Rural healthcare in Canada faces unique challenges, and Dr. Keith McClellan has been at the forefront of addressing them. In this conversation, Dr. McClellan shares his extensive journey in rural medicine, from the founding of the Society of Rural Physicians of Canada to the evolution of healthcare practices in underserved areas. He highlights the urgent need for adaptable medical training, innovative solutions to bridge the gap in access to specialized services, and the growing pressures of specialization among physicians. Dr. McClellan also reflects on the role of technology in improving healthcare delivery and advocates for a more tailored approach to rural healthcare education. The discussion delves into the evolving landscape of family medicine, team-based care in rural settings, and the unique challenges posed by emerging trends like deep space health initiatives.
6:14 - The Evolution of Rural Medicine
Discussion about Dr. McClellan's career path and the evolution of rural healthcare, highlighting the self-reliant and adaptable nature of rural physicians.
12:07 - Founding the Society of Rural Physicians of Canada (SRPC)
Dr. McClellan discusses the advocacy and education challenges that led to the creation of SRPC, aiming to improve rural healthcare and collaboration between physicians.
20:06 - The Future of Rural Physician Education
A debate on whether rural-specific residencies and training programs should be created, and the importance of adapting medical education to the needs of rural communities.
27:06 - Current Advocacy Efforts in Rural Healthcare
The current political and educational advocacy efforts of the SRPC, focusing on enhancing rural doctors' skills and ensuring access to essential services in remote areas.
29:04 - Technological Changes in Healthcare
A critique of how healthcare technology, while having potential, has not been utilized effectively in rural settings, and the overreliance on outdated methods like fax machines.
38:04 - The Role of Specialization in Medicine
The shift in healthcare from generalists handling a broad spectrum of care in rural areas to more specialized, urban-centered healthcare, and its impact on access in remote communities.
50:28 - Rethinking Family Medicine and Specialization
Dr. MacLellan questions the evolution of family medicine into a specialized field, exploring the balance between generalism and specialization in rural healthcare.
57:08 - The Role of Team-Based Care in Primary Health
Discussion on the increasing importance of team-based healthcare models in rural areas, emphasizing collaboration between various healthcare professionals to meet community needs.
1:00:25 - Challenges of Change in Healthcare Systems
How rural healthcare systems are often resistant to change, and the difficulties of integrating new technologies and medical practices in remote regions.
1:06:52 - Cultural Shifts in Medical Training
How changes in medical training are influencing the attitudes and competencies of physicians, particularly in preparing them to serve in rural environments.
1:09:00 - Continuity of Care and Patient Management
Dr. McClellan explains the importance of continuity of care in rural settings, where long-term patient relationships and comprehensive care are essential.
More Resources:
Society of Rural Physicians of Canada: https://ca.cherry.health/partnerships/srpc
Podcast: https://podcasters.spotify.com/pod/show/leaders-in-healthcare
LinkedIn: https://cherryhealth.co/linkedin
Facebook: https://www.facebook.com/cherryhealthinc/
Instagram: @cherry.health
Twitter: @cherryhealthinc
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Transcript:
Dr Jordan Vollrath (00:04.5)
All right, so today we're joined by Dr. Keith MacLellan Dr. MacLellan thank you so much for joining us.
Keith (00:11.82)
Hey, it's a pleasure. Looking forward to it.
Dr Jordan Vollrath (00:15.7)
So before we jump into the accomplishments and the other pieces, tell us a little bit about your background just in healthcare and your role as an actual practitioner. I understand you are still practicing part-time currently as well.
Keith (00:29.056)
Yes, that's right. don't know why, but I am. I guess, you know, I don't know. Everyone likes to talk about themselves. I suppose that's that's easy. But I'll tell you very briefly. But before I do that, just a couple of caveats. And one of them is that the first one is that I don't want to make anyone think that if you're asking about the arc of my career,
that it is something that's applicable to present day medicine or to most of the doctors or others who are listening to this. I trained and grew up in a different time and I followed a career path which I think would be very difficult to do these days and I don't think it would even be applicable to do these days.
