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New Flu Information for 2017-2018 from cdc

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New Flu Information for 2017-2018 from cdc.gov/flu

Getting an annual flu vaccine is the first and best way to protect yourself and your family from the flu. Flu vaccination can reduce flu illnesses, doctors’ visits, and missed work and school due to flu, as well as prevent flu-related hospitalizations.

What’s new this flu season?

A few things are new this season:

  • The recommendation to not use the nasal spray flu vaccine (LAIV) was renewed for the 2017-2018 season. Only injectable flu shots are recommended for use again this season.
  • Flu vaccines have been updated to better match circulating viruses (the influenza A(H1N1) component was updated).
  • Pregnant women may receive the flu vaccine

What flu vaccines are recommended this season?

This season, only injectable flu vaccines (flu shots) are recommended. Some flu shots protect against three flu viruses and some protect against four flu viruses.

Live attenuated influenza vaccine (LAIV) – or the nasal spray vaccine – is not recommended for use during the 2017-2018 season because of concerns about its effectiveness.

What viruses will the 2017-2018 flu vaccines protect against?

There are many different flu viruses and they are constantly changing. The composition of flu vaccines is reviewed annually and updated as needed to match circulating flu viruses. Flu vaccines protect against the three or four viruses (depending on vaccine) that research suggests will be most common. For 2017-2018, three-component vaccines are recommended to contain:

  • an A/Michigan/45/2015 (H1N1)pdm09-like virus (updated)
  • an A/Hong Kong/4801/2014 (H3N2)-like virus
  • a B/Brisbane/60/2008-like (B/Victoria lineage) virus

Quadrivalent (four-component) vaccines, which protect against a second lineage of B viruses, are recommended to be produced using the same viruses recommended for the trivalent vaccines, as well as a B/Phuket/3073/2013-like (B/Yamagata lineage) virus.

When should I get vaccinated?

You should get a flu vaccine before flu begins spreading in your community. It takes about two weeks after vaccination for antibodies to develop in the body that protect against flu, so make plans to get vaccinated early in fall, before flu season begins. CDC recommends that people get a flu vaccine by the end of October, if possible. Getting vaccinated later, however, can still be beneficial and vaccination should continue to be offered throughout the flu season, even into January or later.

Children who need two doses of vaccine to be protected should start the vaccination process sooner, because the two doses must be given at least four weeks apart.

Can I get a flu vaccine if I am allergic to eggs?

The recommendations for people with egg allergies are the same as last season.

  • People who have experienced only hives after exposure to egg can get any licensed flu vaccine that is otherwise appropriate for their age and health.
  • People who have symptoms other than hives after exposure to eggs, such as swelling, respiratory distress, or vomiting; or who have needed epinephrine or another emergency medical intervention, also can get any licensed flu vaccine that is otherwise appropriate for their age and health, but the vaccine should be given in a medical setting and be supervised by a health care provider.

Protective Actions

What should I do to protect myself from flu this season?

CDC recommends a yearly flu vaccine for everyone 6 months of age and older as the first and most important step in protecting against this serious disease.

In addition to getting a seasonal flu vaccine, you can take everyday preventive actions like staying away from sick people and washing your hands to reduce the spread of germs. If you are sick with flu, stay home from work or school to prevent spreading flu to others. In addition, there are prescription medications called antiviral drugs that can be used to treat influenza illness.

What should I do to protect my loved ones from flu this season?

Encourage your loved ones to get vaccinated.

Do some children require two doses of flu vaccine?

Yes. Some children 6 months through 8 years of age will require two doses of flu vaccine for adequate protection from flu. Children in this age group who are getting vaccinated for the first time will need two doses of flu vaccine, spaced at least 28 days apart. Children who have only received one dose in their lifetime also need two doses.

What can I do to protect children who are too young to get vaccinated?

Children younger than 6 months old are at high risk of serious flu complications, but are too young to get a flu vaccine. Because of this, safeguarding them from flu is especially important. If you live with or care for an infant younger than 6 months old, you should get a flu vaccine to help protect them from flu.

