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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

“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.

http://cwf.ca/pdf-docs/publications/December1998-Nurse-Practitioners-and-Canadian-Health-Care-Toward-Quality-and-Cost-Effectiveness.pdf

http://www.cbc.ca/news/canada/montreal/quebec-to-create-500-supernurse-jobs-1.901121

https://www.youtube.com/watch?v=F91gqaQs7Lc

http://www.longwoods.com/content/22268

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.

www.assnat.qc.ca/fr/exprimez-votre-opinion/petition/Petition-5029/index.html

Introducing Scripps

What`s a Scrip?
According to the dictionary, the term scrip has been around for over 400 years. It may be as simple as a scrap of paper or even possess a monetary value. A quick Wikipedia search describes scrips as vouchers, used by companies to provide workers with credit when their wages had been depleted. In the 19th century, the federal government devised a plan to distribute land grants, called scrips, in Western Canada. Scrips were widely used during the Great Depression and after conflicts, to pay employees and POWs. During the Korean and Vietman Wars, U.S. soldiers were sent on leave with a scrip marked with expiration dates which could be spent at establishments cooperating in the program. Most recently, scrips are used as gift certificates or by companies for point of sale transactions (think Canadian Tire Money and Disney Dollars).
scrip def

So – what`s a Scripp?
In 2009, the New Zealand Ministry of Health implemented an innovative and ambitious nationwide program to address obesity and lack of fitness. This program, Green Prescription (GRx), relies on a health professional`s written advice to a patient to be physically active, as part of the patient`s health management.
Research published in New Zealand and British medical journals support Green Prescriptions as an effective and inexpensive way of increasing activity and improving a patient`s quality of life, without evidence of adverse effects.
This concept – of prescribing exercise – has gained international recognition and momentum including in Canada:

cbc

bc

doc

But why limit a script to just exercise?
Scripps – Strategic Care Recommended & Influenced by Physician Prescriptions – conceived of and implemented at Sante Kildare, is a uniquely Canadian, second-generation Green Prescription, designed to promote and wellness beyond exercise. Scripps target patient well-being through recommendations to diet, exercise, income and environment.
More to follow…

Welcome!

I have to admit, never pictured myself as a blogger.

This blog is inspired by my friend, classmate and colleague, Dr. Yoni Freedhoff, who has been writing blogs (weightymatters) for almost 10 years. Yoni has demonstrated that a single, passionate voice can inspire change – both on an individual and societal level.

To borrow from Yoni`s introduction in 2005, my name is Michael Kalin and I’m a medical doctor who specializes in family medicine and I’m located in Cote Saint Luc, Quebec, Canada. I run a multi-disciplinary family practice, known as a GMF or Groupe de Medecine de Famille, that strives to provide the highest level of medical care through health promotion, disease prevention, and in the words of the great Dr. William Osler, undertanding the person behind the illness.

In this blog I will share my thoughts on items relevant to family practice – and invite members of my multidiscplinary team to participate in this discussion with insights of their own. I hope you join us.