So that's one thing. And the second thing is that I just wanna again, emphasize that in rural Canada, there are hundreds and hundreds of physicians and nurse practitioners who actually do a lot and have done a lot more than I do. And I'm not saying that in false modesty. There's just some admirable physicians out there
who respond to the needs of their communities and have done all kinds of services and skills that I have not acquired. And I stand in admiration of them. But very briefly, like I did a, I'm a child of the 60s. So I did a BA in history, mostly medieval and Canadian history, and then a BSc in molecular biology.
and then was admitted to McGill Medical School in 73 and graduated in 77. And I was always a bit of an elitist and I thought the elite doctors of Canada were the rural and remote practitioners. Doctors who did that kind of work, at least I had the greatest admiration for them. So I went to
Keith (02:53.204)
Newfoundland and did a rotating internship, which we were still allowed to do at the time, and went out into practice in Northern Newfoundland on the Great Northern Peninsula, very romantic job. So the only doctor on the whole East Coast of that finger that points to Labrador flying into communities with no roads. a little small nursing station.
and learned my practice there and then later came to where I am now, which is in western Quebec, up the Ottawa River, an area about the size of Belgium, so very broad area with about 20,000 people in it, so small scattered communities all around. But in my case,
it was handy too because even though it had a very remote feel to it, a sort of two-lane highway coming up to our place, it's only about an hour, an hour and a half from Ottawa and Gatineau. So there I just did the usual kind of country practice which was a very broad range, knowledge, you know, a mile wide and an inch deep.
And so I did hospital work and obstetrics and some surgery and office work and house calls and pediatrics and the whole gamut. And every now and again, I'd see something that maybe a skill set that we needed or that our population needed. For example, we lost three patients one year to complete heart block.
So I'd go back to a tertiary care center and learn that skill set. go back to the Royal Victoria Hospital in Montreal and say, you I don't think you need a fellowship to put in a temporary pacemaker. And they agreed and would give me a beeper and I'd put in all their temporary wires for a few weeks and then bring that skill back.
Keith (05:16.618)
And I did that with plastic surgery and orthopedics and ICU and coronary care. So I tended to veer a little bit more into the ICU stuff while doing obstetrics and everything else. that's now I'm pretty much restricted to the office doing primary care.
And I have about 1500 patients and I can manage them pretty well on three days a week. Not too hard. It's a bit like gardening. You just have to keep the row straight and weeded and the rest of the time I'm trying to write a novel. So that's a whole other matter. But I feel very fortunate that this kind of work I took to it very, very well, very easily.
the community around here, even though I've gone off and done locums in various parts of rural and remote Canada, I've gotten lot more from the community than I've given them, I'm sure, but I really feel part of it and thankful for all of that as well.
Dr Jordan Vollrath (06:37.162)
I love the self-reliant attitude, like the, we need a particular skill set. How can I go out and learn this? Which is in, I guess, as you alluded to, stark contrast, I guess, to the how specialized and how outsourced medicine is becoming recently. It's, it's who has this skill set? How can I get them to that person the fastest? I guess, unless you're in a very, very remote area.
Keith (06:37.693)
Okay.
Keith (07:05.974)
You know, incredibly, every time I went back to a tertiary care center and asked them to learn a skill set, they were extremely welcoming and happy to teach me. And essentially what I said to say a super specialist, say a plastic surgeon, and I said, can I spend a few weeks with you and tag along? And they'd say, sure, why? And I said, well, I just want to learn.
what's boring to you, what's dross, what you hate to do. Just teach me that. Or if you go to an adult ICU and you talk to an intensivist and say, do you hate to do? Like what do you not, what's boring? And he'd say, well, know, ventilating and overdose for two days. I mean, that's so boring. You say, well, teach me that, you know. And if you had that kind of attitude, the specialist...
invariably we're extremely welcoming and no problem at all. The problem becomes with the college of physicians and surgeons when you do start to do that and something goes wrong and you don't have the proper qualifications or certifications then it's living a little bit on the borderline.
