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A podcast that brings together primary care providers, healthcare planners, patients, innovators and others to talk about the changes that are happening in primary care in British Columbia.
Morgan: Are you wondering where family
physician roles fit into team-based care?
Do you wanna know more about team-based
care from the perspective of a physician?
Yeah, me too.
Sarah: So Morgan, so far this
season, we've explored 10 different
roles in team-based primary care.
Today's episode is our final role,
family physicians, and we intentionally
left family docs to the end as they're
kind of both the foundation of primary
care and probably the role that is
most familiar to most of our listeners.
Morgan: Sarah, you're right.
The scope of the family doctor probably
isn't entirely surprising to listeners,
but given the current context of Primary
Care, we know that family physicians
are stretched beyond capacity right now.
So today we're gonna explore the
physician role from the vantage
point of teams and how that work
might change as you move into a team.
So we're gonna hear from a number
of different providers about how
they work in teams and what's needed
for teams to be most effective.
We'll also consider what teams provide
to support family doctors and what team
leaders, who are often family physicians,
can do to enhance team function.
Sarah: And how would you describe the
scope of care for a family doctor?
I know that family doctors generally care
for patients from cradle to grave, but
what does that look like in practice?
Morgan: Sarah, I'm glad you asked.
So let's start with 105 priority
topics for my college, shall we?
So a abdominal pain?
No.
Okay.
I won't go through them all.
I think really where I wanna start
is more with the relationship.
I often say that we're specialists
in relationship-centered care
and that extends to the whole
family for many family doctors.
And, you know, the scope of primary
care very much is what we do,
almost by definition, so that's
acute, chronic care, mental health
prevention, wellness, that whole range.
And it can be within practice
and outside of practice.
There's a whole bunch of
stuff that we do clinically.
And I think what's interesting
about family medicine, and obviously
I'm biased, is how it evolves with
our practice, with our population.
So we've become increasingly experts
in the people that we support.
And that includes the knowledge
that we gain over time.
, Sarah: this is something I maybe
hadn't thought about so much.
You know how someone who's working in
an inner city practice like yours really
has a totally different Area of expertise
and scope as a result of working with
a certain patient population, then
another maybe newer to practice family
doctor or someone coming from, a really
rural setting who would have a totally
different kind of focus of their practice.
Morgan: Yeah, I think that's what's
really interesting, and if you move,
I've moved, my practice changed,
my skills, my knowledge changed
because I evolved with my practice.
That I think is something that we
probably all do, but I think is one
of the hallmarks for family docs.
We often talk about the different
roles that family doctors have.
There's that family medicine expert
role, but then there's a whole bunch
of other things that are in the roles
that family, doctors hold, communicator,
collaborator, health advocate,
manager, scholar, and professional.
Those are kind of the official
different roles that we talk
about when we're teaching.
And I think those are interesting
just to highlight because how we
fill those roles, changes in a team
as opposed to being a solo provider.
Sarah: And you can move between those
roles for the same patient, right?
You could be, acting in that
expert space and then, you know,
really moving to communicate with
family and with caregivers.
Then, working with other members of
your team to take on that advocacy role.
And I think it's that continuous
shifting that makes the family
doctor role so interesting and also
so complex if you think about how
it's actually working in practice.
And one of the things that I found
really interesting from our interviews
was for me realizing , that how family
medicine is practiced and how a team
works is also really dependent, not
just on the population they serve,
but on the model of care they work in.
So whether it's a community health
center, an urgent primary care center,
a smaller sort of group practice, the
overall scope of care doesn't change
so much, they see all patients for a
wide range of, healthcare needs, but
you know, where, when and how they
provide care can be really different.
Morgan: That's a great sneak peek at
our next season of the podcast, which
we're planning to launch in the fall,
it's gonna focus on different types
of teams and how they work together.
From solo practices to urgent
primary care centers, to community
health centers and lots of others.
Sarah: And it's gonna be a really
interesting season but back to today's
episode, let's start by hearing from
a couple of family doctors about where
and how they work in primary care.
First is Dr.
Terri Aldred, who's an outreach primary
care doctor with the Carrier Sekani
Family Services in northern bc and
she does so much care out in the
community, across multiple communities
with multiple partner nations, a
bunch of different kinds of health
centers, both in person and virtually.
