Dr.Alika Lafontaine Debriefs After Canadian Medical Association Presidency

About the Episode

Dr. Alika Lafontaine, the first Indigenous physician to lead the Canadian Medical Association, reflects on his tenure as CMA president and the challenges facing the healthcare system. He discusses the need for healthcare system change, the impact of COVID-19, and the importance of addressing burnout and creating healthy working environments.

Dr. Lafontaine highlights the significance of the $196 billion federal investment in healthcare and the strings attached to the funding, such as data sharing and recognition of credentials. He also emphasizes the importance of team-based care and the need for national standards and increased collaboration among healthcare providers.

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Objectives and Discussions

• The COVID-19 pandemic has highlighted the need for healthcare system change and has created a willingness to try new approaches.
• The $196 billion federal investment in healthcare is the largest in history and has strings attached, such as data sharing and recognition of credentials.
• Team-based care is essential for improving patient access, creating healthier working environments, and addressing burnout.
• Pan-Canadian licensure can facilitate physician mobility and improve access to care, especially in rural and underserved areas.
• The healthcare system needs to shift from fragmentation and over-specialization to consolidation and generalization.

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More Resources:

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Twitter: @cherryhealthinc

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Have questions? We want to hear them!

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Transcript

Speaker Identification:

[Host]: Dr. Jordan Vollrath

[Speaker]: Dr. Alika Lafontaine

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Jordan Vollrath (00:27.258)
All right, so today we're joined by a very special guest named McLean's top healthcare innovator of 2023, Dr. Alika Lafontaine has been at the epicenter of healthcare system change for almost two decades. He's the first Indigenous physician and the youngest doctor to lead the Canadian Medical Association in its entire 156 year history and the first Indigenous physician to be listed on the Medical Post's 50 most powerful doctors.

As an experienced health leader, Dr. LaFontaine speaks eloquently and passionately on the politics of healthcare, implementing and scaling equity, effective advocacy, and redesigning health systems. And joining us today to chat about the wrap up of his tenure as the CMA president. Dr. LaFontaine, thank you for joining us.

Alika Lafontaine (01:12.488)
Yeah, thanks for having me.

Jordan Vollrath (01:13.998)
Yeah, so how'd it go? What's it like being the CMA president?

Alika Lafontaine (01:20.799)
I think it's probably like a lot of things in life, you do it, you sprint, and when it's done, it's done. The CMA presidency is probably one of the most enjoyable leadership experiences that I've had. You're around the tables for a lot of really important conversations. This was a change here, obviously, because...

the government was looking to invest more in healthcare. We were trying to figure out how could we structure it so it could be more effective moving forward. And there's just crises everywhere. There's crises with primary care, crises within hospitals and within specialty care. People are really struggling right now. So there's a lot of willingness to try new things.

Jordan Vollrath (02:05.39)
especially with COVID, it seems that like really squeezed people and the system and people are a lot more like open to trying things out just because what we're doing right now is not working.

Alika Lafontaine (02:15.542)
Yeah, I think that's very true. Physicians in particular, I think, get used to kind of a holding pattern. You know, you have transitional points in your career where you're moving from being a medical student to a resident, and so you're open to a lot of change, and then you move from being a resident to a newly-acquired staff, so you're willing to move and try out new things. And then after a few years, I think we all kind of get used to life as it is. We work as hard as we work in other things. And I think COVID was...

You know, the first time in probably a decade from when I had started practice, where I sat back and thought to myself, you know, do I really want to be practicing like I am? Do I want to be working this hard? Do I want to be staying up this late? You know, I'm not young like I used to be, you know, what, what needs to change in order to make sure that my life's sustainable and, you know, I'm still doing the things that keep me happy.

Jordan Vollrath (03:07.342)
What was the year like for you? Like what did the week to week entail? I know lots of traveling, lots of speaking engagements. Were you able to keep up a clinical position still or did that like entirely pause for the time being?

Alika Lafontaine (03:19.894)
You know, I think the CMA presidency year is a lot different than it was in the past. So when you run to be CMA president and you get elected, you actually enter into three year cycles. So the first year is president elect, the second year is president, and then I'm now in my past president year. So each one of the years you get different opportunities and have different roles at the CMA. But during your presidency year, you're kind of the tip of the spear when it comes to system change. So I was on the road more than 200 days, lots on social, lots of interviews. I think there were more than...

230 interviews that I did, published multiple different op-eds. At the end of it, they ran my numbers. I had 6.6 billion social media impressions for stuff that we had worked on. So I mean, we were pretty effective at getting our message up. But more importantly, I think you saw the actions that we were hoping to get. So the 196 billion that the federal government invested over 10 years, you know, that's the largest amount the federal government's ever invested. You know, the next biggest was all the way back in 2004.

And we had some pretty significant strings attached when it came to different types of funding, things that have led to recognition of credentials in different provinces. And I was talking seriously about health human resource plans and data sharing. So it was a pretty satisfying year. It was very, very busy though. I tried to balance clinical at the very beginning, but realized I was either gonna do both poorly or I could try and do one well, so.

Jordan Vollrath (04:40.846)
wise decision. And so, you know, as the past president, and even when you're coming on as the president elect, like you're on the board for the CMA, like how does that kind of decision making and team leadership work or flow through the years?

Alika Lafontaine (04:55.434)
Yeah, so the CMA, like lots of organizations, is governed by a council or a board. So the CMA has representation from all the different jurisdictions in Canada, including Quebec, although we don't have a Quebec Medical Association anymore. That board sits and writes out a strategic plan. The strategic plan that we've been implementing over the past three years has really been centered around a series of priority initiatives, things like Pan-Canadian licensure, team-based care, data sharing, health human resources, among others.

And a lot of the success that I think I had in the past year was due to the work that Catherine Smart did in the year before and Anne Collins did the year before her. And I think that that's how system change works in general is you need a long chain that has multiple people kind of working in the same direction and then suddenly things break.