But not dangerously and I'm sure that I haven't, I'm fairly certain I haven't heard anybody doing this and I know that I brought a lot of services to the community and I wasn't the only one in our group. We had a whole group of doctors who were into this and so we had a rural team that kind of
had a baseline of competencies, emergency room, obstetrics, pediatrics, all that sort of stuff, office, primary care. But then each of us had certain kind of specialized skill sets that were given to us quite voluntarily, quite happily by the subspecialists. It was fun.
Dr Jordan Vollrath (09:34.264)
That does sound fun, getting a little bit of variety. Yeah, the things that are boring to an intensivist would probably terrify and thrill even the most numb of us out there.
Keith (09:34.636)
Yeah.
Keith (09:46.678)
Yeah, or for example, if you spend a couple of weeks in a neonatal ICU taking care of with the nurses and the neonatologist and you see them taking care of tiny little 700 grammars and so on, when you had a mildly ill full term baby,
you were much more comfortable with it. You wouldn't take care of 700 grammars, but if you had a rule of group B strep type thing, which is very boring for a neonatologist, you would be much more comfortable taking care of those sort of things. And we notice this in rural areas now that, and we'll probably talk about it later on with specialization, but more and more.
fields that used to be local and run by family doctors or general surgeons who had also a wide scope of practice are now being transferred to the city. So simple fractures, for example, which we would do all the time, are no longer done. We used to admit kids with croup and bronchiolitis.
even certain meningitis and take care of them locally. Well, it doesn't matter. All that sort of stuff is now no longer in the purview of primary care or whatever you mean by primary care. you've got this transfer of skill sets to the city and people have to travel.
And so we resisted it to the best of our abilities. And I want to say that across Canada, there's a whole bunch of doctors who've done a lot more than I. For example, there's at least, there's hundreds of doctors who do cesarean sections. And they're family doctors, or who do surgery, or do anesthesia. And really, when you think about it, it's...
Keith (12:06.818)
in rural areas, it's lack of access to specialized services that's the real obstacle and that is getting harder. But you still have doctors going out and doing training and doing cesarean sections or doing advanced orthopedics or doing anesthesia and so on. They're holding up the hospital care in rural Canada right now.
Dr Jordan Vollrath (12:40.43)
Well, with that in mind, what was the intent of the SRPC, the Society of Rural Physicians of Canada, as you were one of the founding team members back when this first came into fruition? Did this sort of concept of getting in better touch with resources or being able to provide more specialized care to patients out in these rural and remote areas, was that?
the huge part of the intention behind the formation of the organization?
Keith (13:12.012)
Yes, there were two main forces that did this. And one was advocacy and political. the Society of Rural Physicians of Canada actually started in Mount Forest, Ontario, based on work action. and at that time in the 70s, 80s and early 90s,
emergency room coverage was on fee-for-service only. And so if you had a small town with four or five doctors, you were on call in the emergency room, either on place or at home for any emergency. And you got woken up in the middle of the night and drove in, or you came down from your on-call room, and whatever you saw was a fee-for-service. So it might have been...
a small amount of money. So the Mount Forest people started work action and closing their emergency room and developing some concepts about rural medicine that way, particularly advocacy. And then just about at the same time, the second impulse was for education. That is, we were not getting the education either in medical school.
or in continuing medical education, it's all very well for me to go to a specialist and learn how to do some procedure or skill set. But there was no accreditation or certification or anything like that. There was nothing official in us being able to learn how to do things. And the same with CME. So there were no continuing medical education.
conferences or anything that was specifically oriented towards the needs of rural physicians. So that in 1993, I started a national conference on rural medicine. And what I did was piggyback with the continuing medical education department at McGill. And then we sent out flyers nationally and started the first
Keith (15:40.09)
in 1993, the first national conference on rural and remote medicine. And it stayed for three years in Montreal. And then we started to move it around the country every two or three years, sometimes every year. So the next ones were in Alberta and then in Newfoundland. And we just moved them around. we tried to make most, these were two-day national conferences.
and we tried to make them as much as possible small group and to have rural doctors teach rural doctors. So it wouldn't be the kind of thing where you had the big specialist coming and then lecturing to a whole hall for an hour on some whatever his or her be of their bonnet was. It would be rural doctors saying this is how I manage this, this is how you can do this too and so on.