She works from a clinic in Prince
George, but then also does a lot of
in-person outreach across the region
Terri: So my name is Terri Aldred.
I'm Dakelh, from the Tl’Azt’En Nation
on my mom's side, I'm a member of the
Lysiloo, the Frog Clan, and I'm Metis,
Cree, and mixed European on my dad's side.
And I'm calling in today from the
Lheidli T'enneh traditional territory,
otherwise known as Prince George.
I'm a family doc by trade, and I work
in a number of settings including as
a primary care physician with Carrier
Sekani Family Services, where we serve
12 First Nations in North central
BC, uh, both in person and virtually.
And I also work, as the Medical Director
for Primary Care for FNHA, as well as
helping to stand up the First Nation's
Primary Care Initiatives, uh which
will be 15 centers across the province.
My outreach days start fairly early, And
so I try to be on the road, between 6:30
and 7:00 so I can get to community by
8:30/9:00, depending on road conditions.
So usually it takes me about
two hours to drive out.
And then I show up in clinic and we
kind of just hit the ground running.
Our outreach days are generally super
busy, we see patients all day, including
home visits or going out to the schools.
Sometimes we take part in
community activities or
lunches and provide education.
and then we usually wrap up
clinic around say 4:30/5:00.
We have kind of operated that we will
see whoever comes through the door, we
try to be very low barrier to the point
where, you know, we've built up our
relationships with our communities that
people actually drive in from neighboring
towns on reserve to seek services.
Sarah: And Terri works with a large
team of community health nurses
and care aids who are distributed
throughout the region as well.
The nurses are often taking on
these public health roles, including
immunizations, screening, pre and
postnatal checks, educational activities.
And they also often will hold a
lot of the relationship pieces.
because they care for patients across
a very wide geographical region, her
team are out in the community and
they're responsible for triaging the
more complex care to the doctors who
maybe come in, in these outreach roles.
It's really interesting to think about
how this team works because it is so
distributed across , a large region.
They also have a number of different kind
of roles that maybe you wouldn't be able
to pull together in one clinic, she
has access to counselors, mental health
workers, physiotherapists, occupational
therapists, speech and language,
pathologist, but all of these roles in
kind of tiny little bits who she gets to
pull in and work with in different ways.
Morgan: Yeah, so Terri really described
the scope of practice, but that extra
layer of the rural practice, both in scope
and some of the geographical complexity.
She travels a lot in order to get, out
to talk to patients, and then relying on
people at a distance to help her connect.
And this is a great example of how,
physician care in rural communities
will be very different than your typical
urban family doctor's office where
the majority of care goes into clinic.
Certainly there's outreach, to homes
or to other locations and to long-term
care, but it's, it is quite different.
And I think leveraging and leaning
into the team and the different roles
you have on your team is so important.
And Terri does a great job.
Sarah: the, way that Terri described how
she works was so different from how, Dr.
Daphne Green, who works in a West Kelowna
urgent and primary care center, described
her practice when she spoke with us, and
she works in a much more urban setting.
the team still includes that wide range
of health professional roles, but the
ways in which the team connects and
works together is very different because
they're in this center altogether.
Morgan: And Sarah Daphne's scope
of practice is actually pretty
close to Terri's, in terms of
cradle to grave and the different
services that they both provide.
And yet in some ways it's similar to
also to many family doctors and regular
sort of regular offices as opposed
to the urgent primary care centers.
But then they have in that U P C C
some additional space for procedures
and some capacity for managing
more of that urban urgent care and
helping with unattached patients.
But actually a lot of it's pretty similar.
Sarah: And Daphne did a great job
of describing how she works with
the people in her team to get them
to the right clinician and allow
her to focus on what she does best.
She talked about the patient
journey into her clinic.
Daphne: Well, when a patient
presents to the urgent and primary
care center, they're first met by a
patient ambassador at the front door.
So they're the first set
of eyes on the patient.
And this team member will, if they're
concerned about a patient, report directly
back to the team lead and they'll be,
patient will be brought in straight away.