How effective will flu vaccines be this season?

Influenza vaccine effectiveness (VE) can vary from year to year among different age and risk groups and even by vaccine type. How well the vaccine works can depend in part on the match between the vaccine virus used to produce the vaccine and the circulating viruses that season. It’s not possible to predict what viruses will be most predominant during the upcoming season.

Will this season’s flu vaccine be a good match for circulating viruses?

It’s not possible to predict with certainty if the flu vaccine will be a good match for circulating flu viruses. The flu vaccine is made to protect against the flu viruses that research and surveillance indicate will likely be most common during the season. However, experts must pick which flu viruses to include in the flu vaccine many months in advance in order for flu vaccines to be produced and delivered on time. Also flu viruses change constantly (called drift) – they can change from one season to the next or they can even change within the course of one flu season.

How long does a flu vaccine protect me from getting the flu?

Multiple studies conducted over different seasons and across flu vaccine types and influenza virus subtypes have shown that the body’s immunity to influenza viruses (acquired either through natural infection or vaccination) declines over time.

Can the flu vaccine provide protection even if the flu vaccine is not a “good” match?

Yes, antibodies made in response to vaccination with one flu virus can sometimes provide protection against different but related flu viruses. A less than ideal match may result in reduced vaccine effectiveness against the flu virus that is different from what is in the flu vaccine, but it can still provide some protection against flu illness.

In addition, it’s important to remember that the flu vaccine contains three or four flu viruses (depending on the type of vaccine you receive) so that even when there is a less than ideal match or lower effectiveness against one virus, the flu vaccine may protect against the other flu viruses.

Can I get vaccinated and still get the flu?

Yes. It’s possible to get sick with the flu even if you have been vaccinated (although you won’t know for sure unless you get a flu test). This is possible for the following reasons:

  • You may be exposed to a flu virus shortly before getting vaccinated or during the period that it takes the body to gain protection after getting vaccinated. This exposure may result in you becoming ill with flu before the vaccine begins to protect you.
  • You may be exposed to a flu virus that is not included in the seasonal flu vaccine.

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Recordings in the Office

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Recording doctor appointments can be beneficial – but certain rules need to be respected. Specifically, the recording’s location – public versus private – has certain implications.
The following are concerns and recommendations of the Canadian Medical Protective Association (CMPA):
Privacy issues in public areas
Patients recording in public areas of a doctor’s office, such as waiting rooms and other common spaces, could possibly capture other people who are not involved in the patient’s healthcare encounter. The recordings could include identifiable information about another patient or staff which could breach a person’s privacy.
Impact on the doctor-patient relationship
A patient may have valid reasons for wanting to record a clinical encounter in a private area such as an examination room. They may want to have an accurate record of the physician’s advice, or to share the information with a family member. However, the recording of a clinical encounter by a patient without the physician’s knowledge can be perceived as reflecting a lack of confidence in the relationship on the part of the patient.
Impact on the medical record
Any recording made at the time of the clinical encounter (i.e. contemporaneously) could be considered part of the medical record.

 

Our Policy
Recordings should only be made in private areas. Patients should avoid taking photos and making video and audio recordings in the waiting room or other public areas in order to protect the privacy of other patients and staff members.
Recordings in private locations should be transparent and obtained with the mutual consent of the patient and physician. A copy should be provided and added to official patient health record. The recorded conversations should never be posted on public websites or on social media without the knowledge and approval of all affected parties. the absence of trust and openness may negatively impact the doctor-patient relationship.

 

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Nurse Practitioners: What’s the deal?

Many of you may have noticed nurse practitioners popping up in your family medicine clinics lately. If you haven’t noticed them yet, you are very likely going to notice more of them soon. The Quebec government has invested $25 million dollars to help train new nurse practitioners in Quebec. Their goal is to have at least 2,000 primary care nurse practitioners trained in Quebec by 2025. We still have a long way to go to meet this goal; there are only 428 nurse practitioners in Quebec.