Jordan Vollrath (05:46.322)
Well, and so does that, you know, now that you're in the immediate past president year, that still gives you time to continue pushing the initiatives that you worked on and you're the spearhead for that year. What's continuing on then? Or I guess, where do you want to start with this? Do you want to talk about all the things that you did accomplish and then kind of get into the where we still have some loose ends to tie up?

Alika Lafontaine (06:07.294)
Yeah, I think it's fair to say there's a lot of loose ends until we actually fix stuff in healthcare across the board until, you know, average folks like you or me feel like every day we go into work, it's like a healthier working environment, patients aren't, you know, so stressed out about access or not being able to get care whatsoever. Um, there's a lot of work to go until that point. Um, when you look at stuff that I'm doing this year, I mean, obviously there's a bit of a wind down from the stuff I did last year, things that I really tried to focus on and make a big difference in were

things like Pan Canadian licensure, which I think we made some pretty big jumps. The funding part was really important as well as the strings being attached. I have some legacy stuff that I still participate in. I'm helping out with that Center for Health Workforce that the federal government funded in the budget as part of their startup board. And then just continue to support Dr. Kathleen Ross in her role as president and continue to provide advice and experiences, just sharing with folks around the board.

about what I thought was successful in our year and just trying to build on those successes as we try to continue to make change.

Jordan Vollrath (07:10.338)
Well, so and maybe the biggest or the sexiest of all the things, of course, is the 196 billion. It's got a nice ring to it. What's the significance of that? I guess, you know, what was the role the CMA had to play in that? How do you actually convince the government to cough up that degree of chunk of change?

Alika Lafontaine (07:28.418)
So I think there's two parts of it. The first is folks within government need to feel like they're going to get something out of the money, right? So one of the things that Catherine did a very good job at sharing and that I kind of continued on during my year as president was that more money wasn't going to fix the system. It was spending the money differently. And so I think that was a really important message for the government to hear that we weren't just looking at investing in the system as it was, but we really wanted to try and create something different.

combined with that was clear ideas of what differences we needed to make. And one of the challenges that people often have with advocacy is they sometimes believe that people hear their message more than they actually do. There's a rule of advocacy that I apply where if you start to get sick of yourself and kind of the same things that you say over and over again, do it for a few more months and then you kind of hit that sweet spot where people have actually heard the message. And I...

I'll tell you, there was a lot of times during the year where there were other things that kind of pulled me back and forth, but we were very disciplined in what we tried to share. And you can see that looking back when you ask folks, what was the CMA about last year? We were all about physician mobility, healthy working environments, patient access, making sure that we rebuilt the broken system and invested in different ways. I think that we were successful from that point of view.

Advocacy is always kind of a long arc of change. You know, it takes a little bit longer than you think, but when the change actually starts to happen, it happens pretty quickly.

Jordan Vollrath (09:00.622)
Well, I can imagine it's tough, especially pushing single threads when you're getting pulled in all different directions. I mean, there's so many cries for health care reform right now. Like, it's difficult to even keep it all straight almost.

Alika Lafontaine (09:13.826)
You know, I did an undergraduate in organic chemistry. And one of the things you always see in the basic sciences is kind of this theory of everything, you know? So what's the thread that kind of ties things together? As a leader, especially nowadays, I think a key skill is being able to story tell, bring people into ways of talking about a problem that they can see themselves in. And...

I think framing it from the perspective of patient access and healthy working environments helped to tie together a lot of threads that were tough to tie together before. How do you evaluate whether or not a change was actually going to make a difference for patients? Well, if you left it up to the government, it would be about lower costs or the fact that you could have a couple of people who used to see four patients now see 12. But when it comes to people within the system, I think people accessing it.

What do they care about? They care about access that actually changes the trajectory of where their disease is going. It's places where they can talk openly about their problems where they don't have to do several visits before they finally get up the courage to share what's actually going on. And then for people working in the system, I mean, we want to feel like we're making a difference and we don't want to be overwhelmed with everything that's going on. So that healthy working environment part is a shift that I think we continued and...

fully made in my year that kind of started with Catherine and Anne. And I think that's taken us in a direction where we can talk about things like burnout and other things in different ways.

Jordan Vollrath (10:49.646)
Well, it's just crazy how wild the conversation has shifted towards focusing on that. Like before it was just standard operating procedure. You sort of wore your burnout on your, you know, as a badge of honor. Like this is just how it is, right? You got to toughen up if you're feeling overwhelmed, right? But now it's very much like everyone's recognizing it's not sustainable, right? You cannot continue to practice like that.

Alika Lafontaine (11:00.098)
Yeah.

Alika Lafontaine (11:14.326)
Yeah, and I think a part of that story was realizing that the world had changed around us. It wasn't just us. You know, I think sometimes when you talk about those badges of honor that we wore when, you know, we burned out, I mean, you probably remember in your residency. I remember in my residency, you know, you talk about how long you could stay up before collapsing to the ground. I think my record was five days, 30 hours. I, yeah, I did five days. I knew at the end of five days, I just kind of collapsed in a heap in the middle of the floor and I'd just be out for 16 hours.

Jordan Vollrath (11:33.094)
30 hours, five days, wow, okay.

Alika Lafontaine (11:43.838)
You know, I think the world was different back then, like the requirements of what physicians had to deal with, you know, the things that we can't delegate now, that we used to be able to delegate, you know, new technology, you know, what patients' expectations are, like all those things have shifted, you know, and I think in any system, you can increase your efficiency by getting closer and closer to that supply-demand match.

But eventually your efficiencies are actually found by extracting more value from the people that function in your system, right? So you have that supply demand match, but now you're getting that person to work for 10 hours at the same rate that they used to work eight hours. And I think that transition happened, you know, over COVID and kind of continued on. People got used to asking more than what was reasonable. And I think we're just, we're just paying for that now.

Jordan Vollrath (12:34.962)
Well, it started out as rising to the call of duty, right? Like you get a nose sniffle and now you're in quarantine for 10 days. And then you had to, so it was kind of like, all right, we got to just get through this. But now that the dust is starting to settle a little bit on the whole COVID thing, people are really coming back to the fact that this burnout thing is still very prominent. And kind of going back to the funding and the 196 billion announced by the government.