If, things are looking good, then they'll,
Come to the front desk, one of the MOAs
will check them in, and then they wait
to be assessed by the triage nurse, . And
then they're given a priority as to when
they need to be seen, so someone with a
laceration or an injury or who's acutely
ill will be given a higher priority.
Morgan: I think all that
triage really helps for the
undifferentiated urgent patients.
And then you can see how the team
really helps with that, and that's
important for the U P C C team.
And that's different
than Terri's rural team.
The teams are suited, I think Sarah
this is the important thing, to
the populations that they serve.
Just like my skills changed with the
population that I got to know, both
Terri and Daphne and the teams that
they work in are providing service for
the patients that they need to support.
And so the teams organically
look pretty different.
Sarah: And I think, , the way
they connect to the teams can be
really different being co-located
versus being highly distributed.
And some of the adaptations that we've
seen through covid in primary care have
really been part of how rural teams
have worked together for a long time.
Terri really highlighted in our
conversation why working in teams might
improve job satisfaction for family
doctors, just because you do have
that collegiality, different people to
lean on at different times and you're,
really not working alone in isolation.
Morgan: I think that's really true.
I'm, I feel sort of selfish talking
about this, but teams really help me.
I mean, selfishly, right?
They do.
And being part of the team is
a really, important part of
allowing me to do my best work.
And when I'm not as connected with
my team, I definitely feel it.
And when I am reconnected
with the team, it's joyful.
And sometimes it's, it's sad things we
have to deal with and yet there's that
connection and support across the team.
So many memories, Sarah, of different
things over the years, from all the
themes and the ways that I work with
individual people and things that happen
in strange runs of rare conditions, that
we then start to joke that we gotta
have our psuedo seizure today because
that always happens between Roz and i.
That sort of thing that
keeps the team connected.
And we know that that kind of connection
keeps everybody, all the providers
feeling better and working better.
But to be selfish.
It's particularly true for family doctors.
Sarah: And, you know, there's some great
research coming out , about this as
well, about the link between, working
in teams and, wellbeing for providers.
The Center for Resilience in Healthcare
at the University of Stavanger in Norway.
Now this is really interesting cuz
they're really connected with our, patient
partner Carolyn Canfield, who's done
some great work in resilience, working
with their team and she connected us
into them, but they've recently published
a bunch of work on how teams influence
adaptive capacity, and we'll link to some
of those resources in the show notes.
Our team here did a learning cycle
on adaptive capacity in healthcare
to explore what influences, enhances
or detracts from developing adaptive
capacity or resilience in teams.
This is kind of my, my passion area,
so if I sound excited, this is why.
Morgan: Sarah, give us a quick definition.
Sarah: Right.
So adaptive capacity really
includes kind of three themes,
aligning, coping and innovating.
So aligning is really being able to
orient to patients and balance competing
demands, negotiating across different
levels of needs within the system.
Coping is really about being able
to handle external demands and ex
unexpected things that might pop up.
And then, Innovation is
about improvising and finding
innovative solutions to problems.
So high adaptive capacity means being
able to align, cope, and innovate.
And I think, the satisfaction piece
just factors so highly into that as well.
Morgan: So Sarah, there's a lot
of things that are very specific
that can enhance capacity.
Things like trust in the team,
communication, knowledge, all the
things that we've talked about.
And our learning cycle really
found alignment in how we can
enhance capacity in the teams.
And that, of course is, focusing on
team development, openly discussing
the challenges and ways of improving
team-based care, creating space
for psychological safety within
the team, hiring for readiness and
developing strong relationships.
Taking that time.
We heard it this morning at our
TBC advisory meeting, creating the
time for people to work together
on how they wanna work together.
Those are all very important
things that are very much a
theme of this whole podcast.
Sarah: And I think for anyone who's really
interested, in a previous season of the
podcast, we actually focused on this idea,
so I'd really recommend the people maybe
a loop back to the resilience season.
And so many of these things that
we think of as kind of enablers
of adaptive capacity in teams are
developed through, like you said,
Morgan, that intentional time as a team.
That idea of working together on how
to work together, we keep repeating
this, but it's just so important.
Christie Newton: Create the efficiencies
of a team by building that team well.
right now the teams that we're building
won't necessarily achieve team based
care, and even as you're talking
about it, increased resilience.
