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The cost & courage of caring - stories that spark resilience.
Speaker 2 (00:00.244)
Hello and welcome to episode seven of the Caregivers podcast. I'm Dr. Mark Ropeleski. You can call me Dr. Mark. Today we have with us Dr. Anthony Sanfilippo, heart specialist, researcher, caregiver, director of a medical school. Tony, tell us about the situation as it stands with six million Canadians who don't have a family doctor.
Speaker 1 (00:27.054)
Well, I think we're all aware of what's happening in Ontario and across the country with this issue of patients without family doctors. The figure that you said, Mark, is giving it to about six and a half million. It may be more than that and it's likely to get bigger. These are folks who, over the last decade or so,
have found themselves without access to a family physician or primary care as a result of their physician leaving or them moving away to a place where there was no doctor available for them to affiliate with. These folks are, I think we all recognize, suffering in a lot of ways. The lack of a family doctor has impacts
that are far-reaching. If you consider what family doctors do, they provide responses and care for non-urgent illness that crop up every day. They provide preventative care to provide surveillance for conditions that can be treated early on and left untreated can become big issues.
And really importantly, as our society gets older, they provide chronic care for conditions that require continuing treatment and evolve over time. And all this is happening at a time when our population is getting bigger and it's getting older. And more and more things are fortunately available for them. But in order to access those great things,
you need a contact, you need a link into the system, you need someone who knows you, knows the totality of your needs in your situation, and can provide guidance to whatever treatments you require. Without that, we're seeing lots of consequences of it. We're seeing folks who are finding by default, they have no option but to go to emergency departments.
Speaker 1 (02:51.16)
for conditions that they don't really want to go to an emergency department for, but they have no option if they want to get care. We find folks who are not getting care for things that they would normally want to resolve by when they leave the emergency or they don't go. And so a problem that is treatable early becomes a bigger problem. We're seeing a risk factor.
modification strategies and surveillance strategies for cancers and stuff falling to the side, meaning that folks are likely developing things that could be treated.
or they're not getting screening, yeah. You're right.
Well, I worry lot that we're going to see the effects of this well into the future as folks show up with more advanced phases of things that are treatable. And in terms of chronic care, mean, there are folks who can get, we still manage to take care of acute illness fairly well. Our hospitals and our emergency departments have concentrated and quite rightfully so.
on acute injury and acute medical issues or complex issues. And they do a great job. I got to say, I'm really gratified and impressed with the work that's by our colleagues who look after emergency departments and in hospital care. But those patients who get their acute care are often not resolved completely. They require ongoing care of one type or another.
Speaker 1 (04:31.938)
be it rehab, be it further medications for things like heart failure or inflammatory diseases. And there isn't an easy avenue because those were normally provided through primary care or family doctors. So there's huge suffering out there and there are costs that we're taking on that we don't even recognize. Because as you defer things, they don't go away, they get more expensive.
So this is not just about how long am I gonna be on the wait list. This is, have access to no one. mean, that's where individuals are finding themselves. And to your point about even having required a hospitalization where lots of things happen, and certainly with multiple chronic illnesses these days, lots of things can happen in hospital, but there's no one to look at the discharge summary with the patient and say, okay, I've got your back.
This is what we're going to follow up on and we'll keep you from bouncing back to the hospital. We've got this. And to not have that is daunting to say the least.
Yeah, mean, family doctors who do this really well. You know, mean, you and I have both worked with wonderful family doctors over the years. And in the writing of my book, I had chance to chat with lots of family doctors. In the development of the program at Lakeridge, we were able to collaborate with family medicine in a lot of ways. And as you do that, you become even more
convinced of how vital they are to the whole system. the patients are feeling it, but the whole system is feeling it.
Speaker 2 (06:23.854)
couple of some of the most positive events I've had in my career is when I've been able to do a teaching event where family doctors have been present and you sort of suddenly get a collective feel for each other as a next level sort of team and then like you're the specialist in your field, mine being Crohn's and colitis and then we just sort of have that fresh community feel of liaison between the family practices and ourselves. It's certainly
is a really good feeling and it really nurtures positive working relationships. The challenge too with patients not having a primary care provider or family doctor to anchor their care is that when they do seek help for perhaps a new complaint that's not severe, they'll often tap into some sort of a telehealth or online available
resource that will get them referred somewhere, but they won't get referred to a family practice. They'll get referred to a specialist or a minor complaint. And then that referral needs to be triaged among large numbers of referrals subsequently. And it becomes very difficult to manage at the specialty level when you're getting referrals for things that could be handled at the primary care level. it affects the whole pipeline of patients who are under our care. And, you know, if I think of our group where we get
have in the past gotten roughly between 1,100 and 1,200 referrals a quarter, it becomes especially challenging when basic primary care complaints that could be taken care of by a family doctor can't be. it's, as you said, everything sort of spirals and feeds forward. And I think that's a key message. It's not just that there's not someone I can go to and I'm having a cold. There's no one to coordinate my care. There's no one to make sure
for following the guidelines for cancer prevention. There's no one actually modifying my lifestyle to help me live long, not just long years, but healthy years. And I think we'll get to that a little bit later, but the notion of health span, I think, is one of the most fascinating topics these days because it seems to have potentially been lost from the vision of, when we think about innovation, innovation and illness care is where a lot of the big discoveries are.
Speaker 2 (08:43.874)
The innovative ways to maintain health span and just get patients engaged is such a valuable tool that could be enacted at best at the level of family doctors. And thank God we have the ones that we do because we do see those inroads. Now, as a director of a prominent medical school here in Canada for over 15 years, in addition to all your other roles, you were an observer. And having read your book,
I really felt that all lenses, all eyes were open as you went on this journey yourself, but walk us through how you realized there were serious problems here and how we train and prepare family doctors for the future or medical students to direct them towards family medicine or even make sure that we have adequate cohorts of students who want to do family medicine.
in our cards of young learners who are pursuing their medical studies. I how did you feel staring at all these stories in the eye, leading a prominent medical school? mean, how bad is this?
Well, the issue of the linkage of our medical education process to our societal needs for doctors is the core of the problem, I think, that you're alluding to. We have evolved over 100 and more years a process for educating and training doctors that is
that really has its roots, believe it or not, in the early 20th century, when it was recognized that medical training had to move beyond what was classically available, which was essentially an apprenticeship process, right? So, generally, folks who had some sort of background or interest trained to be doctors,
Speaker 1 (10:56.106)
under doctors who were working. And in North America, you know, a large number of medical communities, if you will, arose that would be willing to train young people who were willing and able to pay and willing to devote the time and basically work under doctors and then eventually become certified by those doctors and by whatever regulatory processes were in place at the time, which were
and far between, obviously. It became aware, it became obvious, and the critical move here was the Flexner Report, actually, where Abraham Flexner, an educator, not a doctor, an educator, was commissioned by the Carnegie Foundation, which was a large, benevolent educational foundation to...
It addressed education across the board. And frankly, world owes a lot to Andrew Carnegie. But they commissioned this report, and Dr. Flexner was given funding and time to actually visit every medical school in the United States at the time. And he decided kind of to expand his scope to the Canadian schools that were in existence at the time, of which there were eight. And he actually visited each one personally.
and out of his report became a recognition that medical education needed to have some structure. It needed to have some scientific foundations. It needed to have a faculty that was committed to education. It needed to have a process to assess its learners. It needed to have a rigor, if you will. And not everything great came out of that report, but the recognition
that medical education needed to be embedded in an educational institution was really put in place at that time. And so it was really then that the process for educating, first of all admitting, but then educating physicians became linked to universities, which were seen as places where that scientific rigor could be provided, where that third-party assessment of the qualifications of the teachers and the
Speaker 1 (13:17.602)
assessment of students could be maintained. It was a great move. It was really transformative in a lot of ways. But over the century, that model of university-based primary medical education and admission hasn't changed. Although it's changed a lot in terms of its structure and specifics, obviously, the fundamental paradigm that
that medical education begins with admission to a university-based medical school and requires a degree program that is run by a university, sanctioned by a university, approved by a university, it hasn't changed. Now what has changed is the recognition that, you're not done. Right? I mean, that
That's a good thing, I our listeners want to know that their doctors went to med school and that they went to a med school that, you know, give them the stamp of approval that they've met the requirements. So, I mean, that's step one, and you're right. And we all want that.