Alika Lafontaine (12:42.891)
Yeah.

Jordan Vollrath (13:02.742)
finding more doctors, training more physicians, increasing pay to match with just inflation and rising business costs. Certainly those are some of the things that having more money in the system will help with. But you mentioned there's other stuff that just needs to be reformed, things that throwing cash at it isn't gonna fix. I don't know if you can talk a little bit about what those are, sort of, what we should be looking out for.

Alika Lafontaine (13:26.23)
Yeah, you know, when you tell the story of healthcare, I think sometimes we project our experiences right now into the past, when that isn't really how things worked. You know, if you look at the dawn of Medicare in Saskatchewan, for example, we often look at the creation of Medicare as, you know, this moral thing that people in Saskatchewan just kind of came alive and generate public support. It really was an economic problem. You know, farmers were getting sick in the depression. They...

were going into hospital, they couldn't afford to pay for the private health care. That was pretty much all they could get. So they moved to the charitable side, which had lower standards and less skilled folks. They weren't getting better, so they weren't going back to work. So the government saw this downward spiral that if they didn't interrupt it through public funding, they were actually going to be in a very, very big, they're going to have very, very big problems. And so that was kind of the origin of Medicare. And when we started scaling things out, like bringing care to the people.

We used to just copy health facilities. So you have a hospital, it would have X number of nurses, X number of doctors, X number of other staff. You would just copy that in a new place that was closer to the folks who needed the care. And so that kind of spread out until the mid to late 90s when we realized that we actually didn't have enough people to do that indefinitely. And with the costs of new equipment, things like CTs, MRIs, specialized surgical equipment.

We actually couldn't just buy like a new one for every single hospital that we wanted to set up. So we started to regionalize and have folks go to centralized places like in Saskatchewan. They had movement by the Ministry of Health to actually shut down a lot of hospitals that were in small towns, you know, and consolidate resources. I still remember a time in training where you could go to any hospital and they'd have a psychiatric ward. Every hospital was a trauma center. Every hospital was a place that you could get cataracts taken out or...

kidney stones removed. And that shift to regionalization, I think, was one of the ways that we managed cost. And then over the past couple of decades, it's all been about austerity, that phrase bending the cost curve. How do we have people do the maximum amount of work for the lowest amount of money? And so if you take those things that we did in the past to solve the problems that we had, you didn't have enough access, you built a new place, you had new types of ways of...

Alika Lafontaine (15:48.822)
doing treatment, you know, new complexity. So as a result, you'd create new specialization. You had low efficiency, high cost. So you'd introduce technology, kind of help manage that. You know, all three of those things have actually led to our current problems. You know, we have so many health facilities everywhere that we've actually lost track of how to measure them. You know, and you probably found this with mapping things out yourself. Like where do you find a centralized list of family docs? You know, why do those lists not differ between

a family doctor that does longitudinal care versus somebody that specializes in youth mental health versus someone who's a surgical assist, et cetera. And so we've lost track of where our resources are. And so I think in a lot of ways that over fragmentation is at the core of a lot of the problems that we have moving throughout the system. We've definitely over specialized. We specialize so much that people want to create new specialties that are general specialties. I still remember being on the Royal College Council and people were discussing...

well, people can't really do general surgery anymore. So maybe we could create, you know, a fellowship to teach them how to do general surgery. And it was kind of, you know, the point of a general surgery rotation is to learn general surgery, you know? And, you know, finally with modernization, it's always a surreal experience to be in Alberta, working from Connect Care, you know, pick up the app on your phone that's secured and, you know, you get a direct message and then you hear the fax machine going on in the background as you send off a prescription, you know, so.

I think those three things together, the over-fragmentation, over-specialization, and the uneven modernization, those things lie at the root of a lot of the problems that we have in healthcare right now. And you could take a lot of the things that you mentioned and kind of pocket them under those bigger problems. And so, you know, what is the solution? Well, if things are fragmented, then you have to do some sort of consolidation where you break down those fragmented parts and you make them whole again, you know?

make national standards, pan Canadian licensure and physician mobility is one of those things, along with a lot of other ones. You know, with specialization, it's got to be a big swing back to generalization. We have to incentivize people to be general providers again, you know, in all the different areas of medicine. And then with uneven modernization, we need national standards when it comes to data. We need national standards when it comes to virtual care. You know, these types of things are things that we're leaning into right now. And I think if we focus on fixing those...

Alika Lafontaine (18:08.906)
solutions that are now our current problems, we do have a path to get out of where we are.

Jordan Vollrath (18:15.054)
So in terms of the pan-Canadian licensure, I was wondering if you could speak a little bit more to that, because this has been hotly debated, very much contested. It seems like a good idea. Now there certainly are the people that are skeptical and think that we're just robbing Peter to pay Paul and taking doctors from one spot to another, or if you're in maybe a higher risk area or underserved spot, the worry is there'll be this exodus of physicians out of your area. Like, what do you have to say to those people that have those concerns?

Alika Lafontaine (18:45.138)
I think the first thing to realize is pan-Canadian licensure is just one part of a lot of changes that have to happen. By itself, it won't solve all the problems, but I do think even if it was the only thing that we changed, it leads us to certain questions that will lead us to different places. If suddenly physician mobility was free across the country, someone could just get up and work in Ontario, the next day work in BC, wouldn't have to register again.

you know, suddenly you transform the ways that you can create teams. You know, imagine me attending the conference here in the conference here in Montreal, uh, meeting a couple of folks who want to create a virtual team. As soon as I get back, I could create that team if Pan Canadian licensure was, was something that was in place. Uh, when it comes to the specific problems, I, I think instead of, uh, talking about unintended consequences, I think the more pragmatic way to frame them is things that we are worried about.

but haven't yet figured out whether we should be worried about them. You know, when we do any procedure inside medicine, we know a list of all the things that could go wrong, but we do like a risk-benefit balance in our head. You know, I think we have to do the same sorts of things with each one of these concerns. For example, the concern that I often hear from folks who are against improved physician mobility, the idea that people would just leave their places of work and transfer other places.