So in a way, they actually became right from the very beginning, although there was a fair amount of education going on, they became basically group therapy masquerading as education.
Dr Jordan Vollrath (16:56.984)
Yeah.
Keith (17:00.264)
and so on.
Dr Jordan Vollrath (17:01.078)
That's part of what put it into such a rapidly growing trajectory that was just the emotional benefits of attending.
Keith (17:09.826)
Yeah, that's right. At the same time, we hooked into McGill's IT department and started an internet bulletin board or a list of trying to connect the doctors. And that's what RuralMed, which is now, don't know how many members it has, but it's just a discussion place on the internet for rural doctors.
And then we went to the Canadian Medical Association and asked them if they'd give us a hand publishing a national journal on rural medicine or an international journal and they were kind enough to help us with that as well. So then we started putting out a peer-reviewed journal of rural medicine with the help of the Canadian Medical Association.
Those were the, that's how it started off. In a sense, we were buccaneers, I think might be the best word. We kept the process, but we pushed the envelope a little bit. And the same thing happened nationally then in advocacy in the sense that we had, we started to
say well at our national medical scene so that would be the CMA and the accrediting colleges, the Royal College, the CFPC, the LMCC, the Federation of Medical Licensing Authorities, Federation of Association of Colleges of Medicine and so on.
They meet and they all had talks and stuff that we sort of elbowed our way in to kind of make our points and for the most part were listened to. Now, I mean, I'm so proud that the SRPC has
Keith (19:36.972)
far less of a sort of buccaneer approach, but it still has a very rural approach to the education and advocacy problems and challenges and solutions. And we're pretty much accepted very much on the national scene and our educational efforts are actually leading, I think, in many fields.
There's a long way to go, I think there was obviously a need for the SRPC and it got established with some pushing and now it's doing extremely well.
Dr Jordan Vollrath (20:26.4)
And when it comes to the education side of things, do you see things progressing towards a specific residency, like an actual designation as a rural physician? Like right now we've got family medicine as the umbrella and you can do your residency in a rural location, but you still come out with the same credential. Do you see things progressing to that next step of actually being different endpoints?
Keith (20:26.848)
Thanks.
Keith (20:55.734)
But that's been a debate since the founding of the SRPC where there was a significant
voice that said that it will if training is based on accreditation and if the only way to make faculties of medicine train rural doctors for the type of practice which is quite procedurally based
Keith (21:35.686)
that it might be best to have and to work towards a college of rural medicine that would be an accredited college like the Royal College and the CFPC in the sense of actually having the power to see that universities and faculties of medicine actually taught rural appropriate curricula. We didn't go that way for a number of reasons.
one of them being defining what rural is. It's very difficult to define what rural is, especially in a country like Canada, which has this enormous geography and very particular demography type of issues. But stats can, definition of rural really doesn't work for healthcare because it lists
bedroom communities of cities as rural and they really aren't rural. We used to joke that one definition of rural was any town without a Tim Hortons, but the way that company is going right now, that doesn't work either. A good definition of remote used to be that, you know,
It's where you are when there's absolutely nothing on the car radio at all. in the end, came down to a definition of rural, which is a functional definition, which is that where the bulk of care is given by generalists, that is not by specialists.
Dr Jordan Vollrath (23:08.334)
Yeah.
Keith (23:29.514)
That's all right, that's fine. That gives you a good idea of whether something is rural or remote or not. But it's kind of hard to define for membership, like for an accredited college, who's rural and who isn't. There's an old saying of when you see one rural town,
Well, you've seen one rural town because the needs are different in the next rural town and the demography is different and so on. So there was this problem as well as just defining ourselves for a college, an autonomous college of rural medicine. There was also the feeling that the college of
family practice was the only generalist game in town. They were our closest allies in the national medical scene and they, the principles of family medicine were all those principles that we could believe in, including comprehensive care and.
cradle to grave and being a resource to your community and all those things. And we thought that there was some hope in the College of Physicians, Family Physicians of Canada in being able to adapt to Canadian rural and Canadian geographic and demographic realities. I mean, know, half, close to 50 % of our GDP in Canada is produced in rural areas.
it's not Belgium and the type of health system that you need is completely different than you do in Mississauga or you know some some big suburb of Calgary or Vancouver so not not better but different and we thought that the College of Family Physicians as a generalist outfit and having its roots in rural
Keith (25:49.61)
medicine historically could adapt. And it wasn't very long before the College of Family Physicians of Canada declared family practices specialty. And there was a lot of...