So what is a nurse practitioner? Simply, they are a family doctor for healthier people. Nurse practitioners are nurses who have gone back to school and received a Master’s degree and extra medical training. They are qualified to write prescriptions for certain medications, they can send you for blood tests, x-rays, ultrasounds, and other tests, and they can do procedures like stitches.

A nurse practitioner can follow healthy people from babies to older adults for their regular check ups. They can also follow healthy pregnant women until they are 32 weeks pregnant. You will also see them in walk-in clinics because they are able to manage most of the acute issues that bring people to a walk-in clinic.  If you are followed by a nurse practitioner all of your health needs are managed by the nurse practitioner much like if you had a family doctor.

Nurse practitioners are not completely alone. They work in partnership with family doctors who are there to act as the nurse practitioner’s specialist. Much like your doctor may send you to see a specialist, like a cardiologist, a nurse practitioner can “refer” to their partner physician. The nurse practitioner may discuss your case with their partner physician or, if needed, the doctor may see you for a visit.

The goal of the nurse practitioner is to help improve access to primary care. Nurse practitioners are able to help relieve the burden of the family doctors by following their own caseload. This increases the number of Quebecers who have a family doctor and it also allows family doctors to follow more complex cases.

 

https://www.oiiq.org/sites/default/files/rapport-statistique-2014-2015.pdf

http://www.cbc.ca/news/canada/montreal/quebec-super-nurses-1.4041873

Jennifer Reoch

Santé Kildare Nurse Practitioner Candidate

No need to worry…Casino Montreal still has unlimited free parking!

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The running meter is a distraction that interferes with medical appointments.”
Dr. Rajendra Kale, former editor CMAJ

Our Facebook post last week on plans to reduce parking fees at Quebec hospitals was our most popular yet. Parking fees can be excessive and their appropriateness has been extensively debated.

In the March 6, 2012 issue of the Canadian Medical Journal (CMAJ), doctors debated the merit and necessity of charging patients for parking. Dr. Tom Closson, President and CEO of the Ontario Hospital Association, argued that parking fees are one of the most common ways of making up the deficit of hospital operating budgets. He stresses that provincial government cutbacks to hospitals eliminate “crucial revenues that hospitals use to fund clinical research and front-line patient care.” He admonishes the Journal’s editorial board, “surely CMAJ has something to say about these and other more relevant issues, instead of banging away on the populist drum about parking fees.

Dr. Tim Meagher of the MUHC takes the opposing position, “I support free hospital parking for patients. I would probably also support free transport to and from hospital visits, reimbursement for time lost from work due to hospital visits, and reimbursement for myriad of ancillary costs that hospital visits generate.”

Dr. Rajendra Kale, editor in chief of the CMAJ, writes “”Parking fees amount to a user fee in disguise.” He urges Canadian hospitals to follow the example set in Scotland and Wales where hospital parking fees are abolished “because they burden (the) patient.” Dr. Kale concludes, “Those opposed to scrapping parking fees for patients need to recognize that such fees are, for all practical purposes, user fees and a barrier to health care. Using revenue generated from such surrogate user fees for health care is against the health policy objective of the Canada Health Act and could become the subject of a legal challenge.”

This opinion was supported by Dr. Brian Goldman, Host of CBC’s White Coat, Black Art, “I think hospital parking fees should be abolished because they punish patients.”
The highlights of the new hospital parking plan, starting April 1, are:
Hospital visitors will be able to park for free at hospitals in Quebec for the first 30 minutes, instead of paying as much as $10 for that first half hour.
• A flat daily rate will not be applied until a vehicle has been parked for more than four hours, a big change from the current practice of charging the maximum daily rate after 90 minutes.
• Health care institutions must offer weekly and monthly parking passes, as well as books of tickets, at reduced rates.
• Health care institutions must offer daily parking passes that allow motorists to come and go without penalty.

 

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Is it my turn yet?