Yeah, they want them to know that they're qualified, right? For sure. And the medical schools were places, but even when I was starting out, medical education was almost the end of medical training, right? I mean, my generation and before me were basically qualified to practice as what at that time were called general practitioners at the end of...
medical school with one or two more years of nonspecific training. That could be pretty much what you wanted to do. But it's recognized you need to do a bit more, you need to get into a hospital more, you need to do more clinical stuff. You need to do some blocks of surgery and medicine and feeds and psych. But then you're qualified to practice and you can get a license anyway. Well, you know, what's happened? Clearly, medicine has expanded way, way, way, way beyond the place where a single
Speaker 1 (15:16.078)
practitioner can provide comprehensive care to everybody who's going to come through the door. The ability, and this is wonderful, Mark, the fact that we can do so many things and have so many treatments available for conditions which even four or five decades ago were either not treatable, not even known. These are wonderful advances, right? We can treat cancer, heart disease has been amazing. But all of these has required
more training and specific training and highly, highly technical training. And so medical education got longer and longer as specialties emerged. And so that medical degree became essentially an entree to training. And, you I don't if it's still you, but many of the listeners may not be aware that, you know, at the end of medical school, graduates now apply.
to one of 30 specialty programs, one of which is family medicine, but they have a choice of all these others as well. And out of those, they branch considerably as well over the next few years. So there's just more, there's like 140 or 50 different types of doctors out there. And we need them all. We need them all. And we, you know, we have, they're all doing wonderful work. But the process is still rooted in the university.
And so we bring in an undifferentiated, bright, wonderful person. Yeah. And then we put them through fundamentally the same undergraduate training process with the idea that they will become an applicant ready to do any of these positions. Now in that time, this young person
has to, in addition to learning all those fundamentals that are going to prepare them for whatever specialty they want to do, they have to figure out what kind of specialty they want to do. Because they didn't come in with any idea of specifically what kind of doctor they want to be.
Speaker 2 (17:24.142)
Some do and then sometimes actually their experiences tell them, that's not what I expected. I think I'm to try something else because it wasn't what I thought it was too. So it is that really experimental phase of sorting things out. right.
Exactly. It's taking on a life of its own within the medical education paradigm. These young folks are spending, they work very hard to compete to get into medical school, but then they find they have to work again to apply to get into one of the residency program and figure out which one they want to do. That's taking over the medical education process to a large degree in medical school. It's been estimated, and I have no.
trouble believing that a quarter of the time in energy that medical students expend during their undergraduate training is consumed with this concept of career selection, right? And they need to. So, and now at the same time that this is going on, we have a dramatically expanding need for doctors out there.
We're growing, absolutely.
We're getting bigger as a population. We are getting more complex in terms of the illnesses that we have and need to be treated. And we need more and more different kinds of doctors. But that need doesn't reference back to medical school or to admission.
Speaker 2 (18:56.667)
Everything keeps happening the way it always has. Yeah.
So medical school and their admission processes are not responsive to, linked to, accountable to the societal needs for different types of doctors. And you can understand this. mean, a university is a place, and they're wonderful. I I love universities. I'm still in the university. But their fundamental place in the world is to help
young people find their place in the world. It's a place where young people can go, they can learn, they can learn about themselves, they interact with other people, they interact with folks who are wise in variety of different ways, and they learn what they want to do and get towards that. And so the purpose of university is to facilitate that. That's their job. Their job is individual accomplishment. But medical school, society needs
certain supplying doctors.
And certain types of doctors, yes.
Speaker 1 (20:05.134)
So where's the link? How do these two worlds come together? And right now they don't. They don't. one of the, and this, if they did, well, what would we be doing? We'd be saying to medical schools, well, look, we have a desperate need for family doctors. You should be turning your processes over to the production of family doctors, blah, blah, blah. Or even more likely,
We don't need just, and I'm not downplaying the need for family doctors, but Mark, you know, we need doctors in lots of different areas. There aren't enough psychiatrists. Try to find a psychiatrist, you know, try to get a psych before.
I don't know if mental health is so important and under managed in so many areas.
pathologists, oncologists. You probably read that in BC, there's a shortage of obstetricians and gynecologists, such that women are having to go other places if they're in the late stages of delivery or have complex delivery needs. Emergency room physicians are closing down. Our departments are closing regularly because they don't have enough
There are just not enough doctors. So in addition to the need for family medicine, we need to expand into paradigm. We need to think broadly beyond just admitting, you know, 100 students to Queens each year that are the brightest people in the world and, you know, hope that they, you know, do things that they will. They'll do things that are wonderful, but are they doing the things that society needs now? And where does that link happen?
Speaker 2 (21:45.198)
So considering that, mean, that's such a fundamental message of yours and it's easily recognizable. It's not a complex relationship. It's supply and demand. We've talked about that. I mean, it of drives the world these days. But what's the most important or what are the most important broken pieces that we just can't seem to meet this demand? We know the demand is there. Where are we not coming up?
with the solution or what's standing in the way of solutions. And what do our listeners and viewers need to be aware of?
Well, think there's a lot of things, but there's three themes that I tried to develop in the book as starting points for discussion. One is the concept that as we think about the societal needs for different kinds of doctors, we have to keep in mind that these are different kinds of doctors, but they're different kinds of people. The fact is that the person who looks after
a community of people in a small community in Northern Ontario is providing a wonderful, wonderful service. They are a very, very different individual in terms of fundamental interests, fundamental skills and proclivities to the person who is going to be working in a large center doing a very specialized, specific, technical, very needed procedure.
area of interest. We need them both, but they're different people. And we call them both doctor. And we admit them to medical school with the same fundamental paradigm.
Speaker 2 (23:36.854)
And sort of learning track, right? They go through all the same classes, they go through all of the same steps to get to graduation. Yet, intrinsically, one is much more likely to end up on one path versus another who would be on a completely divergent path. But as you say, both graduating as doctors for our communities, but both with very different visions from the outset, or basically individuals who are hardwired, probably more likely.
to end up in one role versus another just because of what makes them tick.
I use the analogy in the book, if you were operating a large company to manufacture automobiles, And your goal was to produce all kinds of different automobiles, Trucks and sports cars and SUVs and all that stuff. And you need a workforce to do that. The workforce has to consist of folks who are all kinds of different skills.
You need engineers, need machinists, you need bookkeepers, you need advertising people, you need design people, you need all these different folks, markedly different skill sets. Well, what if your hiring policy was to admit bright young folks who had a vague interest in cars, hadn't really evolved that interest beyond that, and your idea was, let's bring in these bright folks and train them up and hope that they all do enough of the things we need them to do. Well, you would find yourself very quickly
overtraining in some things and not training in the other percent. And at some point, would say, well, why don't we just pick people who already want to be this, that, or the other thing, you know, or have some, God forbid, background that might be relevant to that particular area. And the fact is, Mark, and again, you know this, but we have got no shortage of young people who want to become doctors, right? Queens gets 5,000 applications for a hundred positions.
Speaker 1 (25:34.358)
know, the medical schools across the country are way, way, way oversubscribed with applicants. They turn down way more than they take. We have Canadians that want to be doctors that are going to other countries to learn medicine and hope to get back to Canada to learn. And I can't, I don't believe for one minute that there aren't within that crowd lots of people who would love and be very suited for and be very happy in and thrive.
in the very kind of practices that we are so desperately looking for, you know?
I agree. And they're talented, they're energized. I mean, I've interviewed them for when I was directing our specialty program and I have graduates from abroad who are colleagues and we're all goal oriented. We all believe in the same cause. We all try to advance the care of others as much as we can. We all give, we all care. Those are non-negotiable and they're not determined by where you train.
But you're absolutely right.
I mean, there's core values, right? I I think we could have a very fruitful and interesting discussion about what the core values of every doctor should be, right? And, you we can talk about fundamental human values and fundamental human characteristics that I don't care what you're practicing. You know, that's core to being able to provide care to people that come before you. But beyond that, we all have individual strengths and individual interests.
Speaker 1 (27:10.35)
So the first premise of my book is we need to think differently about admissions, both in terms of scope and in terms of who we're looking for. the other thing to say is that there are folks out there who are a little more advanced in their life development, who've already done some jobs, who've already discovered things about themselves that would maybe make them ideal for certain types of medicine. But I've got to tell you, the way medical admissions are structured today, if you've been out of it for a while,
and you didn't have great marks to begin with, you have no hope of getting, and if you don't have, and especially if finances are a problem or you have other financial, there's no hope of getting back into the system.
or marginalization too, and underrepresented communities as well, and obviously socioeconomic status please as well. But you're getting on a point there which struck me, and as I was thinking about our chat today, has it come to the point where we need to establish that there has to be a comfort that we're going to prescribe what kind of doctor a student is going to become based on our society's needs?
