Doctorless clinic has higher costs

Santé Kildare’s very own Dr Michael Kalin recently had an editorial published in the Montreal Gazette!

Re: “Clinics without doctors viable, U de M report finds” (Montreal Gazette, Sept. 11)

The focus of the study, Quebec’s only “doctorless clinic,” registered 1,700 visits over a nine-month period ending in June 2015. In other words, the nurse practitioners assessed less than 200 patients each month or about eight patients per day.

Régine Laurent, president of the Fédération interprofessionnelles de la santé du Québec, concludes, “What this report shows us, is that changing primary care to include more health professionals — not only doctors — really works and greatly improves accessibility.”

In the midst of the Bill 20 ceasefire between the health minister and the province’s family doctors, I am not sure how or why this clinic is being presented as a model for effectiveness and accessibility. The minister’s intentions were clear to the doctors: more patients, faster care.

Maureen Guthrie, a nurse who works at the clinic, comments that many families in the neighbourhood use the clinic “because they have no family doctor.” In fact, according to the researchers, 64 per cent of the clinic’s patients said they had a family doctor. The problem was getting a timely appointment with their own physician.

Of note, the estimated cost of $68 per patient visit in the doctorless clinic is almost 50 per cent more than the cost of a family physician seeing a walk-in Groupe de Médecins de Famille (GMF) clinic.

Working together to improve patient care and accessibility should be everyone’s goal. A multidisciplinary team of doctors, collaborating with nurses and other health-care professionals, as promoted in the GMF model remains the best option.

Michael Kalin, Montreal

Sun Safety

It’s that time of year – school’s out, La Ronde is open and the sun is shining! So let’s take a look at how to stay safe in the sun!

 Sure there are definite benefits to sunlight:

 – It can help with mood (for example people with seasonal affective disorder have improved mood when they are exposed to sunlight, which is why sunlamps are used for therapy during winter months)

– UVB is an important ingredient for the skin to be able to make Vitamin D (all you need is 15 minutes to a couple hours depending on skin tone and on the amount of skin exposed to make more than 10,000 units of vitamin D!)

– Some skin conditions can improve in sunlight (eg. eczema, psoriasis) which is why PUVA is a treatment sometimes used by dermatologists for people with really severe cases

But don’t forget the risks!

– Dehydration! Heat exhaustion! Heat stroke!

– Sun burn

– Skin damage: sunburns, wrinkles, skin cancer!

– More sun burn

– Damage to eyes leading to cataracts and cancers of the eye

– Even more sun burn

            Ever had a really bad sunburn? It can be excruciating, it can blister and you can even get a fever. It’s not worth missing a few days of summer to sit at home covering yourself in aloe vera. So here’s what you can do to protect yourself!

1) Stay informed!

 – Check out the UV index each day (for example the weather network broadcasts it daily). More than 3? Protect yourself!

2) Avoid the times of day when the suns’ rays are strongest

 – 10am until 2pm is peak sunburn time

3) Wear a hat!!!

– I don’t care if hats don’t suit you. Do it. The tip of your nose will thank you.

4) Wear sunscreen – and wear it properly!

 – Choose broad spectrum sunscreens that cover UVA and UVB rays. Use at least SPF 15, but better to aim for SPF 30. Don’t bother with anything higher than SPF 50, the increase in sun protection is negligible (in fact the FDA is making companies in the US market products as 50+ because the difference between 50, 60, 70 and up is almost zilch!)

 – Put it everywhere and apply liberally

 – Reapply every 2 hours, or more often if you are swimming or sweating

 – Don’t forget the tops of ears, the tops of feet, backs of hands, back of the legs! And double up on the nose!!

5) Wear protective clothing

 – I hated it as a kid but wearing a t-shirt over my bathing suit at the beach saved me from a lot of burns!

6) Check your medications with your pharmacist

 – Some medications (for examples some antibiotics, chemotherapies, diabetes medications, heart medications, diuretics, antidepressants, anti-inflammatories, antihistamines, birth control pills and topical creams) can increase your sensitivity to the sun.

7) Drink LOTS of water – heat exhaustion can sneak up on you. Be on the lookout for warning signs, especially when doing physical activity in the sun.