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It is no secret that we are (extremely) frustrated with long waiting times. Consecutive governments repeatedly promise to fix this problem but wait times only seem to grow longer.
As noted by the Fraser Institute: “excessively long wait times remain a defining characteristic of Canada’s health-care system, but this year (2016) is the longest we’ve ever seen and that should trouble all Canadians.” Bacchus Barua, senior economist at the Institute, continues, “long wait times aren’t simply minor inconveniences, they can result in increased suffering for patients, lost productivity at work, a decreased quality of life, and in the worst cases, disability or death.”
http://globalnews.ca/news/3083826/medical-wait-times-in-canada-are-longer-than-ever-hitting-20-weeks-in-2016-fraser-institute/

 

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The Canadian Institute of Health Information (CIHI) released a report based on The Commonwealth Fund’s 2016 international survey that highlighted this continued issue. According to the survey, Canada scored the poorest of all 11 countries surveyed when it came to access to specialists.  Fifty-six percent of Canadians wait longer than a month to see a specialist—as compared to the international average of 36 percent.

Dr. Josh Tepper, CEO of Health Quality Ontario, along with Vanessa Milne and Sachin Pendharkar, published “Four ways Canada can shorten wait times for specialists” at Healthydebate.ca.  Their prescription for success focuses on simple, achievable concepts:

 

1.Do virtual consults, not visits

Not every patient needs to see a specialist.  Often the family physician needs some guidance and a virtual consult system can help.

The Rapid Access to Consultative Expertise (RACE) is a phone based system available in parts of British Columbia. Family physicians call a central phone number during business hours on weekdays, and a specialist calls back within a couple of hours.

The success of RACE in B.C. inspired a similar program in Ontario, called The Champlain BASE e-Consult service. In this system, primary care providers complete a form that includes patient information and the medical question. Test results and images can be attached. The information is then sent to a specialist.

From 2010 to 2015, the BASE service was used in over 10,000 consultations in the Champlain region. The average wait time for a response from the specialist was two days.  Most impressively, in 40% of cases the patient did not need to see the specialist.

 

2.Add physician directories and e-referrals

Alberta currently offers paperless referrals through e-Referrals. The system includes referrals to Oncologists and Orthopedics.  Family doctors get an idea of wait times BEFORE submitting the referral and can chose a specific specialist.

 

3.Try pre-assessment in specialized clinics

Another approach is adding an assessment step in between the referral and the specialist.  This method has been successfully introduced for patients with severe low back pain (Interprofessional Spine Assessment and Education Clinics (ISAEC)).

Known as CareAxis in B.C., Saskatchewan, Ontario and Quebec, wait times are reduced by training physiotherapists to triage potential surgical candidates.

 

4.Switch to central intake

Pooled referral systems (aka central intakes) allow family doctors to select a specific specialist or the first-available.  Newfoundland, Ontario, Saskatchewan and Calgary all use this model.  Quebec’s model, CRDS, launched in the Fall of 2016, offers central intake for 9 specialties: Cardiology, ENT, Gastroenterology, General Pediatrics, Nephrology, Neurology, Ophthalmology, Orthopedics, and Urology.

Information can be found at:

Tél. : 514-762-CRDS (2737)
Téléc.: 514-732-5121
Courriel: crdsmontreal.ccsmtl@ssss.gouv.qc.ca

https://www.santemontreal.qc.ca/professionnels/medecins/crds-centre-de-repartition-des-demandes-de-services-montrealais/

So…can wait times be fixed?

All four models can help reduce wait times and simplify the process.  However, the authors caution, “Canada is notorious for being a land of pilot projects in health care, where good ideas aren’t scaled well. For systems like this, where getting buy-in from many professionals is crucial, that problem is especially important to overcome.”