There was a lot of tension over that within the college, but eventually it was passed. And that's when I thought, you know, I don't want to be a generalist, a specialist in generalism or some sort of oxymoron like that. And it doesn't fit at all to what rural needs. So maybe we should look at
other ways to do it. The majority of the members of the SRPC are proud CFPC certificates or fellows and I'm going to leave it to them to decide how to do it or if they can.
I think many of them think they can still change the CFTC from the inside and that might be possible. Good luck.
Dr Jordan Vollrath (27:20.168)
What are they trying to accomplish at this point? I guess when it comes to the two arms of the education and the advocacy, what is the advocacy side of the SRPC working on right now? What is the actual main or couple of main objectives?
Keith (27:20.61)
So we're going to leave it at that.
Keith (27:36.012)
Well, you'd have to ask. I've been out of the executive for quite a while now, so I don't want to speak to them about that, for them about that. But from an educational point of view, I do know that they're doing the advanced skills training and they're allowing rural doctors now to be paid to go off and learn extra skills where they come back and bring them to their community.
That's a fantastic initiative and I applaud it. Politically, on a national scene, you know, mean, they attend, I'm sure, all the big meetings of all the Canadian national medical groups and they make their points known.
I don't know what other, they make links with other national rural or non-medical rural organizations. nationally, mean, healthcare is provincial. And as you know, there's a limit to what the federal government can do, even if it wanted to do it. And so I think on the national level, it's slow going.
Dr Jordan Vollrath (29:03.886)
Over your time in healthcare, how have you seen things change? Where have the biggest changes actually been? it in the technology? Is it in the roles and the expectations for the doctors? Or where have you actually seen things evolve the fastest?
Keith (29:04.396)
So that would be very interesting.
Keith (29:22.902)
Well, technology is not, I think we spoke a little bit about this before we started, but technology hasn't really been used the way it could have been used, I think. And where it has been used in rural Canada, you know, I went to a, there was the Info Highway, which was a big federal provincial billion dollar project to accelerate
technology and information in healthcare. And there was a, stood up in the conference, which was made up of hundreds of bureaucrats and health planners and so on, and said, you know, what we need to bring this technology to the next stage is a bureaucratic vision.
So I got up and introduced myself as the token rural person at the conference and said, know, bureaucratic visions are a bit like meteorites. Most of them burn up brightly in the atmosphere, but some with a lot of weight make it through and they usually crater out in rural Canada somewhere. And our hospital basements are full of old equipment, IT equipment.
big television sets and computers that are rusting in the basement from some project or another that was taken usually by the IT department of the Faculty of Medicine and they would take off the shelf technology and then say, can we use this to help these poor rural people? And then come out to us and say, do we have a deal for you? Here's all these. And it would, you know, when the budget ran out and
that was it. so I'm still using a fax machine. The technology that has had the most effect on me has been rather negative compared to say just picking up the telephone and talking to a specialist, which I can still do in the middle of the night when I have a problem. I just pick up the telephone and say...