Our society and the healthcare system is the car factory that you referred to in that example. And that business needs to stay afloat. Our system needs to stay afloat. Our healthcare provisions for our community, for our citizens needs to stay afloat. I mean, for students who've worked so hard to get into medical school, would they even consider it insulting that they would be told, you know, we're looking for future family doctors now and
I know you'd like to be a trauma surgeon or a kidney specialist, or I could pick anyone. I'm just two that popped into my head, but we really need family doctors right now. And this year we're enriching for family doctors because Canadians need family doctors. Are we at a point where that would actually fly or are we like insulting these hard workers who've, based on just their positioning, feel that
Speaker 2 (29:20.194)
I need to explore, I have a right to explore, I've earned this position and the ability to decide my own fate.
I think forcing people into careers they don't want to do is a huge mistake.
Right, but recognizing those who want to do a career and funneling them.
That's the key, right? Well, you don't have to do that, Mark. We don't have to force people to do things they don't want to do because I think there's lots of out there who want to do it. We just need to find them.
We just need to welcome them.
Speaker 1 (29:45.996)
We just need to find the right, and how do we find them? We find them by creating, this is the second point, is creating educational structures that are specific to the purpose, right? Right now, medical school is not specific to any particular purpose. It is, we've talked earlier, it's a generic kind of training, pluripotential for any specialty. If we had educational processes that were specific to the training of family doctors or whatever's.
Right? Psychiatrists, lab people. If we had training and we were looking for, and we said, look, you're going to come into this and we're going to train you to become a wonderful family doctor or a wonderful psychiatrist or wonderful whatever it is. And here's what, and that's the only place that's where this goes. That's what this training is about. Well, that right away is the best filter you can have because people are selecting themselves. Yeah, I want to do that. Right? You're not going to go to electrician school if you want to be.
you know, a carpenter, right? Now we also need to have the admission processes that ensure that that's a valid, you know, that's true, that they've got the skills and all that stuff. But if you start with the premise that your educational training is specific to that purpose, you're halfway there. And look, I don't, nobody can convince me that there aren't people out there who want to, these are wonderful jobs, you know, these are wonderful careers. You know, becoming a family doctor,
can be, notwithstanding all the issues that they're dealing with, can be an incredibly rewarding career. Becoming any kind of medical specialist, think about it, you get to help people, you get well paid, I mean, how is that not something people would want to do? If we provided those opportunities and described what they were for, we wouldn't have to force people to do anything. And we can't, you can't force, you can't.
take someone who wants to do something else and that's gonna get you a year or two of unhappy practice and then something's gonna happen.
Speaker 2 (31:53.442)
So if we, you allude to in your book that there's such a complex array of approval bodies and oversight bodies that begin at entry to med school to the time you finish your training and your sub-specialization, your licensing, et cetera. It's unclear to me how well they all communicate. But if we were to sort of start thinking about moving the needle forward to creating such funnels based on societal need,
what would be the necessary change that would need to occur to align the training with the needs? Is it the med schools? Is it provincial licensing bodies? I don't know. I haven't figured it out myself, but I mean, I've daydreamed about it, wondering, imagine if we could solve this. And there are lots of other things to solve, and I hope to get into some of those with you because, you know, we need to also, I mean,
Well, you know, when I
Speaker 2 (32:56.686)
Proof is not in the goodwill, but in the evidence, I think. if we're going to attract individuals to a field like comprehensive family medicine, we want to make sure that that practice environment and everything that accompanies it allows doctors to be doctors. And I know you're quite passionate about that and we'll touch on that a little bit later. What's the first domino that allows the new way of thinking to start taking root? Short of, you know, societal advocacy and I would...
know, our listeners today, and if this sparks some interest, it's important conversations to have because voices from everywhere are important, not just ours or our colleagues.
Yeah. So, you've hit on, you know, core core issue. I get to, when I'm, you know, I get asked to talk about these themes to different audiences. And when I, I spoke a little while ago to a, to a local audience and not doctors, know, the public. And when they hear this, I get the same question all the time. get, well, why don't, why don't you just fix this? I mean, needs.
much explanation. mean, it's no great revelation or insight on my part to sort of point out where these issues are. The question that keeps coming up is, why don't you guys just go ahead and fix it, right? You're doctors, you're smart, fix this. Well, what people don't recognize, as you said, there are lots and lots of organizations that are
responsible for components of the medical education and approval process that are doing them well. They're doing their bit really, really well. They have developed these processes. Some of these organizations are hundreds of years old. They have evolved processes, they have government mandates, they have lots of reason to do this well. They hire very, very bright people.
Speaker 1 (35:07.542)
and they do their job very well and God bless them for doing it.
They do a lot of pride too.
Yeah, the problem is that when you look at the whole process, it's not working, but their part is. So it's kind of like that parlor game, you know, the parlor game where you whisper a word to someone, a phrase, and then they whisper it to the next person and they whisper it to the next and it goes around the telephone game. By the time it gets to the end, it bears no resemblance to what was started, right?
telephone game,
Speaker 1 (35:43.552)
Everybody is doing their job. Everybody is doing their job. Well, they are reliably with good faith, as best to their ability, passing the message on. But nobody's looking at the final product. And nobody's saying, okay, that doesn't sound right anymore. Let's fix it here. Okay. So how do you get at this? Well, I don't know if you watched all the president's men, but there was a
There was a point in that movie where they were trying to sort out the complexity of the scandal that occurred in the context of the 1972 presidential election. And this reporter was going around trying to figure out how this terrible thing could have possibly happened, right? And he had an informant, and the informant's advice to him was follow the money. And if you...
If you follow the money in the healthcare system, you recognize that it's almost all getting paid from the same source, right? Although the money comes federally, it's handled by provinces, okay? So provinces fund medical schools. Medical students think they fund their medical education and they do. I'm not putting that down. At most, it's a third of the cost of their medical education, right?
it better.
Speaker 1 (37:11.374)
Provinces fund residency training. Providence fund the colleges that approve doctors. They fund in various ways and through different ministries the whole thing. Are they getting value? That same province, that same provincial government has a mandate of healthcare.
Right? We have a Canada Health Act that says that every citizen is entitled to universal and unfettered access to care and it's wonderful. And it is largely administered through provinces and territories. So they have this mandate and it's a clear expectation. No government would last a second if it tried to compromise that. It's a component of every election.
their pain, are they getting the product? And so how could they start to, and I don't, I navigate throwing the system up and, but it is entirely reasonable, I think, for a province to say to a medical school or to a college or to a resident's training position, look, we expect some, we expect some outcomes from this.
We've got a problem here. How are you contributing to the resolution of the problem? Now, you know, and I know that these are not short-term issues, right? But if we don't start grappling with it today, it's only going to, it's getting worse. We will not solve this doing the same stuff. You know, if we think that we can somehow
you know, open another few spots here or there or the other place, and this is going to all get better? We're dreaming, right? That'll settle maybe the government PR for a month or two, but that's not going to solve this problem.
Speaker 2 (39:26.03)
Can the medical schools even function without provincial government funding?
Speaker 2 (39:36.334)
Either that or med school tuition is going to go up through the roof and become beyond unaffordable.
Yeah, mean, for tuitions alone to cover the cost of medical education, it would be available to very, very few. And it's already very high and arguably out of the reach of many young people, many of whom are growing up in small communities.
Some are doing jobs that they're doing because they need to do, but could very effectively and happily transition to medical roles. who never saw that as a, so finances are a big part of this. So I'm not suggesting you blow up medical school. I love medical schools. But I'm saying that there needs to be a thoughtful dialogue about how
how medical schools are accountable to society for the doctors. They are responsible for admitting and training. That gateway to the profession is admissions to medical school. You can't become a doctor in Canada, as you said earlier, without a medical degree. You can't get a medical degree without being admitted to a medical program. Once you get into a medical program, everybody becomes a doctor.
So it is an absolute gateway to the profession. It is clear as any that the gateway to the profession is through admission to medical school. Where is the accountability in that process to downstream needs? I'm not saying we should force people to do stuff they don't want to do. I'm saying design the system to produce what you want.