Morgan: That was Dr.
Christie Newton, a family doc,
current president of the College
of Family physicians of Canada,
and, a colleague and friend.
she really hits it home, Sarah,
that the time invested, of course,
in developing the team pays off.
Sarah: And we also chatted with Dr.
Anne Nguyen, who's a family doc
who now works with doctors of BC
in the physician health program.
And she shared a bit about her
experience working at Cool Aid
as part of, your team Morgan.
Morgan: And a shout out to Anne's
daughter who just graduated grade eight.
Sarah: Nice.
Anne: I mean, team-based care is
one of, I think, the ingredients
to a thriving primary care system.
So I think the work of PCNs and creating
teams, functional teams, because as
we know a really dysfunctional team
actually erodes people's wellbeing.
But a high functioning team, meaning
a team where there's transparency,
support, A healthy degree of management,
but a healthy degree of autonomy,
fair compensation, support, backup,
during illness and stress, all of
those things are really, really key.
So I think when you have a shared value
system that really helps and creates
a very cohesive team where there's
like equity, transparency, really
excellent management where people
feel supported and really encouraged
to practice to their maximal scope.
The work is hard but people have an
intrinsic satisfaction because they see
themselves making a difference, right?
And then frankly, what makes Cool
Aid work well is the team-based
model means you can take time off.
To go on vacation, you can take care
of your family and you know someone's
gonna take care of your patients.
And that's huge.
Sarah: And we've talked about this before
in terms of the impacts that teams can
make on the resilience of the system,
but I think hearing it from family
doctors who are saying, Hey teams, you
know, make a big difference to my own
health and wellbeing is really important.
Morgan: Especially in 2023 where
we really need to have that.
So Sarah, let's loop into something that
I think is important, the change in teams
and leadership and the role that a family
doctor can play in a team as a leader.
So much of the culture of
teams is set by a leader.
. there are things that leaders can
do to enhance capacity of the team.
Rahul Gupta: So what I've noticed works
is when you have a leader who actually has
taken the time to develop relationships
across the team, who does come from a kind
of a trusting mindset around the goodness
of people and has managed to not let their
ego, dictate many of their decisions.
And I will say most of the
situations, encourages the team to
come together, to discover where they
can make some decisions together.
Like, where does the team have power
to shape their reality and that's
where I've seen some success happen.
Where team members actually feel like
they are empowered to be involved
in decision making in ways that make
sense for them, that gets them engaged.
And that can include even just our vision
statement, our, hours of operation,
how we navigate our time at work, whether
it's at home or in the office space.
I think those things are really key.
And, the idea with compassion huddles,
I think that anything that brings people
together frequently as a touchpoint,
whether it's even a couple times a
day, depending on how often the team
gets together, at least weekly, with
a purpose of really connecting with
each other first , and then maybe
seeing, okay, are there particular
issues we have to think about and
address as a team on a practical level.
I think those kinds of things to me are
some of the recipes I've seen work well.
Sarah: That was Dr.
Rahul Gupta, family doctor, and one of the
designers and facilitators of the quality
team coaching for rural BC program.
We'll link to this in the show notes.
Rahul worked alongside Dr.
Dana Hubler, another family physician to
develop this curriculum for rural teams.
Both of them now work with a team
to facilitate the program, and it's
been such an incredible resource.
Here's what Dana said when talking
about what they found was most
important to supporting teams.
Dana Hubler: what we saw when we
dug into the research around this
is that like self and situational
awareness are actually key enablers.
We jump into, all the mental models
all the structures, but self and
situational awareness, so that we're
actually contributing to the wellbeing
of one another, that's where we
really came to is and the evidence
supports that but we skip over that.
We think about co-location and team
mapping and team composition, but we skip
over that teams are made up of people and
they need self and situational awareness.
Sarah: that focus on people as part of
teams is critical, Each member of a team
needs to take time to consider themselves
as both contributing to the wellbeing
of others and kind of receiving that
support, enhancing their own wellbeing,
Morgan: And leadership
doesn't have to be formal.
I don't have and haven't had a
formal role in our clinic in terms of
leadership and yet, in different ways
I support different parts of the team.