Keith (31:52.315)
And I get a reply right away. But I agree with most, many doctors anyway, saying that the electronic medical record has put a sort of a time, I wouldn't say wasting, but a time eating aspect into my practice. So it organizes things much better.
but it takes up so much of my time to type in my notes and type in all the various things that I think I could be a lot more efficient without it. Now in Quebec, I'm not sure about other provinces, but they have something called the DSQ. It's just a little key fob that I plug into my any computer anywhere where I am.
and put in some passwords and then I can access any patient in Quebec's medication list up to date from the pharmacies, all their investigations in imaging and blood work. And if I just look at that, I can usually figure out what a patient was a stranger to me is all about and what's been done. I really don't need their
family practitioners endless clinical notes, which often I don't trust anyways because they're in templates. So the electronic medical record has been helpful for getting results, but there are other options that are much easier and cleaner and faster. And it's been a real
a time eater for me. So that's one big change that I see with technology. Some of the other stuff, for example, echocardiograms, they used to be sort of an interesting adjunct to the stethoscope and now have become
Keith (34:17.314)
kind of like essential in managing a whole host of common problems. And by common, like atrial fibrillation, is whatever it is, is 10 % of the population after a certain age. Well, echocardiograms are image heavy. They're very hard to transmit over the internet. They're extremely bulky. So when...
The University of Ottawa now has the contract for all the echocardiograms in the Arctic. Well, twice a year they bring two echocardiogram machines and fly them up to the Arctic and then a couple of echocardiographers and technicians and take and do all the valves and do all the echocardiograms and bring them back to Ottawa to interpret.
So wouldn't it be very cool if we could develop care closer to home for echocardiograms? Technologically, I think it's totally possible. technology has not helped very much bridge the gap between the...
lack of and degradation of access to specialty care in rural Canada. You still, if you're going to deliver a baby, know, technology can't do very much for that. You need to have a labor room, you need to have a doctor, you need to have a nurse, you need to have c-sections. You need someone who can
as the surgical skills to do C-sections and someone else who can do the anesthesia for the C-sections. And then you need the post-op care. So if you don't have that, then you're going to lose your obstetrics mostly, in most places. And if you think that a definition of a community, one definition is where you were born, then,
Keith (36:40.158)
What we're seeing now is that women in certain parts of Canada, this has been documented, I've seen it myself up in the James Bay area, they just won't, they'll just deliver in the bush on their own. They won't, rather than travel at 38 weeks and stay in a motel in Edmonton or in Val d'Or or something like that, they'll just deliver on their own.
or present to the hospital whose obstetrics have been closed in, you know, about to deliver and no one has the skill sets left for that. I'm wondering a little bit, but those are some of the changes from the technological point of view. Technology hasn't helped that much. And in some cases has sort of hindered, but it could.
and it should and I think it's the only big hope for rural health care delivery is it has to be technology. Advocacy at the national level and the provincial level can help to a certain extent. Education can certainly help but and group therapy masquerading as education can help a lot too.
But what we really need is technology that's focused on this type of distance problem.
Dr Jordan Vollrath (38:14.254)
Well, it's really interesting just the perspective on, you know, technology is not the savior in the end all and the crowning jewel that it's touted to be. It's really interesting, especially for me as a person who, you I haven't been around since EMRs were standard practice, at least here in Alberta. But when you look at it from that perspective of, well, initially my input was just unitary. I had my one piece of paper.
Keith (38:14.786)
Trust me, it's an easy and simple thing.
Dr Jordan Vollrath (38:43.072)
And this was the input for everything. put my, you know, my patient records here. I'd put my consult notes here. I'd put my physical exam here. My prescriptions went right there. And then now you come with the EMR technology and now suddenly there's 20 different places that you have to start from when you begin entering the information. And this is where that time lag is coming from. You know, the person still needs to use it and they still need to be efficient.
see all their patients in a day, but now this is actually slowing things down. But perhaps this is, I guess, where the AI now augmentation is going. You know, have your solitary input right in the AI field, and then it starts to disseminate things to the appropriate areas. Perhaps this will actually start to rectify some of what you were talking about.
Keith (39:35.232)
Yeah, I like the idea, although I don't understand it very much, but I like the idea of the potential of AI to do this. It's interesting with EMRs, not that I'm against them, but for the amount of time and effort, I haven't, and I don't think there exists a study that shows improvement in healthcare or better outcomes because of that amount of time that I put into it. And if I...