Speaker 2 (41:32.974)
to nurture the target. So tell me, you've had the opportunity and almost, I'd say the luxury to be able to take your thoughts and share them with non-MD, non-administrative community members, as you mentioned in some of those talks you've given. And that's such a wonderful sample or snapshot of our society who are
but removed from the medical system itself in terms of the fact that they're not part of it. But what did that sample tell you? I mean, the more they heard you talk, what is the pulse? If we had to take a pulse of that audience and extrapolate to maybe that's really the pulse of Canadians if we're at, and that,
Where can we build the voice? Because this sounds like a message that we can't ignore.
Well, let's do that in a couple of ways. I'll get back to my sort of anecdotal experience with audiences in a sec, but if we just step back and look at what we hear from patients and from society when they're asked about their trust in the medical system and their feelings about the healthcare system in general, I think what we hear is,
increasing levels of ambivalence, to say the least, about their trust that there's a healthcare system out there that is equipped to look after them, and that the medical profession in particular, and this is very distressing, and thank those of us in it, we're seeing decreasing levels of trust in the medical profession. And yet at the same time, the same time, trust in their individual care providers is strong.
Speaker 1 (43:30.402)
You know, there's always been this dichotomy that if a patient is talking about an institution or a group, that's a very, very different thing than if they're talking about the provider that they have. Their relationships with their doctors remain strong. And in fact, getting back to my personal experience, I get patients coming up to me talking about how hard their doctor's working. My poor family doctor has run off his or her feet, you know?
They greatly appreciate what their doctors are doing for them. When they go to emerge, they don't like being in emerge, I can tell you. Nobody does. But they appreciate how hard the doctors are working there. They can see it. They can see it. They can see the nurses working really, really hard, the therapists working hard, the x-ray tech. They see what's happening. So there's a marked difference between
how people perceive the system and how they perceive their care provider. And when I'm talking to folks, the thing that strikes me is just how gracious people are in the face of all this, right? I mean, you get some folks who are just angry, just angry. And this is fair, I paid my taxes, I'm a good citizen, blah, blah, blah. I ought to be able to, yeah. But by and large,
I'm more surprised by the number of people who aren't. Who are sort of seeing that this isn't anybody's individual fault.
especially if you're, as you say, you're working in overdrive and you're trying to meet the requirements and demands of individuals' care, but you know you hit these bottlenecks where, you know, whether it's a wait list, whether it's there is no one available to, you have to drive seven hours away to get access to that care that you need, there are all kind of variables. And at one point, as in primary care, I think you just say like,
Speaker 2 (45:36.526)
can't do anymore right now with the resources that I have, but boy am I invested in your care and I care about you.
You know, there's a bit of a generational thing here too, right? The people who are getting the most care these days are of a generation that went through life in which deprivation and stress and public problems were not unknown to them. Okay? You know, in terms of, you know, wars and depressions and such. These are people who are wonderful, wonderful folks who, and you you take care of them like I do.
who are grateful for the care they get or grateful for what they have are accepting or forgiving, all that stuff. But they're the ones who are bearing the brunt of this right now because they've got the chronic problems and they got the greatest needs. They're waiting for their hip replacements for a year or two. They're hoping to get their cataracts within the next few months. Their cancer care is delayed, all that stuff. And yet they are just a wonderful, wonderful
generation of people. But, you know, in a way I tell them sometimes, you know, listen to your grandchildren. You know, and I know it's a bit facetious, but you know, you have a right to say something about this, right? And I had a guy who, you know, this fellow came up to me because he'd finally found a care provider.
but was getting different messages from different folks and was asking how they'd reconcile. They said, well, you've got to advocate to those providers for some direction. But there's an acceptance. And that's wonderful, but I fear that it doesn't obstruct, but it maybe delays the kind of responses of me.
Speaker 2 (47:38.338)
Sure. So how do we initiate change is something that keeps popping into my head because it sounds to me like the people of Main Street need to have a voice. And because Main Street needs their family doctors. Towns where Main Street hasn't had a family doctor in 15 or 20 years is not an uncommon story.
And you get patients talking about it and their experiences having no one to quarterback their care, so to speak. I it brings tears to their eyes, let alone if a doctor actually arrives in town, people are in tears of joy. you know,
There's got to be a way that sort of reconciles the need and then creating an environment that actually welcomes and nurtures those professionals once they establish practice. And I'd love to get your thoughts about something that recently appeared on CBC. The town of Polwood, BC hadn't had a family doctor in their small town or small city in ages, but they are growing.
The demand is growing, the population is growing, and their mayor, Mayor Kobayashi, who's an engineer by trade, who's a problem solver and gets things done, figured out that it was entirely legal to be able to hire family doctors as city employees, aligned with people who have chosen that profession, who feel their callings to be a family doctor, could now actually enter practice
where they could be doctors, not paper shufflers, not hiring and firing, administrative assistants, or dealing with labor code issues, or other elements to run a small business in its complexity, not torn between having to see volumes that allow them to make their overhead, and in doing so, have to rush through appointments, typing into looking at screens as opposed to facing their patients, because they're just in that state of overwhelm.
Speaker 2 (49:54.904)
Here in with this very novel and innovative approach, I think there are four physicians are hoping on the way in the near term, at least three, last I saw on the news, will be entering, knowing what their income is going to be on a fixed salary. Things will be taken care of for them so they can look after people and actually have the time to invest in developing
the strategies that are not just gonna make people live longer, but live healthy lives longer, as you pointed out, making sure their cancer screenings in check, making sure there's someone who knows them, who gets their reports when they're discharged from hospital. mean, hats off to creative thinking, and I know that's caught a lot of attention, and towns elsewhere in Canada have looked into that option.
You know, yes, certain traditional funding comes from the provinces. Well, here it's just being funneled through the city. As a city employee, these doctors have benefits like any other city employee. But while it may not be conventional, I'd hope that ideological view of how it needs to be administered doesn't stand in the way of innovation because these individuals who got their family doctor finally after years were in tears at the prospect of
being able to be looked after. To be looked after is an incredible feeling, to feeling that you're cared for, and now they finally have it. So I'd love to know your thoughts about, I mean, that's such a win in that scenario. And if we could build those wins along the pipeline and the funnel, identifying respective candidates to be family doctors, nurture them through their training, expose them to what they best need.
and then bring them into environments where they can be the best doctors they could be and not burn out doing paperwork and having to run a business that they get no training for. I mean, you talk about all the training we get to be doctors, to get our MD degree, and even in residency, there's no training on how to run a business.
Speaker 1 (52:12.014)
It's a great story. I love it. There are others, of course, across the country. I think as one hears it, you're really happy for that community and for those patients. But you've to stand back and say, why is a community mayor solving a problem of access to healthcare? What indictment is this?
for our global system, that a community, and God bless them that they do it. I mean, they want to do it for their neighbors. But do we really have a system where we're gonna have every mayor of every community figure out how to make sure that there are enough doctors for their community? And in terms of the broader perspective, we should look afar. I mean, there are countries around the world that...
administer healthcare very, very differently than we do. I mean, you live on a certain street, you belong to a certain health unit, like you do a school. And that's not just about, you know, tragic acute injuries, it's about healthcare, right? And you're part of it, you're enrolled. Let me step back. I mean, here's another analogy I'll throw at you, just to, because we're talking about the model of care delivery, right?
And we're talking about really the fact that the model that has been in existence, where doctors were independent, where they were contractors, where they were paid based on service, isn't working everywhere. And the place that's not working the most is family medicine. But let's just stand back. Let's imagine, Mark, that you are the mayor or governor of a community.
family.
Speaker 1 (54:06.83)
And say part of your responsibility as mayor is to ensure that there is fire prevention in your community, right? You're responsible for your say, you're not a fireman, you don't know anything about fires, but you're responsible for ensuring that if somebody's house goes aflame, that there is adequate resources to deal with that. And for years and years, you've had two fire departments, one in the East and one in the Lack West, and they run really, really well and everything has been great.
But over the last 10 years, your community's grown by 30%, right? And you've got this whole new area, and your population's much, higher. And guess what? Your fire department's starting to have a problem. There are more fires, because whereas the fire department went around with preventative strategies, they can't do that anymore. There's more damage, because it's harder to get to the fires. There's longer to put them up.
And your firemen are getting upset. You know, they're getting overworked, they're getting distressed, they can't Yeah, and they're standing, they can't stand to see that, you know, they can't do the job they used to do. So how are you going to deal with that? Well, one option is you could say to your firemen, well, you're going to have to just buck it up and do more. We contracted you to look after fires. You go look after fires. And in fact, if you don't put out the fires as you should, we're going to dock your pay.