And I think it's important that we
don't have to do all those things either
as a leader or as a solo provider.
And that's where the team is great,
that we can each take different
parts of the leadership, the
planning, and developing of the team.
Sarah: And I think as a primary care
provider, I imagine it can be pretty easy
to fall into traditional hierarchies,
which might position, the family
doc as sort of the, head of the team.
And I don't think you can ignore
the hierarchies, but really try
to find ways to disrupt them.
Ways that create maybe new ways of
working together, that draw on the
skills and talents of the full team.
Morgan: Sarah, I like that
idea of going back to the
different kinds of roles we have.
Because it doesn't mean you have
to be all of them at all times.
And that comes back to that equity and
distribution and sharing of authority
and autonomy and accountability.
So I think that keeping that in mind,
and that's such a big change for
people to think about, when you're
all things then you want to be parts
of all things it's a hard change.
Sarah: Gotta let go of some things.
Morgan: you do.
And when you do that, I don't
know anybody who wants to go back.
I think that you find the joy in there
and, that's the, proof and the pudding
for this is that there's a balance and
there's that capacity that you're boyed
up by the team and you're doing the
parts of the work that you like to do.
And that's just, it's just so important.
You're not giving anything up in a
sense, because you're doing little bits
of it, but you're giving up the large
chunks of it to focus in other areas.
Carolyn Canfield, our friend and
patient advocate and disruptor
really hits the nail on this.
Carolyn: Most practitioners I know in
primary care at the end of the day, they
really need time with their families.
They really need time on their own.
They need to get some exercise
and they need to get rest.
And they're not going to be sitting
down and reading through the journals
for an hour and a half that evening.
So, being able to interact with
other professionals to learn what
the latest evidence is or the latest
practice or, be able to talk about
problems, be able to talk about
stress, that's really important to me.
We ask so much of our practitioners
in the way of compassion and patience
and generosity to their patients.
To be able to have the reserves to do
that and to being the member of a family
and, a citizen in a neighborhood, it's
pretty challenging . So I do think
connection with peers, uh, shared
adversity is a whole lot easier to handle
than feeling alone with the adversity.
Sarah: So with all this, you might
be wondering where to start, what
types of team members or what skills
are gonna help, or how can you
enhance how your team works together?
Morgan: So first, I think if you're
already part of a team, start talking
about how you wanna work together.
Talk about your skills, connect
regularly, make that space and think
about how you're working together.
Daphne: I mean, on occasion we've
gone round in the huddle, and
each day someone will actually, be
asked, what's one thing about you?
What's one skill that you have that
maybe not everybody's aware of?
And I learned recently that one of
our social workers, used to work, as
a dental assistant, I think, and she
really understands the nitty gritty
of, getting funding for people who
haven't got extended medical benefits.
So, the opportunity for team members to
tell us a little bit about themselves,
that the huddle has been good.
Morgan: So Daphne's approach, and this
is very much the approach we encourage
through our team mapping as well, explore
the edges of scope, talk about how
you do different parts of the work, and
then uncover those unique intersections
between your interests and the scope
of your work, and then appreciate
how that uniquely fits into the team.
Sarah: Terri also shared a few ways
that her team has been facilitating
connections as a virtual team,
some of the enhancements to virtual
work during COVID really changed
how their team works together.
Terri: I think it also helped with the
team-based care method because even if
we did connect as a team, say through
, texting or calling one another, now we
were able to zoom in, say when the care
aid was there, if they had a concern
or if they wanted us to, lay a second
set of eyes on like a wound or, um,
if the nurse made a home visit and she
was wanting to, have the doc zoom in
to, update the patient on something.
And so I think that it made
the virtual technology even more
accessible and brought us into homes,
and it also connected us in a new
way to our allied team members.
so one of the ways that we've kind of
helped to try to build that wraparound
care and bring all the different people
who might be involved in the care of an
individuals by having case conferences
and we do get patient consent and then
they can also decide which team members
that they want uh to be involved And
they can also decide if they want to be
involved in the meeting themselves and
so we'll bring in you know different
care team members that support those
individuals So we may have the doc there
the MOA, the nurse and like a counselor,
the care aids, the social worker, and
um outreach workers and different people
and so it also gives us the opportunity
to learn from one another to kind of
learn what each other's scopes are
what each of the team members can do
and are doing for a client or patient.
so the idea of how we build a team
and how we support one another in a
situation where we aren't all always
in the same spaces but we are generally
always sharing those spaces over time.