            – Signs of heat exhaustion are: weakness, fainting, muscle cramps, headache, nausea and vomiting, cool clammy skin and fever

            – It’s important to prevent heat exhaustion by staying cool and drinking lots of water because heat exhaustion can lead to heat stroke, which can be dangerous.

8) And don’t forget about your eyes!

 – Wear sunglasses whenever possible

 – Check that they protect against UVA and UVB rays

What about kids??

All the same advice holds true for kids – but you have to be even more careful. Kids’ skin is extra sensitive to the sun and they are more at risk for getting dehydration and heat stroke.

 Basically follow all the aforementioned rules but BE MORE STRICT with little ones!

And what about babies under 6 months? Well, really they shouldn’t be in the sun. But that’s a lot easier said than done! So keep baby as protected from the sun as possible, remember that babies can burn from reflected sun or even dappled sun. Dress baby in loose, cool clothes and a hat to cover as much skin as possible. And then if you can’t avoid having baby in the sun definitely put a little bit of SPF 30 on only the sun exposed areas (like the hands or feet or face).

For more information check out the following:

The Canadian Pediatric Society

Health Canada

Canadian Dermatology Association


We Walk the Walk……We Talk the Talk

Have you seen Dr. Mike Evan’s video 23 ½ hours?  If not, I urge you to click on the link.  It will change your life.

Ok, now that you have watched it you know what to do.  Why not do it with it us?  Every single day of the work week, weather pending, we walk at lunch time.  The benefit of walking with Group Santé Kildare is that there will always be a healthcare professional walking with you.  Our professionals include nurses, dietitians and over 20 doctors.  Imagine how motivating it would be to walk with people who practice what they preach!

Dr. Mike explains in his video that you don’t even have to do the 30 minutes of walking consecutively.  You can stay fit by doing three 10-minute slots  or two 15-minute session powerwalks.  Keep your intensity at a moderate pace. Your heart rate should be elevated and you are sweating a bit, you can talk but not carry on a whole conversation.    If you are not sure about your pace, you can always sport a heart monitor like the new Fitbit Charge HR.  It also tracks steps taken (10,000/day is ideal), calories burned and quality of sleep. 

Sometimes walking in a group can break the isolation and monotony of walking alone.  Your healthcare professionals will provide a hefty dose of motivation and encouragement.  Come join us!  Bring a water bottle and a good pair of walking shoes. Let’s go!




“Supernurse” or what?…

On my first visit to Clinic Santé Kildare I was showered with welcoming smiles, the atmosphere of a friendly and reassuring environment, and enthusiastic promises of the opportunity to work at the Best GMF clinic in Montreal.  Today, two weeks into working here in my “newfound home”, I am happy to admit that I am savoring each moment of being a part of such a cohesive and supportive multidisciplinary team. While holding a belief that many of us, primary care nurse practitioners (NP), have to deal with a range of fears and anxiety when first stepping into our field I cannot overemphasize the importance of the work environment.

As a relatively new profession in Quebec we face numerous challenges due to the lack of public awareness. While NPs have been successfully practicing in US for over 40 years in Canada there are few people that are familiar with our profession. All provinces and territories currently have legislation in place for the NP role however the level of autonomy of the nurse practitioner varies greatly province to province. Quebec was one of the last provinces to introduce NPs. It was not until 2003 that we had our official legislation. Is it any surprise then that the very first primary care NP graduates could be counted on the fingers of one hand – only 3 in 2007?! Meanwhile, in July 2010, Quebec announced it will spend $117 million to boost the number of nurse practitioners from 56 to 556 before 2018. In 2012 we almost made it to 100.

Increasing the numbers is great, but what about public awareness?! The media has dubbed our profession “super-nurse”.  I do not know how that is helpful. Every time I introduce myself or mention my title to a patient or a health care professional it feels like one interaction is merely not enough to shed some light on the whole scope of our role and responsibilities. Some patients still think I am a doctor; I am not. Others believe that nurses and nurse practitioners are one and the same… yet another misunderstanding. Although we do start off as registered nurses, we have a minimum of two years of clinical experience in primary care, and receive graduate level education and training. To become a nurse practitioner upon successful completion of the Graduate Diploma Primary Care Nurse Practitioner program we are required to pass the advanced practice licensing exam of the Order of Nurse of Quebec. We work in collaboration with clients partnering physicians and other health-care providers in the provision of high-quality patient-centered care.