I think that does kind of ignore the way that physicians practice. As an anesthesiologist, I came to Grand Prairie with a plan for two years. I've now been there for 12. If Pan-Canadian licensure suddenly opened up tomorrow, I'm not moving to Vancouver. I'm not just going to get up and move to Toronto. There are other reasons why people decide to leave the places that they are. If someone does get up and leave, it probably has less to do with Pan-Canadian licensure and more to do with just an unhealthy working environment.

You know, people do not want to stay where they don't feel valued or feel like they can make a difference. Now, where are places that PCL will have more immediate effects? I think it'll make it easier for people to locum. You know, the reality is a lot of us don't work full time because we get burned out. But there's also a reality that you can use some of that available bandwidth to work somewhere else because sometimes you can have the same bad situation but just have another person yelling at you and it's okay.

Alika Lafontaine (21:05.374)
I think there'll be a lot more uptake for locums. For folks who work in rural communities, especially in Canada's North, being able to migrate across the North, I think is something that would have an enormous amount of benefit. The benefit of improved physician mobility and pan-Canadian licensure for trainees, people would check out places they never otherwise would have checked out. How great would it be for a graduating family medicine grad to go visit the North because it's super easy.

to register there. They may try it, they may like it, they may try it, they may not like it, but you'll get eyes on places that you otherwise wouldn't have gone. And I think when you trace it back to people who actually live in these locations and what they say will happen, it's often very different from what people who live in urban centers say. The people who are most afraid of position mobility tend to be in urban centers. They don't live in rural locations. They're not providing care in rural locations. If you look at the Society for Rural Practice, for example,

they've been trying to push for Pan Canadian licensure for more than a decade. And those are the folks who actually do provide care in the places who need it the most.

Jordan Vollrath (22:13.13)
If there's a couple forms and a thousand dollar registration fees, the only thing anchoring those physicians into your clinic, you might have some bigger problems you need to reevaluate. And it makes total sense, right? Like getting people out there, making it more flexible to go up north or go into one of the corners of the province where there just aren't. I mean, I experienced the same sort of situations myself in terms of that downtime efficiency when I was locuming all over the place. I was doing a lot of

Alika Lafontaine (22:20.65)
Yeah.

Jordan Vollrath (22:41.606)
short notice, kind of last minute coverage, and people that were getting sick or whatever sort of incidental things came up. And then it just wound up not being a sustainable way to practice because it was just very difficult to like consecutively line things up. And then now you have downtime, right? So it was like a very much needed form of operations, but it just, it wasn't efficient. It wasn't effective.

And so if we can increase the efficiency of our current workforce, I think it's gonna make a big dent in the total patient care demand.

Alika Lafontaine (23:15.39)
Yeah, I definitely agree. And I think, like I said before, PCL will take us to conversations that we otherwise wouldn't have. One of the ongoing struggles that I think the folks who work in primary care struggle with is income inequity. Imagine if instead of 13 walled off jurisdictions full of primary care providers, suddenly that was all treated as a big group because now they're mobile across the country.

we probably would actually achieve income equity across the country in a much shorter timeframe than we are right now. So, you know, there's a lot of opportunities. Of course, there's things that will have to change. Our regulatory system is not really designed to follow people over long distances. You know, the regulatory system really was designed for folks who would work in one location for their entire career. You know, it's not designed for people who practice in multiple locations in a province, notwithstanding across jurisdictions.

Will the regulatory system have to change in order to accommodate the new realities of how people work? I think it will, but it's also not really designed for the world that we live in right now. So I think these changes are going to happen sooner or later. And you know, physician mobility is one of several things that can make a big impact on healthcare right now.

Jordan Vollrath (24:33.762)
Well, physicians are very much, you know, show me the evidence. Where's the research? I want to see a paper backing this up. Is that what's happening right now in the Atlantic provinces? Like, is that going to percolate for a few years before we see the actual cross the country licensure start moving into the actual execution phase? Or should we expect change sooner?

Alika Lafontaine (24:52.334)
Yeah. So I think that the biggest motivator for Pan Canadian licensure has been the strings attached within the bilateral agreements in the health transfers. So the health transfers that happened in February of 2022, or sorry, 2023, they were divided into four different areas. So there's the unrestricted funding where provinces and territories can do whatever they want with the money.

There's the Canada Health Transfer, which is the traditional kind of funding mechanism. It has some focuses on things that people should focus on, but it's not detailed like some of the other parts. There's the bilateral agreements where there are other strings that are attached. This is where recognition of credentialing came in. And then there's the kind of other set of funding, the funding for the Canada Health Workforce Centre, the $2 billion for Indigenous health, among other things. So...

What's the reason why things have really moved forward when it comes to licensure and physician mobility in the past year? It's really because the bilateral agreement said a string attached. I'd actually say that full stop. The health system doesn't always do things because it's the most researcher data driven. The reason why health systems do things is because government make those decisions, however they make them. And so I think that that's why you're starting to see big changes. The Atlantic registry.

Lots of provinces have changed the way that they license international grads, for example, you know, BC, Nova Scotia, Ontario, and now accept grads from the US, which they didn't in the same way before. BC just announced out of the health ministers meeting in PEI that happened in October, you know, having pancadene licensure is one of the top five things that people want to work towards within the next year. And also that it's releasing the license where anyone working in BC can practice anywhere else in the country. So

I think you are starting to see an acceleration, but the reason why is because governments decided that that's what they're gonna do. Some of that was led by evidence, some of that was because of expert opinion. Probably the biggest thing was that we're really in a crisis and they need to do stuff that's different.

Jordan Vollrath (26:58.878)
Tell me more about the strings attached with the new federal funding. I know you've mentioned a few times that that's like one of the most important factors now coming along with the deal. Why does that matter so much?