Leaky too, yep.
Speaker 1 (55:33.898)
And that's the current approach to the province of Quebec, which is saying to its doctors, you know, you are going to be responsible for certain targets and if you don't meet them, you're going to have financial consequences because we don't believe you're working hard enough. The second approach you could take is to say, well, let's produce an environment where any qualified fireman can come in and put out fires and we'll pay them by the fire.
So if you're a qualified fireman and you put out a fire for us, we'll pay you so much for it. So we'll pay you by the fire. And have an environment where you contract for specific things like putting out fires. And that's kind of like opening up, you know, free access to specific services in a medical community. But the third option is to say, well, we need a new fire department.
We need to resource and supplement it. We need three now, okay? And what we're gonna say to our firemen is, we expect you to prevent fires, we expect you to put them out, we expect that there will be no more fires in your community than anywhere else, we expect that there'll be no more damage than anywhere else. And by the way, we're gonna ask the people who live there how they feel about the fire protection, because they're living there, they know.
and we're gonna go with their feedback to the large extent too. That's what we expect. And if you're not doing the job, we're gonna fire you and bring in somebody else. Well, what would you do? And these communities are going with model three. I think that the family doctors, doctors in specific, you're quite right. Want to do what they're trained to do. They wanna be doctors. They want to look after people.
they want to provide the care they're able to provide. And when they're not able to do that, for one reason or another, we see problems. We see problems with productivity, we see problems with patient outcomes, but we see consequences for those doctors also.
Speaker 2 (57:48.032)
more of the stress and burnout.
Yeah, well, know, lots of distress. So yes, we need to put them into environments where they can do their job. And what does that mean? That means trusting them to be doctors, which means you don't count every little widget they do, you look at outcomes. If those doctors that are planted in that community, what's the expectation? Well, the expectation should not be that you see ex-Kajillion patients in a year.
or have so many encounters or take so many blood pressures or prescribe so many pills, it should be that your population has as good or better outcomes as any other population in terms of things we can measure. And we can measure stuff, right? We can measure how many heart attacks occur and how many people are having to be admitted to hospital and how many people have to go for urgent surgery. How many people show up. You know, we can count that stuff.
We can also ask the patients, okay? We can say, look, when you had a problem, were you able to be seen? Were you happy with what you're, did you understand what was wrong with you? We could come up with a number of metrics and we could say, look, we don't care how you do it. You're the doctor, you figure it out. We don't care if you see people in the office. We don't care if you have long hours. We don't care. What we care about is this outcome.
Okay, and we're going to negotiate how much we pay you. And you know, that'll be competitive compared to your equivalents across the country or whatever. We'll have to come to an agreement about that. There'll be benefits, there'll be whatevers. But we want you to look after healthcare. And you figure out who you need to work with and what kind of teams you need and what kind of processes. I mean, that would...
Speaker 1 (59:45.006)
And I got to tell you that when that community put out a call, they were flooded with applications. Because I believe, particularly the generation of folks that are coming out of training these days, they want to practice. They care about what they do, they care about their profession, they care about the patients they're seeing. And what is damaging is when they're not able
to do, what they are trained to do, what's in their heart to do, and what's in their capacity to
And that's a huge point, right? Their capacity, because capacity is determined by a lot of things, and that includes your own sense of being able to be present with your patients, and to also be present in the moment as a caregiver to your patient. And that's informed by a lot of factors. And no more than ever are we realizing that burnout across healthcare is a systemic problem.
that a lot of that is informed by work conditions, work environments, elements of scarcity, not being able to do what you know you should be able to do for your patient, but you just can't because you're not afforded the toolkit, the access to what you need to, and that weighs on people as well.
Yeah, I think it's pretty clear.
Speaker 2 (01:01:15.918)
If we're going to think about the longevity of this investment in using the family doctor example, we don't just want to get them there. We want them to stay healthy and we want them to, we don't want them to leave after a year and saying, this is impossible. I've entered into this ring of fire where
there's so little I can do because of such a high demand that these individuals burn out sometimes within a year or a year and a half and they just walk away from a community because it's the company, if you will, the fire department, whichever, is just not built to sustain their presence there. in medical school and in residency training now, I think wellness has been almost tokenized
I'm always amazed at how many people I've interviewed over the years who seem to have kind of wellness figured out when they're under the umbrella of medical school or residency. But then when you go into the real world, then you see the real statistics that crop up and the spectrum of things that can go wrong when wellness is compromised by systemic factors that don't allow doctors to be doctors who feel that there are
constantly under moral duress. And certainly that's something we've touched on on the podcast, but is very much alive and well to the South where profits still count more than people, whether those people are patients or physicians. But what are we going to need to do if we're successful initiating this transformation to creating funnels and getting family doctors and
to practices where they can be and do what their calling is. What's the next level in terms of primary care provider, family doctor, wellness in that environment and how do we sustain it? There's certainly a generation that are very well invested in trying to engage in self-care that's reasonable. Yet very often we feel like those tools just fall by the wayside when the current cohorts enter the
Speaker 1 (01:03:36.654)
I think there's lots to it, but part of it, I think, relates back to what we talking previously. And that is the process by which we admit people to careers for which they are interested and suited and passionate about. You know, if you bring someone into a career that for them is satisfying,
and is the culmination of what they want to do, then that in itself will be sustaining. I mean, I believe that providing medical care in an environment that's effective is effective for the patient, but I believe it's also invigorating for the provider. I think that providing, helping someone, you know.
the ability to help someone through a personal problem, tragedy, even if it's small or large, is valuable for that person. But I truly believe that it brings value to the giver as well. And we've all felt that, right? And we see our students go through it. I mean, see it with our students all the time. Our students, when they're going through medical school, will come to a point where for the first time, despite all their
preparation and training and brightness, they will for the first time come upon an experience where they actually personally intervene in someone else's life in a positive way. And it can be small. It can be coming up with a diagnosis that nobody else came up with. It can be doing a suture. It can be assisting in the OR. It can be something where they, by virtue of their presence, their skills, their interests, their compassion, their caring, they helped somebody.
Nobody else did that, they did it. And when that happens, Mark, that person's hooked. That's like a drug. That ability to help someone else is, and we all, you know what I'm talking about, it is sustaining. And so putting people, so medical school, I believe medical school, medical training, is nothing other than putting people into those environments, right?
Speaker 1 (01:06:00.174)
Right. Helping them find them, helping them train in them in a healthy, supportive, nurturing way, and then putting them into the environment where they can be the provider working with other people doing it. That's what we do. That's fundamentally what everything else is detailed around that.
And that's the hope that we enter the engagement with for sure.
Yeah, yeah. No, I know I'm drastically simplifying a very complicated process, but in terms of dealing with this issue of both how we get people into things they want to do and how we keep them there, I think that initial selection, that binding is important. And what I see too though is that it's becoming damaged because as the system becomes more troublesome, these bright young folks
are looking to find environments where they feel that they can function. And that may be areas where their activities are much more specific, where they're less engaged with holistic patient care. They're easier, they're safer, right? And so there's a draw away from generalism, which we need a lot of. So there's sort of,
mutually supportive things. So I think the first answer to your question is matching people to careers, right? That work and putting them in work environments where they can do that. I think that there's models out there for care delivery systems that are a whole lot better than what we've done in the past. And I think as we develop multidisciplinary environments for people to work.
Speaker 1 (01:07:53.368)
We got to make sure that they don't just divide up the same work process in multiple spots. So if a job is bad, and if it has all those aspects that you've been talking about, frankly, doing less of it is not a lot better. If the job is fundamentally dissatisfying, if it's frustrating, if it's not allowing you to do what you want to do, then
Right.
Speaker 1 (01:08:23.214)
reducing it by 25 % is not going to make your life a lot better. You need to fundamentally change the paradigm. And so how can we do that? How do we get rid of those aspects of work that aren't particularly, that aren't related to fundamental doctor skills?