If I know all the investigations the person's had, technology gives me that and all the medications that they're on and technology gives me that, that's important. And I can do it without an EMR. The rest is mostly for myself to remember. I'm talking to myself. I'm not talking.
to a physician in Alberta in case my patient goes to Alberta or something. And when they get really sick in the hospital, like an intensive care doctor taking care of a very sick patient really doesn't care what's in the primary care, EMR, and all those clinical notes, and whether the patient had a fit test or when was their last mammogram.
and stuff like that, it makes no difference to the outcome of the patient at all. the other thing that I noticed, we're all becoming, for very good reasons, it isn't bad, we're all becoming more specialized. So, this is true for all workforces.
So it's true for teachers, it's true for lawyers, it's true for mechanics. If you take your tractor into the local mechanic and it needs a diesel pump repaired, then it has to be sent off to a diesel pump specialist. And it's true in nursing, it's true in social work. Everything is differentiating.
Keith (41:57.81)
work is differentiating and some differentiating. the denser a population, the more that needs to be done and the more easily it's done. So in very dense populations like Belgium that we were talking about in UK or Northeastern United States or the metropolitan areas of Canada, which there are not that many, but anyhow, the ones that are there like Toronto and Vancouver, Montreal.
and you have dense populations, everyone's work is going to differentiate, including doctors' works. And then, so there's that force of society that's there, it's just there. You can't say it's bad or good, it's just there. as well, though, another force is our own preferences. I I approach problems by differentiating things.
I pretty much don't want to get into an airplane that's been cobbled together by a group of jacks of all trades and flown by a pilot who's not accredited. So I recognize within myself that I value specialization. And I recognize also that a lot of doctors and physicians
are uncomfortable by two things. One of them is projection of anxiety and worry, the sick people, the ones who are unwell and unhealthy, and they sort of project that onto a physician, which has been for thousands of years that way, but it's uncomfortable to be projected upon with people's dis-ease.
for any amount of time. the other thing is that physicians are uncomfortable when they don't know what's going on or they don't know everything that's going on. so you got to double whammy when you're a family physician who is supposed to be comprehensive.
Keith (44:21.334)
Well, then you're going to be projected on with worry and dis-ease for your whole career. And a lot of the good you'll actually do is just the projection too. But as well, you're going to be working in a sort of murky, uncertain area that you just don't know if things are going to work or not.
and the pressure is to figure it all out all at once because then there's the next patient. So you're sort of functioning a bit like a tertiary care emergency room doc that has a lot of sub-specialties behind them. So you just consult cardiology, consult GI, but you can't do that as a family physician. that pressure I've always had.
right from the very start. I wasn't some sort of super competent person at all. I dealt with it because I thought that was the normal medical, that was the doctor's role was just to deal with this pressure of uncertainty and pressure of projection. But I don't think, I think those two pressures
have become even stronger these days compared to say 30 years ago. And that's why young physicians who are coming out, I totally get it. Like if they're not been prepared for it, and I don't know how you prepare someone for that type of uncertainty. And if they're not a personality disorder of some sort or another,
I totally get it that they're extremely uncomfortable with this. And why not, in order to make yourself more comfortable, have a focused practice, where you pretty much know what all the parameters and you may still get projection, but at least you don't get the uncertainty as much. so I've seen
Keith (46:42.496)
more and more of that. And it's interesting in terms of primary care reform, you know, in the 1960s they had, for example, in Quebec they had the Castonguet report about primary, a reorganization of primary care. And what they suggested was the same thing that they suggested in the 1990s when the federal government put
900 million dollars into primary care transition fund and it's the same thing that's being suggested now which is though what we need is teams you see and we're going to have teams of people physicians and nurses nurse practitioners psychologists and so on and they will become primary care teams well it it's a great thought
It didn't, it's interesting that no one's asking how come it didn't work in the 60s, how come it didn't work in the 90s. And I think one reason is that they haven't, there's just one reason, is they haven't really taken into account our specialization tendencies, which are extremely strong from exterior and from interior as well. And if you, if you do take those into account,
when you're trying to design primary care. What about, it might lead you into paths that haven't yet been talked about. If you accept that even nurse practitioners are now specializing into nurse practitioner for oncology, a nurse practitioner for the cystic fibrosis clinics, you know, even...