Alika Lafontaine (27:09.93)
Yeah, so, you know, I think that we have been told for years that we needed these made in our jurisdiction types approaches to health, you know, and at one point in time, it probably did make sense to approach things that way. The reality of where we're at now, especially in COVID and the years following, you know, the peaks of those first waves is that we're all swimming in the same problems right now. You know, there's an issue with primary care across the country.

emergency room wait times are long across the entire country. Millions of health services have been delayed across the country. You know, no one's really spared from the shared crises that we're kind of, uh, kind of dealing with. And so, um, what's going to take us out of there? Governments creating different rules for how funding gets allocated, but then also how we're getting incentivized to do different things, behave differently within the healthcare system. So, uh, strings attached in past budgets going back to like 2017.

They had specific areas that they wanted to work in, but the way that they were structured is that you would kind of spend the money in those areas and then if the federal government felt that you were not spending them in the right areas, they would come back and say, well, give us some of the money back. And then if you fix what you're doing, you can go through a process where you get the money again. In the funding agreement that just got signed this year, it's front end funding.

restrictions. So what it means is that if you don't make the change, you can't access the money, right? So with the Canada healthcare transfer, there was a string attached related to data. You had to sign on to depersonalized sharing of data, you know, persistent patient ID, which means that across different databases, you'd have the same identifier, which you really need for like a national data construct or database. Provinces and territories had to agree to that before they even got the money.

You know, same with bilateral agreements. And this is one of the reasons why the bilateral agreements have taken so long to sign. It's because there was a recognition that if you did not agree to these things, you did not get the money. And I think that that's a positive thing for healthcare in Canada. Obviously it depends on what those strings are. You know, you got to make sure they're in the right areas and that they'll actually make a difference. But based on what I've seen over the year that I was CMA president and what I see happening right now.

Alika Lafontaine (29:30.788)
I think we are at the beginning of a new chain cycle, something that is actually going to make things better over the next few years.

Jordan Vollrath (29:36.082)
It sounds like it's going to be improving just the general idea of accountability within healthcare. And from my experience, that seems to be an overlooked thing, especially as an individual practitioner. Right? It's like there's very little oversight as to what you're actually doing. You kind of get like a blank check from the government and a pat on the back and they say, all right, go have fun after you graduate. And then that's sort of the extent of it.

improving just the systemic level accountability, the individual level accountability. I don't know, is that something that the CMA thinks is a high priority?

Alika Lafontaine (30:15.33)
So I think that goes back to an earlier statement I made about us just losing track of where all our resources are. So we use levels of abstraction to describe what we actually mean to describe. For example, when we talk about scopes of practice, what you're literally saying is that people can potentially do things within the sandbox, but you're not actually asking what you literally do. And so when you work in teams and

You know this through your practice. I know that in teams that we work with in the OAR, being able to have people task shift. So me do some nursing duties, nursing duties, helping our nurses, helping me out when I'm doing my duties, really, really important to effective operationalization of teams, finishing tasks. You know, you get higher levels of safety when people share tasks, you know, that that's probably where we should migrate towards looking when it comes to a lot of these discussions. But that's going to require us to measure things differently.

and it's going to require us to have different types of conversations. You know, um, in Alberta, we've had, I think a lot of attempts at intimidation by, you know, political leaders. There's, there's the pharmacists that do extended practice, uh, like the clinic down in Lethbridge. There's been talk about nurse practitioners creating their own independent clinics that provide, uh, what they say is similar, uh, services to family docs. You know, I, I think that the whole idea that you practice by yourself or you practice in a non multidisciplinary setting.

that probably should just be eliminated entirely, you know, over the next few years. We know that practicing solo is not a great idea. We also know that there's a lot of things that doctors aren't as knowledgeable about, you know, navigating social systems, nutrition, you know, stuff like that. So it would make sense for us to be pushed together, working together. You know, it would also make sense for us not to...

continue to fight over whether or not we can do things within the scope of practice, but actually discuss what are you literally going to do and then reward and incentivize based on what you literally do. I think we do have the technological capacity to do that, but it requires us to break free of the ways that we used to do things. Folks who work in multidisciplinary settings, capitation settings or patient care networks where they're not being micromanaged, et cetera.

Alika Lafontaine (32:37.462)
You know, people really do feel like they make better care. Patients have better experiences and I think they have better outcomes. You know, everyone who's a part of that team in a well-designed team-based setting actually feels like they're making a difference. And so you have lower levels of burnout, you know, higher levels of, you know, people working for longer periods of time. You know, that's what we got to build as we move forward, but it requires us to really think about stuff differently.

Jordan Vollrath (33:02.066)
And what needs to change then in order to actually push that team-based model of care? Is it simply billing codes? Is it a matter of education? Is it getting buy-in from all the different groups and associations, you know, the NPs, the nurses, the pharmacists, the dieticians, the everybody? Like, what seems to be the holdup? Because this is like the hot topic buzzword that you can't go, you know, further than a minute without hearing in healthcare.

Alika Lafontaine (33:27.394)
You know, I think government just has to make a choice that it's going to happen. You know, one of the things that I think, especially, you know, Birdo, we've realized is that when government decides to do something, we kind of just have to figure it out. And I think that we've, um, we've kind of lost the plot when it comes to a lot of these changes, thinking that, you know, we have to negotiate with each other when in reality, what has to happen.

is ministers of health and premiers and governments have to decide what kind of healthcare system they wanna build. Communicate that to all of us and then leave it in our hands to figure out how it'll work. This will require a lot of changes, regulatory, it'll have to change the way that I think people are paid, the way that they're measured. We're gonna have to shift from this idea that once you get into the gate of healthcare, you're kind of just free to do whatever you want to. Now there's a little bit more attention to what you do.

And I think we also have to keep in mind too that the end goal of everything is not to have the lowest cost possible, it's to have the highest amount of health generated as a result of these new types of structures. And I think if we change our view towards really incentivizing access, if you can show that you're providing more access for patients that they're getting more health benefit out of their encounters with you, if we have a focus on healthy working environments as a way to...

keep people engaged in the workforce and working as much as they're willing. I think that those are much better metrics than cost per volume.