Yeah, they're detractors, right? Yeah. Well, mean, the I can think of a story recently when I was out of town seeing patients and I bumped into a family physician who was doing a locum and they were telling me about some of the work they've done ad hoc trying to help out in walk-in clinics where on a Saturday morning
for a clinic that was going to be open for three and a half hours with, I think one individual who would be there half the time for administrative help had 60 individuals waiting as of 8 a.m. to be seen for a three hour block. And the turmoil and distress that this family physician had in telling me the story of what it was like to be in that walk-in clinic with individuals in need, some they had to send to the hospital, some
were angry, some were in distress, some had mental health issues.
mean, you can't run a service, and I'm not saying that that was her optimal way of doing it. That's what she stepped into. But somewhere in there, someone's rationalizing that that's an okay way to deliver proper healthcare. that just, we can't fall into the trap, and all of this work and raising it and developing awareness and the need and then creating these funnels to train family physicians who are going to provide
Speaker 2 (01:10:16.77)
wonderful complex community care for a community of individuals and then have them in an environment that almost guarantees that they're going to fail or burn out or hit the wall because there's just too much else that's standing in their way. hats off to Mayor of Coldwood and to other mayors who are thinking about these options as well.
looking at their opportunities. Maybe they won't be able to do it immediately, but maybe they can plan for six months or a year from now where they'll have the budget to renovate a locale where they can then create this for their citizens as well. it's all about seeding the ground so that these people we actually have trained have a nurturing environment to do their job and to make a difference and to...
actually experience that fulfillment you're talking about. And we've all experienced it as care providers. I mean, it's very rewarding and it reinforces our calling, our vocation, why we care, why we give of ourselves. And as professionals, sometimes that's the pre-slope between the ideal professional who's totally self-sacrificing and then there's...
The flip side is where you get yourself into trouble, where you don't take care of yourself well enough, and then you're dealing with health issues. it doesn't end at the entrance to the new office you're about to start in your profession. And there has to be the next level of awareness that ensures that our investments in people and the care providers of tomorrow actually have the best chance of success. Otherwise,
Once again, we're just fooling ourselves.
Speaker 1 (01:12:05.206)
You know what helps is to reset the thinking, So our classic thinking is about a doctor in a space providing care. Let's just sit around a table, blue sky, and think instead about what patients actually need, okay? So if you're, again, getting back to that hypothetical community that you're mayor of,
The medical needs of that community could be considered to encompass four fundamental domains, right? One domain is acute and complex care, okay? Like acute injury, illness, acute injury, catastrophic injuries, and complex care. A second is new but non-urgent medical issues that arise. A third,
is chronic care, in other words, understood conditions that are not going away but require ongoing care, and a fourth is preventative care. Those are the four needs that any community has for medical care. It all falls into that. The number one thing, the acute care, the first thing I mentioned, is I think pretty well provided by our hospitals.
You know, they provide access for acute, they've actually become, without any intention mark, they've become almost exclusively the domain of that aspect of care. So that acute care, acute catastrophic care, complex interventions, surgeries and such, get done in hospital settings or under, better put, under the umbrella of a hospital governance system. Okay? But in order to do that,
they have moved away from those other three aspects of care, which they used to provide to some extent. And that's not anybody's fault, that's just they've had to. Well, what if we think about ways of delivering those other three components of care and take some lessons from what works about the hospital governance system, right? So what works about hospital governance? I'm not saying it's perfect, but it has a board, right? It has a board.
Speaker 1 (01:14:30.54)
that is responsible to ensure that the mission gets carried out. It's responsible for hiring people to do those jobs. Responsible for providing environments where those things can happen. And it's funded, you know, from the government and from the community, right? With that mandate. Well, what if we had a similar structure with the mandate for the other three things?
How would you do that? Well, it'd be really fun to sit down, wouldn't it? And think about how you do that. How do you provide ways for people who, know, wake up in the middle of the night with belly pain that they don't know what to do with, and it's not bad enough to go to a merge, but, you know, I don't know what it is, or I come down with shingles or, you know, whatever the hell. How do you get cared for that, right? Why is it that the only avenue is, you know, wait, see if it goes away or go to a merge? You know, you know, um,
Can we develop environments where that happens? Can we develop environments where people with chronic medical illnesses, whatever they are, you can go and get care for, like our heart function clinics are starting to do. And I know you have inflammatory bowel clinics and diabetes clinics. know, how do they, they sort of become, you know, isolated. Why can't they be under this umbrella? And what about that preventative part of it? Then the discussion becomes how do doctors fit into that?
What do we need doctors to do? And we're not gonna hire doctors to do stuff that they're not trained to do because it doesn't make any sense, right? They're not gonna hire you to fill out, know, Lumio forms for three hours a day in that system because they need you doing assessments of this other thing, right? How do nurses fit into that? How do therapists, how many do we need? What environments do they need to work in? How do we make it so that it's fun to go there to work? know, how do you, where do they have lunch?
Where do they go?
Speaker 2 (01:16:28.357)
So we spoke with Todd Otten recently. I mean, that's the office utopia. It's a culture that you build in caregiving and care providing in a group dynamic where everybody has a shared value system and they buy into the mission. And to your point, that's what we need to build. you know, the perfect example of that patient who wakes up with some belly pain at night, not sick enough to go to the merge, but they need to be able to pick up the phone in the morning and say,
you know, I'm not really feeling well and have a structure that receives that call and says, we have an emergent spot open tomorrow afternoon, come by at two. The stories I hear is, I got an appointment three weeks from now. Like, that's not a salute. That's not access to healthcare.
Yeah, yeah. And, you know, there are telephone services, but they can't just be deciding whether or not you should go to a merge.
No.
And we live in an age where you can do a lot. and I are looking at each other. You can be talking to your patient. You can be doing aspects of clinical assessment electronically that we couldn't adrift of doing before. It's not just a phone call. We can do things in innovative ways and provide interventions.
Speaker 1 (01:17:57.646)
care, diagnostics, in a much more sophisticated way than waiver could be for. It isn't always necessary for patient to get dressed, get in the car, drive to the merge, and wait to get seen. So, yeah, I mean, it would be intriguing, fascinating, and I think invigory for young doctors to start thinking about how to create those environments.
I agree. So, you know, when I think about what our patients and listeners
are facing these days, I always think of the other important people in their life. So their partners, their spouses, you might be a child of someone who's sick, you might be distant relative, but you're a caregiver. And you're looking after these individuals who trying to navigate a system that's very broken, that has lots of potential...
high-risk spots where communication can be broken, where follow-up is not immediately accessible, where the risk of readmission to hospital goes up, and that's no victory in itself.
There's so much that's on the line for patients, but also their caregivers who are there at their side, partnering with them in this journey. But there is hope and we've seen some refreshing change. I might, as I greet that, I can only hope that we're not just doing something upfront at the top, but downstream, they'll still enter the same quagmire where they won't be allowed to be the doctors they're trained to be.
Speaker 2 (01:19:45.784)
But with the sight of hope, let's talk a little bit. I'd love to hear your take on some of the new developments because we are witnessing them. There's the Lakeridge program in Oshawa, Ontario, which is basically starting to echo a little bit of our conversation and how they're training students to become family doctors. this was something initiated, was it initiated while you ran the medical school or was it a little bit after?
Yeah, no, was initiated as I was finishing my term as Associate Dean. Yeah. So the Likwage program is one that is designed to specifically admit and train young people to become family doctors. So it is a offshoot of the MD program at Queens. The major differences are that it is a six-year rather than four-year program.
Can you tell us about that?
Speaker 1 (01:20:45.806)
and that in addition, the students can progress through the sixth years without the need to apply specifically to family medicine. They're being selected with the idea that they want to become community-based family doctors providing continuing competence of care. That's the deal coming in, right? And so these young folks have already decided that this is what they want to do. They want to become family doctors.
And the training mark is geared towards that goal. So they're not sampling every other specialty because they've already decided what specialty they want to do. And they can spend time instead in community-based clinical experiences early on in family health teams where they learn what it is to be a family doctor. They learn the role. They do simple things to begin with. They increase their complexity as they go through.
So, and they do not have this added pressure of applying to other specialty programs or exploring because they're more advanced than that. So the training they get is concentrated in family medicine. This program was put in Lakeridge in Oshawa because Queens had a strong footprint there already. And there's a very strong support from the local medical community and the hospital network at Lakeridge.
to support this program. I can tell you that the engagement from both the community and the medical group there has been outstanding. Whereas it's difficult to get preceptors to take students traditionally, we had waiting lists of preceptors because you
Preceptors, mean doctors who are willing to teach these students.
Speaker 1 (01:22:37.516)
Right. Wow. And that reflects, I believe lots of things that reflects the engagement of the program, but it also reflects the fact that, that any doctor that's in practice is much more, is going to be much more likely to and much more content and much more effective in training someone who wants to do that. They want. Whereas, you know, if it's someone who
Yes.