You know I think team-based care when
everybody's based in the same clinic
still has its challenges but it also
has some ease in that you can do lunch
and learn sessions or you can talk to
people in the hallway or you know things
like that that we don't necessarily
have And so it has been something
that we've had to be very intentional
about and keep coming back to.
Sarah: And for listeners who are maybe
not yet practicing in team-based care
models, there's so many small steps
that you can take to get started.
We asked a few of the physicians what
advice they would have for people
who are jumping into team-based care
and here's what Daphne had to say.
Daphne: Well, if anybody at all is
thinking about growing into a team, maybe
taking a nurse into the family practice
as the first step, I'd say just do it.
You will not look back.
It will have challenges and
frustrations, but it's generally it's
a win-win all around for everybody.
I particularly in an urgent care center
where there's no fee for service model,
it really works exceptionally well.
When I was private practice, things
like, well baby checks, , chronic
disease management, new patient
registrations, all of that would initially
be handled by my practice nurse.
complex care plans was another great
way of using a nurse where the nurse
would see the patient first, go over
Any issues they may have, go through
management of their chronic disease, make
sure their lab work was all up to date,
all that type of thing, then I would
see them, everything's there and I can
be there deal with the medical issues.
Morgan: Sarah, I think starting with a
nurse, that's really good advice In terms
of what we learned a couple episodes
ago, they have a really wide scope.
They're a profession that we've worked
with in hospital more closely, and there's
so many ways that they can support primary
care relatively quickly and naturally.
Sarah: That's a great suggestion.
And also think Terri, shared some
advice about how to build patient
engagement into your team's model.
Terri: And so as part of our primary care
team there's actually a built in patient
engagement model where we go back and
re-ask community how are you feeling now
And so that cycle happens about every
five years And the results have definitely
been Supportive of our approach.
Working within Carrier Sekani
Family Services they have their
own like engagement model.
Carrier Sekani actually goes and
does regular engagements with each
of their member nations they have
their Annual A G M which they do in
community as well as ongoing engagement
with say their chief and councils.
So it's a unique opportunity similar
to First Nations Health Authority where
the community that we serve our patients
are also the people who help govern
what we do and ensure the services
that we offer are meeting their needs
Morgan: Terri brings us back full circle
to the relationship with our patients.
So engaging the patients is critical so
they understand what's happening and then
they become part of the team as well.
Okay, so that brings us to the end of
this episode and we're one episode
away from the end of season five.
Sarah: We are, and I just wanna highlight
that we started with the patient in
this season and now we're bringing
it back to the patient at the end,
and I think that's really important.
Morgan: Absolutely.
So then to wrap up this episode,
what's the take home message from
today's focus on family physicians?
Sarah: So first, I think family
physician roles can vary considerably
depending on the model of care and the
communities that people are working in.
This can impact how people are
connecting in person or virtually
with a team and really how the,
physicians choose to practice.
Morgan: I think number two is
that the teams will enhance the
overall capacity both to provide
care, but of us personally.
And particularly for family doctors,
getting that additional support helps with
our wellbeing and that allows the team
and primary care to continue to work well.
Sarah: And the third thing, I think,
the question of where to start.
The best place to start, it's just
to start, take a small step toward
team-based care by thinking about a single
role you might bring into your team.
Doing a few shifts with a team in
your area, or starting to work with
a team who's already in your clinic,
maybe a little bit differently,
maybe having some of those role
conversations, creating those
opportunities to connect and thinking
about how you're gonna work together.
Morgan: Thanks Sarah for letting
me talk about myself and my role
for the last, uh, whole episode.
Sarah: Right.
It was great!
And thanks for listening
to this episode of Team Up.
Morgan: Join us next week
when we wrap up this season.
Sarah: and we'd love to
hear from you as always.
So please drop us an email at issu family
med.ubc.ca with any reactions to this
episode or ideas for future episodes.
Thanks.