight and your insights and how to build a stronger, more sustainable and patient centered healthcare system. And to everyone who joined us tonight as a listener. Thank you so much for taking the time to join. It's not too late to tweet your thoughts about The session or any ideas you have or things you want to contribute to the conversation about how we should do health differently during COVID and beyond, so please use hashtag CMA health summit. We'd love to see your ideas helps us think about future events and to inform these discussions and questions for our next time. May 11. Will be that next EMA health summit session and we are going to be focusing on health care and economic prosperity. So for now, good night, and thanks for joining