Speaker 1 (01:23:06.574)
is sampling that practice for to sort of what it is. It's a very different commitment, right? And it's a continuing commitment. The idea is to develop relationships between practicing physicians and learners that are continuing. So it's a very different paradigm. They're now in their third year, they've admitted their third class. I tell you that the admission process is also different, right? The admission process isn't about, do you want to be a doctor and you know,
what experiences have you had, know, volunteering stuff. It's about how do know you want to be a family doctor? And it's looking for qualities that the, and we went through a process of thinking about, you know, we actually brought in family doctors who had experience with the mission processes. We brought in community members. We brought in HR people. We had HR people in our community, you know, who didn't know what medicine, but knew about how to pick people out of crowds, right? And, and,
we thought, okay, what's a process that will allow us to identify and allow a person who has this interest to come forward and be known? And it's not about necessarily, I mean, they need a certain degree of academic accomplishment for sure. And these students have equivalent academics to in the other crowd. But in addition to that, they have a commitment to family medicine and they have a life experience that reinforces that commitment. It's not just about you want to be a family doctor.
What in your experience has allowed you to make that decision? That's the deeper question, right? How do you know you want to be a family doctor? Well, you know, the fact that, you know, you had a lovely family doctor when you were growing up and they were, that's not enough. No. What's your life experience that allows you to know that this is, that you're committed to do this? And that, that is a much deeper.
more penetrating and frankly more interesting admission process than the standard.
Speaker 2 (01:25:10.54)
it certainly seems more aligned with you were to do a need-based assessment of our communities and our society. It seems to be well aligned and upfront proof that something can be done and is doable of recognizing what you recognize during your journey as an educator. So how many students are admitted per year in that program?
per year. It's really a, it's kind of a prototype program, Designed with the idea of, you know, can we do this, right? Can it be done? Can we do an admission process that's effective? But you know what? It's the, you know, I've had a chance, the students are great, of course, the community is great. But you know, the same process,
Scalable. Yeah.
Speaker 1 (01:26:05.976)
can be scaled up, but it can also be applied to other areas, right? The same paradigm, you know, we need just to throw the psychiatrist, right? Well, why couldn't you do the same thing? I mean, do we really think that, you know, that among those undifferentiated, you know, a hundred that we admit, you're gonna just magically get enough who wanna do psychiatry, you know, or whatever it is you need, but it's all I
Not in rich at the top, you're right. And it's like, put it casting a net early on.
Yeah, and again, know, interesting conversation about what those core elements should be, right? What should every doctor do? And maybe that first year needs to be a fundamental core year. And it'd be great. I think it'd be really interesting to think about what elements any doctor should have and how we embed that early on. But then, you know, I mean, if you're off on that track, why are we making you apply three years later?
Absolutely. So, recognizing some of the numbers recently that about 40 % of all graduates might choose family medicine as a path, and then maybe only half of those would end up in primary community care, coordinating the healthcare of their citizens.
How many of these once successful programs like the Lakerage program are we going to need across Canada? I every province is probably going to need one if we're going to make up that difference so that we actually have family doctors for our communities. I mean, there's a lot to learn from this experience, but there's also a lot that can be shared and there needs to be a lot of open-mindedness to sort of see if when the successes arise.
Speaker 2 (01:28:04.61)
I have no doubt this is going to be successful, that they need to be widely adopted and again not met with provincial, inter-provincial siloed thinking.
Yep. So as we sit today, we have a need for doctors that is huge. Right. And even, you know, even with the opening of these new medical schools that are being opened, if they operate in the same paradigm that the others do and that you just described the ratios, it's not going to touch this problem. It's going to barely replace the people who are leaving.
Right? So we need to think in terms of how to replenish the physician population now, and at the same time, how to build a sustainable system into the future. And those are different things. And there's no one thing that's going to do this. I did an article a little while ago on
options for increasing the medical workforce, right? I think we've got to look seriously at how we, you know, utilize, and the great resource we have is a wonderful population of young people who want to become doctors. And we have very well functioning medical schools. I mean, Canada is blessed with medical schools, soon to be 20, that are all good, right?
They're all very, very good. They're all established mostly in very well-running universities with good faculty and all that. So we've got great strengths and we have a culture in Canada of comprehensive care. We value health care. We value it as a commodity for our citizens. We've got lots and lots of advantages, but we need scale. We need to think about how to
Speaker 1 (01:30:10.378)
increase the number of these young people we can bring into medicine and how to train them. And so I think that's more than just having more schools, it's about how we do things. I think we need training tracks for family medicine and others, think we can think about, get away from this idea of a single preliminary training track and think instead about
maybe four or five different tracks, one family medicine, one surgical specialties, one mental health, pediatrics be a track, laboratory medicine is a necessary, hugely important aspect of care. We could be thinking about having people imagine themselves in these roles and then differentiating further. Now, we're not gonna have 150 different types of medical school, but we can have processes where people
funnel through to those practices. We can also, Mark, have processes where we take advantage of folks who are trained in other places, right? So we've got as many Canadians training in medicine outside Canada as we do in Canada, probably more. Nobody knows for sure. But these are young people who already know the Canadian system, who by and large probably want to come back, but you know what? They don't.
once they go to places like Australia and, you know, different parts of the States and develop a life there, develop partners there, you know, get a dog, they're likely to stay in those places, right? And by the way, the same needs that we're addressing here are being addressed in those places with our people. Our Canadians are going their way. So we need to identify those folks and say, hey, you know, here we are.
You know, let's not make them pariahs, you know, applying for a small number of positions. Let's welcome them. Let's provide opportunities for them to show that they're well trained. Because, you know, know there's a certain, I know medical education outside Canada is not all homogeneous. And believe me, I'm more aware that than most. But there are lots of really good medical schools out there. And our students are in them. They're Australia.
Speaker 1 (01:32:34.688)
England, Ireland, there's lots of really, really good schools that our students go to. Let's let them show us that they are willing and able to come back to Canada and make it possible for them to do so. That would double the number of potential applicants to medical school, to physician roles right away, okay? Thirdly, you know, we all know that there are lots of very, very capable people who trained in medicine outside of Canada.
but who have immigrated to Canada and have taken up roles in Canada that are non-medical because they can't get into our system. And I get completely that, you know, we have to be scrupulous about training requirements and stuff. But, you know, I can't believe that, but why wouldn't we allow those people, and I know we are, and I know the colleges are working hard to develop, you know, processes by which these folks
can demonstrate their qualification and get roles, but let's, but you know, we should continue to facilitate that. And let's prioritize our biggest need, which is family medicine right now. Why don't we say, look, but be careful that we need people who really want to be family doctors. So those are some thoughts just about, you and at the same time, none of this,
should stop us from increasing the capacity of our current medical education process. And if that, and this is going to be a little controversial, but if that can be accomplished in universities, that's great. But does it have to be accomplished in universities? know, can medical education, does it have to be in the same paradigm as every other area of training within a university, or can it be seen as something more responsive to societal needs?
more linked to Sosia Oni's, more directly funded. You we need to think differently.
Speaker 2 (01:34:41.003)
There's a lot of fuel for hope here if we just make some really good decisions as a society that hits the ball out of the park.
More recently, the most recent medical school that's accepted its first cohort is Toronto Metropolitan University, and very community-informed curriculum already from the outset.
mandated to really address the needs of society and communities and the mere fact that it's localized in one of the most ethically diverse communities in Canada shows that it needs to train its students with such sensitivities. We're that next step closer, it seems, on that sort of ideal vision of the kind of
potential family doctors we want to be able to train. What are your thoughts about that new curriculum and that new university training program?
I don't know the details of their process. I know a little bit about it, but I don't know the details of it. The concept that we need to train folks who are willing to able to take up roles in our increasingly diverse community is absolutely true. And it gets to that issue we were talking about before. And that is what are the fundamental components of every medical school, right? I think everybody who comes into medicine.
Speaker 1 (01:36:16.396)
ought to have certain skills, certain attributes, certain capacities. And among those is the ability to care for individuals in whatever strata of society they find themselves, right? So I applaud what TMU is doing in that regard, but I think that should be something we do across the board for medical schools, right? I don't think anybody, that should be the exclusive enclave of anybody.
The other thing I would say is that if the fundamental paradigm is that we're going to do three or four years of core pluripotential education and then have these students apply to 30 different specialties like every other school, then I don't think we've done enough to address these societal needs.