We are not there to replace nurses or doctors! We are there to integrate our in-depth knowledge of advanced nursing practice and theory, health management and health promotion, disease and injury prevention to provide comprehensive health services. The application of these equips us with necessary skills to

·      make a diagnosis i.e. to identify a disease, disorder or condition;

·      communicate the diagnosis to the client and other health-care professionals as appropriate;

·      initiate, order or prescribe consultations and referrals (with some limitations);

·      order and interpret screening and diagnostic tests (with some limitations);

·      recommend, prescribe or reorder drugs (with some exceptions).

We can also help the residents who don’t have a family doctor to get primary care. As NPs we are trained to look at the person and his or her lifestyle and work together on a strategy that not only addresses the illness but also ensures illness maintenance and prevention.

You would certainly agree that for Canada’s health-care system, which faces long wait times and a shortage of doctors and money, this is a good thing. We all hope that spending health-care dollars on more nurse practitioners will help bridge the gaps in the system.

The Death of Family Medicine

The Death of Family Medicine

Moments ago, while sitting on the ward completing a death certificate, a disturbing thought entered my mind. It should have been of the lonely man who just died of esophageal cancer, but instead it was of my profession. Tonight, after months of reading and studying Bill 20, it felt like I was writing a death certificate for Family Medicine.

It might sound melodramatic, but this how many of us feel – abandoned, powerless, misunderstood, betrayed. Despite our eloquent speeches and thoughtful editorials, the Minister of Health stubbornly pushes ahead with proposed Bill 20.

What is Bill 20? Truthfully, most of us don`t know. The Minister of Health has provided few clues besides threats of unspecified quotas. We know he will restrict IVF based on age, and deny women the choice to discuss and seek care publically and privately beyond age 42. We know he will demand proof of sexual relations for women under age 42, as well as psychiatric assessments in certain cases, before funding IVF. However, for Family Physicians, there are few to no details.

The Minister has stated one clear objective – a Family Doctor for each citizen – but the Bill to improve access will likely accomplish the opposite because it fails to recognize who Family Doctors are and what we do.

Let`s assume Bill 20 passes and each Family Doctor is legislated to increase his or her patient roster to 1000-1500 patients. Simply, one of two outcomes will happen: Family Doctors will comply or not. For those who choose not to increase the number of patients, a salary cut of 30% will be imposed. For the remainder, the practices will swell and patients, who already experience long wait times to see the doctor, will have to wait longer.

Next, the Minister will impose minimum daily quotas. Again, doctors will have the same two options: comply or absorb a 30% pay cut. Predictably, patient care is compromised: appointments are shorter and hurried.

You see, it`s easy to manipulate statistics, or in this case, patients and Family Doctors. After all, is it not more convenient to blame the lack of Family Doctors on Family Doctors as opposed to, say, Government policy? It seems as if there is nothing that Family Doctors cannot be faulted for nowadays – spending too much time with patients, spending too much time with our families, spending too much time at the hospital, spending too much time teaching, etc.

However, the paradox of Bill 20 is that while it will increase the number of citizens who have a Family Doctor, it will actually worsen access. After all, how many hours a day can each Family Doctor legitimately work? The dirty secret of Bill 20 is that patients actually lose choices and access by being limited only to their Family Doctor. Forget about calling the walk-in clinic around the corner on nights and weekends – you are contractually bound to your Family Doctor. Break this bond and your Family Doctor gets fined. How much? You guessed it – 30%.

The great irony of Bill 20 is that not having a Family Doctor improves access. Having a Family Doctor should improve care but only if patients are treated as individuals not numbers.

All this brings us back to the essence of Family Medicine. Who is a Family Doctor? Unlike “GPs“, Family Doctors are specialists who provide community-based, skilled, comprehensive care to a defined population. This care is forged through the doctor-patient relationship and emphasizes evidence-based health promotion and disease prevention while advocating for patients and respecting community resources.

But Family Doctors are people to. We are husbands and wives, mothers and fathers, children and caregivers. We are not civil servants; we do not receive pensions or vacation time or sick time. We pay for our supplies and our equipment, our rents and our staff, and we do not get paid when we do not work. We all made choices to go in to the service of others, and at times, made sacrifices for this education and training.