Jordan Vollrath (34:58.342)
How did the team-based care model get to be the forefront, you know, that center focal point for all of the advocacy? Because we hear about it constantly. Is there like any locations, any studies, any like provinces that are currently practicing that way with data behind it in terms of what the actual outcomes were?

Alika Lafontaine (35:18.358)
Yeah, you know, there was a town in Alberta that won an award, I think it was 10 years after PCNs first came in, those patient care networks. Alberta used to be, you know, the national leader when it came to team-based care. You know, we often look to some of our locations here in the provinces, you know, examples. There's team-based care models in places that have a difficult time recruiting doctors, like the Renfrew model in kind of southern Ontario, where they have paramedics.

I helped to triage folks into different areas. There are little pockets of where it's working really well, but when you're looking at data of whether or not this works, I mean, you don't have to go too far. Places that tend to have the highest levels of satisfaction are places where the burden of patient care is actually shared. If you look at HMOs in the States, for example.

you know, what do they do when patients come in for surgery? They actually get the most experienced surgeon in the department to be the one to identify where that patient needs to go. And then when patients come and sit down, they actually sit down with the entire team over the time that they're there. They see everyone that they need to see within the hour that they've kind of set aside in the day. And then the whole team moves on to the next one. So I don't think it's a question of whether or not there's evidence that these types of structures,

lead to higher satisfaction of patients and providers and lead to more effective care. And in a lot of cases, lower cost. I think it's really just adopting them. And there's been a lot of resistance, I think, just to stick with our age-old model where people kind of practice independently. They're not required to work with people from other disciplines. When we talk about team-based care, it's often you have like a team of NPs, nurse practitioners who work with a team of pharmacists who work with a team of family doctors, but they all don't.

work in the same place. They don't talk about the same patient at the same time. Everyone's kind of doing their own thing and they just occasionally overlap. You know, that's not really team-based care when you're talking about how it's supposed to operate.

Jordan Vollrath (37:23.574)
What does that true to its core team-based care look like then? So I did my training at the Sheldon Schumer Center here in Calgary. And so that's like what comes to mind, right? Like there was a pharmacist that you talked to. There was a whole bunch of nurses that would see patients, right? Then the other allied health care models. But then, of course, everybody's on an ARP or just salaried. So it's hard to compare apples to apples, even if you had health care outcomes versus budget input. Like what does that true?

patient medical home team-based care actually look like in practice.

Alika Lafontaine (37:56.866)
You know, I'd say if I was to describe it in a sentence, you know you're doing team-based care if the patient does not have to spend a ton of time navigating the system. You know, because the team takes that on. A patient shows up at, you know, the right or wrong door. That team member that they come in contact with goes back to the broader team and says, you know, I have this person, where do they need to go? Who needs to see them? How are we gonna work this up? And then everyone kind of shares tasks together. So...

I think that that's probably the best marker for high functioning team-based care models. But that also talks about how we need to measure things differently.

Jordan Vollrath (38:33.746)
The three-year residency. What do you think there? Is that the solution to all of Canada's healthcare problems?

Alika Lafontaine (38:37.729)
Hehehehe

Alika Lafontaine (38:42.23)
Yeah, so I would say as a non-family physician, I don't really have a hot take. I think structurally accreditation bodies do put time into thinking about why certain things can happen. And although we may just become aware of them, they've probably been talking about those changes for a very, very long time. I wouldn't be surprised if this discussion about a third year goes back five, maybe even 10 years from where we're at today.

I've definitely heard a lot of resistance from a lot of different places. People are very concerned about what will happen as far as numbers of graduating family physicians, whether or not people are gonna choose to go into a different specialty based on that extra year. I think at the end of the day, the thing that really needs to be clarified is just like what's the reason behind the extra years. And I think there are some things that...

that maybe are part of the discussion that we don't talk openly about. You know, when I was part of the Alberta Medical Association and we talked about how do we do income relativity between different specialties, the length of time that you trained was actually a big component based on whatever your income band was relative to someone else. So if you trained for five years versus two, there actually was a significant gap between what you'd argue you should be paid. And you know, I don't think that those models...

necessarily make a ton of sense anymore. We obviously know that we have a huge shortage in primary care. We know that without primary care, you actually don't get a lot of what you need for specialty care. Like it's a symbiotic relationship. And so can we solve some of these problems in different ways other than extending by a year? I think we could, but we have to get really clear on what problem we're actually trying to solve.

Jordan Vollrath (40:29.65)
Bye!

Jordan Vollrath (40:34.15)
So I've been living in my family medicine bubble. What's going on in the specialist world in terms of hospital care, in terms of the ERs? What does that systems reform look like on the other side of things? I can't imagine everyone across the board is just shouting from the rooftops about the family care side of things. What else is going on behind the scenes?

Alika Lafontaine (40:57.27)
You know, I will say that specialists generally are recognizing more and more every day the value of primary care. You know, without family doctors as a surgeon, you lose a referral pathway for, you know, patients that you see. You know, you lose a valuable partner to make sure that you triage patients appropriately. And you know, family docs, especially in rural locations, they do...

more than just working in clinics. They work in hospitals, at surgical assist, they deliver babies, you know, they do additional specializations in everything from palliative care to cancer care to youth mental health. So, you know, I think that specialists generally, based on the folks that I talked to, have a deeper and more comprehensive appreciation for what their colleagues in family medicine have been doing, which maybe they didn't have before.

When it comes to stuff in hospitals, health human resources is a problem pretty much everywhere. In anesthesia, the area that I work in, there's a lot of pressure to try and do more work with the same amount of personnel. So moving into physician extenders, how do you move towards a more team-based structure? In the US, you often have one anesthesiologist covering more than one operating room. That's not really a practice that we do here in Canada. Lots of pressure to...

bring that into operating rooms across the country. And then also ally providers in the same way that family physicians are navigating, you know, new methods of primary care with pharmacists and nurse practitioners. You know, there's increasing talk about folks who are non-anesthesia to do those sorts of functions or people who aren't surgeons working in rural communities. So I think that they're the same kinds of discussions. They obviously have their nuances because it's hospital-based, not community-based. But...