So I'm a listener at home and...
tuned into listening to this conversation between you and I.
Does this conversation fuel hope for the listener? Are we fueling hope here? I kind of get a sense that there's some momentum in the right direction from our conversation today. We've recognized things, I really want to hear from you and to make sure individuals understand is what can you do sitting at home? What can you do in your community center?
Speaker 2 (01:37:53.826)
to start having these conversations and how do community stakeholders get their voice heard?
Well, the first thing I say is that solutions start with awareness. So in medicine, you know, we don't treat until we understand what's going on. You know, we have a patient has a problem. Before we subject that patient to change, to treatment, to intervention, we want to understand what's happening with them. And I think everything we've been talking about for the last while,
and the book is about trying to understand better what the problem actually is and to begin to develop some directions that we can go. So a community member, think should be encouraged that the medical community is talking about this as a fundamental problem, that it sees it as a structural issue, that it doesn't see it as simply, you know,
around the borders of a problem. It's like, you know, if your house is falling down, painting it ain't gonna work. You're gonna have to work on the foundation, right? Absolutely. And we have a house that will not, is not gonna be benefited by painting. We need foundational change. And I hope that the learner will hear that some of us at least are, you know, talking about that and encouraging others to do so. And I think that
The listener at home, I think we all, and you and I are consumers of healthcare too, right? I think we need to be aware that the way we access care is gonna look different, should look different going forward than it has in the past. What shouldn't change, and it may look different in terms of where you go for certain things, about how you interact with people.
Speaker 1 (01:40:00.334)
in terms of how AI is working for us and around us, it's going to change in a lot of ways. But what should not change, Mark, is the fact that your care is going to be provided by an individual who knows you, who cares about you, who has some understanding of you as a bigger individual than just a problem. Who isn't going to see you
as someone with a bad hip or a bad eye or a bad heart, but is gonna see you as someone who has a role in life, who has issues that they need to deal with, and will be there to help them when they need the help. And how we provide that, that's a human side to that, and there's a structural side to that. And we need to work on both.
Well, your book was a great read. If you're sitting at home and you haven't had a chance to read through this, it's written in a way that individuals from different backgrounds can appreciate your message. That's what I really loved about it. And it's adaptable. Fred and Graham, anything that you've heard from this conversation that's been left dangling that you think we could really give a one-two punch to?
You know, my wife is a first generation Canadian. I guess what I'm wondering is how much added stress to an already taxed are current immigration policies, and it doesn't even have to be current policies, but I guess just general immigration policy impacting the resources that we're trying to sort of bring to bear so that we can care for all Canadians, new Canadians, all Canadians. What is the impact of our immigration policy on
the current level of care that's being offered to Canadians? It's a great question. And just for context, I'm a first generation too.
Speaker 1 (01:41:58.698)
So there has always been in Canada, a component of the population that is an immigrant population, right? And when I was a child, I was one of those. And it's a wonderful thing about our country, right? And it's what gives us character. When I was growing up in Toronto, you didn't need to speak English where I lived, you
The concept of immigration and multiculturalism in Canada of diverse populations of diverse religious backgrounds is not uncommon to us. And we should be the place where we welcome people from different countries. And we have been. Does immigration stress the medical system, I think is what you're asking.
And it requires doctors to have certain skills, They're the similar skills to have with anybody else, but they're kind of magnified, right? So doctors need to be able to communicate effectively with anyone they encounter, okay? And that means listening to them and being able to express themselves in effective ways. And for folks who have difficulty with English or comprehension or hearing,
or anything, doctors need to have the tools to be able to effectively deal with those patients. And that's something we need to teach in medical schools. A challenge we've had, sorry, is it Fred I'm talking to? Challenge we've had, Fred, is that some of our medical schools are not in places where we have enough of those folks around to allow students to learn about them. So we've had to find ways to do that. TMU doesn't have that challenge, right? It's in a...
population area where there is a large immigrant population. So they can teach people how to connect with folks from different cultures. But what we cannot do is say, look, we're going to be satisfied with inadequate communication or inadequate care, or we're going to only be specific to a particular population. That's not the answer. We also need to have
Speaker 1 (01:44:22.52)
physicians who are aware that the application of medical care in specific populations might not work or might not be effective, might not be acceptable, right? Because of cultural issues or understandings or religious beliefs. That we need to be open to. We need to understand, we need to teach that. As that means personal tolerance, personal acceptance, but also the tools to understand. So those things have to come into medical curriculum too.
particular thing should be aware of. So immigration, multi-diverse populations do bring greater challenges to the application of medical care, and medical schools have to adapt to that. That's not new, but it's going to be more difficult for some places than others just because of where they are.
potentially highly controversial, but we used the example earlier of a small city that had a fire department that was capable of sort of servicing the existing population and neighborhoods. And then when you start building new subdivisions and adding more people and more populations and more needs and more diverse needs, obviously the increase in population has, you you're still dealing with just the same small fire department.
and I understand the need to build new medical schools and we're doing that and all of that seems very hopeful. Are we able to effectively deal with the number of new Canadians that are coming here? And rightly so, just in terms of the actual sheer numbers of people who want to come to Canada, and I believe that we are a society that is very welcoming to different groups of people, but just in terms of the numbers of people that we see coming in now, what kind of impact is just...
the sheer volume of humanity that we have now expecting service the way we all want to be cared for. What are the impacts of those larger numbers on the existing system? Well, they're huge, Fred. They're huge, right? It's not just numbers either, it's complexity, right? So if you look at the last 30 years, for example, the population of Canada has doubled. We forget about this. Population in Canada is now 41 million people.
Speaker 1 (01:46:44.3)
It's the 37th largest population in the world, right? And we're a big country. We think of ourselves as being sparsely populated because we're so big, but we actually have a fairly significant population compared worldwide and it's growing dramatically. At the same time, we've gotten older and medical care has become more complex, right? So there's much, much more to do. The patient with the heart attack 20 years ago, 30 years ago was put to bed and hoped for the best.
Now it takes a half dozen doctors doing care in the middle of the night. And that's wonderful. It's great. But it's hugely intense. everything, all the problems we're dealing with, they're about population growth, they're about complexity, they're about aging. And it's huge. And we've not kept up. That's the reason, that's the thing that Mark and I have been talking about, the processes for admitting, training, the machinery to produce doctors
hasn't nearly capped up with the needs you're describing.
We've covered a lot of things today. Is there anything, Tony, that you absolutely wanted to get out that we didn't get a chance to cover? We've covered a lot, and I think there's a resounding message here.
Well, you know, I'd like to, you know, make sure that we concentrate on the strengths that we have, right? So we have lots of great things in Canada. You know, I don't think any of us would want to be anywhere else in terms of where to practice medicine or to live as a citizen. And we have the tools and the smarts and the drive to do this.
Speaker 1 (01:48:29.39)
We need to move away from our traditional role. It's like Clayton Christensen would say in his book about disruptive innovation and the innovator's dilemma. We cannot allow our comfort with our traditional success in our processes to prevent us from recognizing the problem and engaging solution.
Dr. Sanfilippo, I'd to thank you for being here today. Your book is called The Doctors We Need. think we could also, if we had to think of another title, it's The Thinking We Need, or The Kind of Thinking We Need, if we are going to provide for patients, if we are going to provide a system that allows caregivers to flourish as they look after their loved ones, a system that allows young medical practitioners to...
in a balanced way of living where they can fulfill their calling and also carry out their vocation in the most healthy way possible. All of these, I think, are within reach, but it takes some systemic change, systemic awareness. And you've beautifully brought that out in your book in that it's all about a first mover. And I feel the first mover is started to move the dial. So I would encourage anyone who's
who's interested in who values this discussion and values the future of our wonderful healthcare system in Canada to give your book a read, to think about what its implications are, to speak amongst yourselves and to help nurture that open-minded conversation that we need to have to build and adapt our healthcare system for the amazing future that awaits us in this country.
Well, thanks very much, Mark. I very much appreciate the opportunity to chat with you and all the best with future podcasts.
Speaker 2 (01:50:32.686)
That wraps up today's episode. What a wonderful discussion, identifying need and starting to target solutions, thinking not only of the patient and the caregiver, but also the person delivering the healthcare. Subscribe if you think this is valuable and give us a review, give us your comments. We'd love to hear them. This is a conversation that fortunately has a beginning, but doesn't necessarily have an end.
It's going to grow and it was wonderful having you here today. So until we meet again.
I'd happy to do so.
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