So, why the obituary for Family Medicine in Quebec? Frankly, who will choose to stay? Would you accept a 30% pay cut? The older Family Doctors may choose to close shop; the younger doctors may not consider starting at all. For the rest of us, will we be content practicing a form of medicine that bears little resemblance to our chosen and beloved profession? The heart of Family Medicine lies in the special doctor-patient relationship: a professional friendship cultivated over a lifetime, built on trust and caring. Family Medicine is about listening and teaching, educating and treating. We may click more cards with fast-food medicine, but we won’t be healthier.

So on this lonely evening, I fear for the future of Family Medicine in Quebec. The deliberations for Bill 20 have just begun. Make your voice heard. Don`t settle for a system that makes you Patient #1499; insist on a system that gives you choices, timely access and quality care. Every patient deserves a real Family Doctor who has the time to listen.

King Pharoah

It’s no secret that doctors often make lousy leaders. Just think of Francois (Papa Doc) Duvalier (Public Health, Haiti), Bashar Al-Assad (Ophthalmology, Syria), and Radovan Karadžić (Psychiatry, Bosnia).

There are many reasons for the dearth of physicians in politics – after all, the qualities that make the best politicians are not necessarily the same attributes of the finest clinicians. Great politicians may be opportunistic, ambitious, partisan, and calculating. Alternatively, the best clinicians are driven by humility, empathy, curiosity, and passion for patient care. When the physician and politician collide, one is reminded of the famous joke – “What’s the difference between God and a Doctor? God doesn’t think He’s a Doctor.”

To be successful, in both fields, one must understand the limits to one’s skills and power. A leader must recognize what he or she can realistically accomplish; to control situations not simply react to them.

Regrettably, our neophyte Health Minister, Dr. Gaetan Barrette, has charged to power as a victorious conqueror. Like so many before him, he is determined to save us from ourselves. With swift edicts and magisterial decrees, He alone will fix the health care system. Apparently, the solution is simple; like Pharoah, Dr. Barrette has commanded that we all work harder or be punished. Mercifully, Minister Barrette’s proposed contraception policy only imposes steep fines and not discarding in-vitro newborns into the Saint Lawrence River.

Some aspects of Dr. Barrette’s proposed Bill 20 purpose are noble – to promote access to family medicine and specialized services. However, towards this end, Dr. Barrette has prescribed a disappointing, misguided and unimpressive treatment. Like an overbearing parent, Dr. Barrette demands “certain obligations…to provide medical care to a minimum caseload of patients” likes chores for an allowance. Failure to comply will result in monetary punishment to be judged and executed by the authority of the Minister of Health Himself.
Other aspects of Bill 20 are simply nauseating. Women over age 42 are forbidden to have children by IVF, public or private, in Quebec and elsewhere, with fines of up to $150 000. Moreover, the Bill legislates a mandatory prerequisite “period of sexual relations…determined by government regulation.” This is not a typo.
In the end, the Minister will inform us, “by directive, of the rules that [we] must follow.” Supreme Ruler Barrette, like Kim Jong-un, claims to speak for the people and to act in their best interest.

How does this Bill improve access? What brilliant, insightful and innovative mechanisms are established to improve access? Simply – none. The Minister is convinced that doctors that can be scared into seeing more patients, women can be intimidated to work longer hours, and women in their 40s can be frightened not to have children. It is a Bill befit for the “Democratic People’s Republic of Quebec “– not our Quebec.
Our goal for this Bill should be access to quality and timely care – not patients seen. We should be building on a model that allows young physicians to balance family and work, decrease stress, improve flexibility and encourage part-time physicians to carry a broader work load. A load not defined by quantity, but in its complexity (ie. mental health, chronic illness, elderly, etc.).
We need a Minister who listens, a leader who collaborates, and a government that cares about people more than numbers. We need to celebrate families and diversity. Dr. Barrette has no place in our bedrooms or in our offices.
Bill 20 is not bad medicine, it is poison. Bill 20 criminalizes fertility in older women. It antagonizes and discourages young doctors who wish to make a life and family in Quebec and will push older doctors to early retirement. Take note Minister Barrette – Pharoah’s regime ended with the great Exodus. Bill 20 threatens us all.

Dr. Michael Kalin is the Medical Director of GMF Sante Kildare located in Cote Saint Luc.