Yeah, especially with the health human resources and burnout. Those conversations are happening everywhere.

Jordan Vollrath (42:54.774)
And when it comes to other practitioners increasing their scope and doing more things, I mean, is there just bound to be some growing pains with how we deal with those interactions and where we draw those lines? Um, cause I don't know, a lot of the sentiment you hear is, you know, they're just encroaching on our turf basically and outrage around that, but having a health workforce that practices to the fullest scope that they possibly can having that team based model.

Is there a smoother way to actually get to that point where more people are contributing at a higher level without throwing a bunch of wrenches into the system?

Alika Lafontaine (43:32.554)
I think the biggest challenge you always have when you have multiple different providers doing the same service is that people always migrate towards the places that are the best type of lifestyle and pay the best. That's not to say that that's all anyone ever does, but in anyone's practice, there's always a mix of things that are really, really tough and things that are somewhat easier just to balance out your day. I personally think that if we continue to talk about scopes of practice...

will continue to have these conversations that lead to friction between folks who do similar types of services. I think what we could do with technology now, especially with the data sharing agreements that have been signed with the Canada Health Transfer is eventually migrate to a place where we instead just ask, well, what do you guys literally do? When you see a patient from their first encounter to say getting a bowel resection because they've been diagnosed with cancer, there's a series of touch points that happen over that.

journey that patient is taking that things have to get done. And I think that it's not beyond us to actually identify what things within that clinical pathway have to be done and then ask ourselves the question, what is getting done and what is not? When you look at different tasks, and we know this from the competency by design work that's happened with specialty training by the Royal College, you can actually map out how many times you have to do something before.

you have some level of competency, you know, early in training. Should you be practicing independently if it will need an X amount of procedures or had X amount of experiences, you know, how can you work in a team-based setting to have a mix of seniority and skills? So, you know, you can continue to build up, um, you know, skills that you developed in training as you become kind of early to mid-career staff. You know, I, I think that that's really where we have to migrate. Um, and I think if you look at the things that literally get done,

If you're talking about physicians, nurse practitioners, pharmacists, physiotherapists, you know, all these other allied health providers working together, it will become pretty clear where there are gaps, where there aren't gaps. And the truth is, you know, unless you have exactly the same training, you actually can't do exactly the same sorts of things, you know. And so I think that those discussions make a whole lot more sense to me. And I think they respect people's time and attention when it comes to actually developing certain things and just recognizing where...

Alika Lafontaine (45:58.498)
where they can contribute value to, you know, patients trying to figure out what they need.

Jordan Vollrath (46:03.438)
It seems like the hottest point of contention or the spot where that interface seems to be the most controversial is around prescriptions. You know, like there's a whole lot of care that can be done and delivered that doesn't involve prescribing the medication. Why do you think that's become sort of that focal point for all the outrage to go to?

Alika Lafontaine (46:23.638)
You know, I think when you talk about prescriptions, it's a good example of how you have multiple people kind of working together to solve a patient problem, where patients assign blame if something goes wrong, and then how you can misdiagnose something and it can lead to worse outcomes. So, you know, everything from antibiotic resistance, and the truth is they're...

are people who are poor at prescribing antibiotics from every specialty within medicine and across different, yeah, you know, there's lots of folks that do that incorrectly. There are other things where, you know, a patient who has abdominal pain, you know, if you've never gone through training to differentiate between, you know, appendicitis versus kidney stones versus, you know, everything else that's on the differential when you have flank pain,

Jordan Vollrath (46:56.846)
Yeah, we can't take a free pass on that.

Alika Lafontaine (47:20.906)
You know, you may just assume that it's one thing and then you set the patient down a path where they could be seriously harmed. You know, how do you mitigate all of that? Well, once again, it's team-based structures, you know, making sure that people share information, they learn from each other, you have that mix of seniority and skills. But then I think the other thing that we really have to confront is, are we treating everyone who does the task equally? You know, is the standards the same for everyone? Are there certain...

requirements for kind of ethical practice that are consistent. You know, I look at what physicians are required to do when it comes to prescribing medication. You know, we're not allowed to both own and dispense when it comes to prescribed medications. You know, I think that sort of ethical standard needs to be talked about when it comes to pharmacists who both diagnose and dispense. You know, so.

You know, it's these types of questions that we just have to work through. Does that mean anyone's doing anything wrong or right or other things? No, I think that's just the evolution of the conversation and really taking regulation, registration, and the way that we manage tasks into today instead of, you know, where it continues to be, which is yesterday.

Jordan Vollrath (48:33.158)
But maybe it's another area where that accountability could be increased or improved upon, right? Like as a physician, again, there's nobody looking over my shoulder other than the CMPA if it really goes bad in terms of have you been prescribing the right medications, you know, the efficiency of your care. And something across the board for any prescribers might be an interesting program to look at.

Alika Lafontaine (48:58.358)
And the truth is we could learn a lot from other specialties as well. One of the best learning experiences when it came to medication for me was being on ICU for a few months and doing those daily rounds with pharmacists who worked in the hospital. I learned a lot about medication interactions, things that you don't necessarily read and the inserts that you have with medication. Learn different ways of critically thinking through things.

And I think at the end of the day, that's really what we should try to migrate towards. You know, you have tasks that need to be done. Let's treat people equally when it comes to those who can do them. But let's also differentiate when tasks should be done by someone and when they should be done by someone else. Because there are things that, you know, doctors are best suited for. There are things that nurses are best suited for, as well as every other type of health provider.

Jordan Vollrath (49:49.746)
Um, so shifting gears a little, you know, as the first indigenous voice as president for the CMA, what did that mean for yourself personally for the Canadian healthcare system going forward? It's obviously monumental step in terms of the system at large. Like what was going through your head when you first got the announcement that you were going to be up for the task there.