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The truth about GMF’s

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“Created to improve access, Montreal clinics often turn away patients,” published in the Gazette on February 15, 2017, is a misleading and misrepresentative article. It makes false assumptions and reaches incorrect conclusions.
The article states that “there are 86 family medicine groups in Montreal that rely on government funding to stay open longer than private doctors’ offices.” The author contends that “fewer than half the clinics are actually open seven days a week.”
The reality is GMFs are neither super-clinics nor general walk-ins. They are grouped, private, family medicine practices that offer care to a defined, registered patient population. Emphasis is placed on assiduité, fidélisation and prise en charge. In other words, GMFs prioritize their own patients while super-clinics or GMF-reseau (known previously as cliniques-reseau) are designed primarily for patients who do not have a family doctor.
These distinctions are available at: http://www.msss.gouv.qc.ca/professionnels/statistiques-donnees-services-sante-services-sociaux/acces-premiere-ligne/ and http://sante.gouv.qc.ca/systeme-sante-en-bref/groupe-de-medecine-de-famille-gmf/.
GMFs do not all receive the same funding and are not expected to maintain the same number of operating hours or days. While larger GMFs are open 68 hours/week, smaller GMFs only need to be open 5 or 6 days/week.
Yes – GMF walk-in clinics generally extend appointments to non-registered patients whenever possible. “All” patients can come irrespective of age, gender or medical history. Clinics, doctors, nurses are all working to improve access and help patients in need. But the GMF is not a “general” walk-in clinic – and hasn’t been since their inception in the early 2000s.
At the end of the day, the article should have asked – “can patients obtain timely appointments with their own family doctor?” Bottom line – register with a family doctor.

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Learning from Effective Primary Care Teams

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Santé Kildare was selected to participate in the University of Toronto Department of Family and Community Medicine Quality Improvement “teaming” project in 2016.  High functioning primary care teams were chosen across Canada with the goal of developing a blueprint and action plan to guide primary care teams to function effectively. The ultimate outcome leading to improved health of populations, improved and patient and provider experiences and improved value.  Santé Kildare was the only clinic studied from Quebec.

Launched in late 2014, the Quality Improvement (QI) Program set out to answer the question: What makes primary care teams effective or high-functioning?

“The evolution of health care provision in the community is moving from a single primary care provider (usually a family physician) providing health care patient by patient in a reactive context, to an organizational one – a primary care team proactively meeting the needs of a defined population. Teaming – a verb – refers to the collective actions or processes associated with a primary health care team performing optimally”.

In April 2016, the environmental scan for the teaming project was completed with case studies of nominated, high-functioning primary care teams. The case studies, representing teams from Alberta, Ontario and Quebec, marked the last element of the scan that included a robust literature review and a series of expert interviews.

Last Fall, the Quality Improvement (QI) Program published themes that were identified as attributes of high-functioning teams.  They include:

  1. A practice environment where members of an interprofessional team work in close proximity (co-location)
  2. Effective use of electronic medical records (EMRs)
  3. A focus on patient experience
  4. An effective communication culture
  5. Leadership
  6. Right skill mix
  7. A combination of clarity and flexibility around roles
  8. Ensuring that all team members work to their full scope of practice
  9. Professional development
  10. Collaboration with external partners and agencies

It was pleasure for Santé Kildare to participate in this project.  The full report can be found here.

Check-ups matter!

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Check-ups matter!

My 15 year old daughter is a skillful debater. We have lively discussions about politics, religion, school, and the Marvel Cinematic Universe. But when she wants to win the debate, she conjures up an obscure reference in a fictitious journal to prove her point – definitively. After all, who can dispute a prestigious scientific publication?

This week, the healthy check-up in Quebec fell victim to a “meta-analysis.“ Experts confidently announced that “medical science no longer recommends these types of exams.“ Even the Minister of Health challenged “What does an annual visit prevent? Nothing.”

Specifically, these experts were citing a 2012 analysis by Lasse T Krogsbøll of the Cochrane Collaboration. His analysis of sixteen randomized studies concluded that “general health checks are unlikely to be beneficial.”

Further words of reassurance were imported from the Maritimes where a media relations advisor for the Nova Scotia Department of Health and Wellness added ““We’re not aware of any concerns or issues since this change (eliminating the health annual check-up) took effect.“

And to allay any final concerns, the experts assured the public that when they “go to (the) doctors at any time for other reasons like an ankle injury or a bad chest infection, …a good doctor will use that opportunity to ask how things are going otherwise.“

With all this seemingly overwhelming scientific evidence condemning the relevance of the health check-up, why are we sad to see it go? Simply – because it shouldn`t.
We increasingly live in a world where human contact for the delivery of services is endangered – and it bothers us. Mail home delivery is threatened, bank branches are not profitable, established brick-and-mortar retail stores are restructuring. Seeing your doctor seemed immune – or at least it felt that it should be. Where else could a person go after accumulating a long “list“ of health problems full of fears, questions and concerns. Dr. Oz? Google? Just like the Crawleys in Downton Abbey, we all want a Dr. Carson to look out for and to look after us and our families. Someone who knows us, listens and cares.

The problem with scientific studies is that they are often misquoted and rarely read. The “definitive“ Cochrane review questioned whether general health checks in adults reduce morbidity and mortality from disease. It did not include geriatric trials. It did not study the value of the doctor-patient relationship. Most of the studies were not conducted in Canada, and according to the authors, “most of the trials were old, which makes the results less applicable to today`s settings because the treatments used for conditions and risk factors have changed.“

To be exact, nine of the fourteen studies included were conducted over thirty-five years ago. The most recent study was initiated twenty-five years ago. That`s like current Habs General Manager Marc Bergevin conducting the 2016 draft based on scouting reports from Sam Pollock and Irving Grundman in the 1970s and 1980s.

The Cochrane Review further qualifies its findings, commenting that “because the majority of the included studies were unblinded with considerable loss to follow-up, analysis of outcomes other than death and hospitalization may be subject to bias.“
Even the Canadian Task Force on the Periodic Health Examination from 1979, purportedly anti- check-up, recommended “ a specific strategy comprising a lifetime health care plan based on a set of age- and sex-related health protection packages.“ Maybe not annually, but more selectively.

Scientific meta-analyses are only as good as the data that is entered. There is lots of talk about the importance of Corsi scores in hockey, but as far as I can tell, neither the Pittsburgh Penguins nor the San Jose Sharks lead the NHL informatics race. Nevertheless, one of these two teams will be raise the Stanley Cup.

Interestingly, if experts are going to quote the merits of the Maritime experience, in which journal has this well-designed experiment been published?

In the end, we are quoting weak medical data from a generation ago, in another jurisdiction, with poor follow-up. None of these studies examine the essence of why general check-ups really matter. Seeing your family doctor on a routine basis fosters a trusting, lasting relationship. It does not exist to order tests; its existence provides comfort and security, knowledge and understanding. Health promotion is not a brochure or a pep-talk: it is a collaborative effort to live better. It is not a sprint, but a marathon.

Honestly, do “experts“ really expect family doctors to do a prostate exam because the patient conveniently limped in with an ankle sprain? Or discuss colorectal screening while the patient is febrile with a bad chest infection?

Air Canada (hopefully) does not wait for the airplane to make funny noises before checking it out. They don`t wait for one wing to fall off before checking the other. Routine maintenance is neither a luxury nor superfluous – it is common sense. Let`s not embrace a crisis-initiated medical model – but improve our efforts towards health promotion. Let`s design a system that rewards doctors for keeping healthy people healthy.

In the end, all the analysis to devalue the annual check-up simply cannot compete with the primal benefit of nurturing a meaningful, trusting, patient-physician relationship. Studies, even “scientific“ ones, need to be understood and properly applied.

Consider the 2003 systemic review of parachute use to prevent death and major trauma related to gravitational challenge published in the prestigious British Medical Journal. Despite a rigorous review, the authors “were unable to identify any randomised controlled trials of parachute intervention.“ As such, they concluded, “the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomized controlled trials. Advocates of evidence based medicine have criticized the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organized and participated in a double blind, randomized, placebo controlled, crossover trial of the parachute.”

Please use a parachute – and please continue to see your family physician for general check-ups.

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

http://wpmedia.montrealgazette.com/2015/09/montreal-que-january-24-2012-stock-photos-for-use.jpeg?quality=55&strip=all&w=840&h=630&crop=1