Alika Lafontaine (50:13.418)
Yeah, you know, being the first from any representative group is always something that feels a little overwhelming. So, you know, my family is from Saskatchewan. My grandfather was, you know, a big Métis activist back in the day. I have mixed Indigenous ancestry. My Métis heritage goes through Red River. I also have, you know, Oji Cree ancestry and then my mom's Polynesian from the island of

lots of different cultures kind of mixed in there that are Indigenous. I think one of the things that I really enjoyed during the year was being able to amplify other voices. We had the opportunity to meet using proper protocol with Inuit Tapiri Kanatami, the ITK Inuit organization, Métis National Council, MNC. We met with the Assembly of First Nations.

I was able to talk to leaders, get their direct feedback on what we were doing right, what we were doing wrong, being able to initiate an apology process near the end of my year that I still am a part of moving forward and that I'll probably be a part of delivering at the end of my past presidency year. All of these things come together as little steps in a long path that we have to take as a profession.

But I'd say for anyone who comes from a group that traditionally hasn't been in leadership, historically or otherwise, really encourage you to move forward. We need voices that represent the lived experiences of folks around the tables as we're trying to change things for the better. And your voice is important, my voice is important. The more people that we can have around these tables kind of making changes and sharing where they're coming from, I think the better off we're gonna be when we actually start to implement plans.

Jordan Vollrath (52:04.139)
And how are things going with the Safe Spaces Network?

Alika Lafontaine (52:09.142)
Yeah, so Safe Spaces was a project that I launched with my brother before I became CMA president. It's an anonymous platform reporting healthcare harm and waste. And so we set up a network in BC, Saskatchewan, and we just opened up our network in Ontario at the end of September. What we do is we provide people the opportunity to share their experiences without having to put their names attached to it. And we also have a way for people who work in the healthcare system.

to let us know they work in the healthcare system without actually knowing who they are. And so I think the mix of those two things is helping us to collect data from folks that the otherwise wouldn't have shared. I don't think it's broadly known that there's not a lot of folks who actually do report harm when it does happen. Some studies have it as low as 4%. So there's a hundred things that go wrong that should be reported. Only four people actually report those and we base all of our quality improvement and patient safety off of that.

That's not a lot of information to be making decisions on how to make things better. And I think that people have good reasons for not sharing. Number one, risk of retaliation is pretty big. And then people often don't feel like it's worth the trouble. I'm going to report things, I'm going to have this blowback as a result. And at the end of the day, nothing's going to change anyway. And so how do you create those environments to make sure that people actually see the change that happens? The reporting platform is one way.

And then making sure that supports movement and change in the other areas that have to happen. I think it's pretty important. But Safe Space continues to grow and we continue to get reports. And if any of the folks listening to the podcast want to report into the platform, feel free to visit safespacenetworks.ca and kind of share your story.

Jordan Vollrath (53:58.746)
It's just another area where that accountability is a positive system force.

Alika Lafontaine (54:04.47)
No, I think absolutely. And one of the things that's been a theme in my leadership journey is just stories. I think that sometimes we think the reason why change happens is because of double blind, randomized blinded control trials, when in reality, it's the stories attached to those trials, it's the stories related to the issues that we're trying to move forward. And anything that helps to increase the amount of feedback that you get from people, helps you organize it, and then...

helps to distill out what people are actually trying to say in a way that's authentic. I think that those are things that can change the world.

Jordan Vollrath (54:41.882)
So the year's over, now you've got your immediate past president year coming up. What's next for you? What does life look like?

Alika Lafontaine (54:50.89)
Yeah, so there's going to be a podcast that is coming out that I'm the host of. It's with the Canada Race Relations Foundation. It's going to be called the healthcare divide that's coming out in November. We have a six episode season coming out. Still continue to do keynote speaking, just presented out here in Montreal at Vascular 2023. So we'll continue to share the good word when it comes to system change and other things. Going back to clinical practice, you know, getting back to anesthesia has been fantastic.

For anyone who takes a longer break from practice to do other things, it is scary to go back. But I have such a wonderful department in Grand Prairie. I couldn't ask for better coworkers and they really supported me as I kind of came back to full-time independent practice again. And then just spending time reading and writing and spending time with family that I didn't get last year. The CMA presidency was an amazing experience.

I am happy to be returning back to life again.

Jordan Vollrath (55:51.826)
It was a busy year, I'd imagine. Tons of travel, tons of speaking all over the place. How many hours a week do you think you worked on average? Was that like a 2.0 FTE position? Or what was that actually like?

Alika Lafontaine (56:00.862)
Oh, geez. Yeah, it was just a continuous string of traveling and being home. I would go for three days and then I'd be back for a day and then be gone for four. Then I'd be back for a day. Then I'd be gone for two weeks. Then I'd be back for a day. So it was, my kids never knew when I was going to be home. So it is kind of nice to know that they notice when I'm gone because last year they just got used to me not being at the house. So

It is nice to reconnect with them and kind of be there in a way that I wasn't last year.

Jordan Vollrath (56:33.794)
Noble duty for sure. Thank you for stepping up to the plate on behalf of the rest of us Awesome while we're coming up on our time. Thank you so much for joining us I don't know if there's anything else that you wanted to throw out there before we wrap up

Alika Lafontaine (56:38.55)
No, I appreciate that.

Alika Lafontaine (56:47.882)
Yeah, no, I just say that, you know, there's never been a bigger opportunity to change the way that we do things in healthcare. And the funding is in place, you know, we're starting to talk about different areas. For any of the listeners who are interested in getting involved, I really encourage you to bring those ideas forward. You know, there is likely to be a big shift in the way that we practice.

you know, changes the sort of thing that seems like it takes forever. And then suddenly it happens overnight. And I think we're, we're coming into that quicker part of system change. And I'm hoping that it's going to be a, a better future for both patients and providers.

Jordan Vollrath (57:29.182)
Well, thank you again and best of luck with the new podcast and transition back into practice. Thank you so much for joining us.

Alika Lafontaine (57:35.566)
Thanks for having me.