So even the... Sorry, you have to cut that out. So if...
Dr Jordan Vollrath (48:50.806)
No worries, we'll edit this little segment out here.
Keith (49:00.308)
If I were redesigning primary care and having been now almost exclusively in primary care for the last eight years compared to a very broad rural practice, procedural practice before, at least a quarter of my billings are anxiety and I've not been trained in anxiety.
I don't know five different psychotherapy theories or anything like that. I just know SSRIs, right? So someone comes in anxious, within 30 seconds I'm trying to figure out whether I should put them on. What's the reason not to put them on SSRI? Same back pain. So I see back pain and I'm not qualified for
back pain and now that I'm an older doc I just say I can't do back pain. That's why they have physiotherapists and kinesiologists and chiropractors and massage therapists, Tai Chi and I don't know what else but like I'm unless you got a tumor in there I'm not qualified to give you any advice on back pain. I haven't been trained on it but that's what I see.
Supposing you had a primary care team that had physiotherapists, psychologists, social workers, dietitians, and nurse practitioners, who we understand will probably differentiate, but not all of them will. And you actually took family medicine out of there completely.
And you said to, we recognize the differentiation and the pressures on doctors and they are going to differentiate. So why don't we take the half, the 50 % of medical school graduates who are now going into family medicine and instead put them into general specialty residency and produce more internists.
Keith (51:26.316)
psychiatrists, geriatricians, pediatricians, so on, and hospitalists who are becoming a specialty anyway. And actually gradually phase out this whole idea from the 70s of generalist, comprehensive, long-term cradle to grave stuff. Just phase it slowly out and say, well, was nice while we thought about it.
but the prevention and the primary care is mostly stuff that doctors don't train for. We'll make the hospitalists link with these non-physician primary care teams so that the hospitalist has as one of their duties a link with the community. But the hospitalist will be a specialist just like the emergency medicine guy is a specialist just like anything else.
So, I don't think that the current plans that I've read, although they sound really nice, they don't take into account either the pressures of being at the forefront of undifferentiated pain and suffering, nor the social and internal forces that push us to
differentiation to specialization. I think they should take that into account. not entirely, I have, I've always worked with nurse practitioners in the North and Newfoundland. When I arrived there, there were two guys that had been fighting with chainsaws and one had ripped the cheek of the other one right open. And the nurse practitioner was doing a three layer closure. here in this office here, I have a nurse practitioner.
She was 10 years on the floor in our hospital and wanted something else. so I trained her, or helped train her, and she does more. She sees more patients in a week, and she does more procedures, IUDs, endometrial biopsies, joint injections, skin biopsies, all that stuff. I taught her all those things.
Keith (53:52.928)
than the recent graduates of the family practice department. now the recent graduates are, because politicians are under pressure to have every patient in Canada must have a family doctor, must be able to see a family doctor. There's a variety of provincial programs. We have one here in Quebec, which is essentially walk-in clinic.
So the government is paying family practitioners to attend walk-in clinics and see patients for minor stuff and be paid more than doing comprehensive care.
Recently in Quebec, there's been a mulling that we'll just take well patients, the worried well, patients who are not vulnerable and you could define like sick, they have chronic disease of some sort, but we're not vulnerable and pay family physicians only to see vulnerable patients and take the healthy people away from their practice and put them into
walk-in clinics and you know what a lot of the patients appreciate walk-in clinics because the kid has a sore ear and they just walk in and get the antibiotics and leave and that's that's it so anyways the i i'm no longer entirely convinced unless it changes in a major sort of way i'm no longer entirely convinced that
the old model of the family practitioner, even though I was one, is viable. And the new models that are being brought out, I just don't see paying somebody at upper middle class income to do mostly statins, SSRIs, low back pay, things like that, and refer them to specialists.
Keith (56:06.074)
My nurses we have separate set of nurses here that just do chronic disease management. They do diabetes, COPD, hypertension, things like that. They do great. They don't need me at all. So what's this, you know, three years post-secondary school, four years medical school, two years residency?
Keith (56:34.6)
and learning about, you know, pathology and anatomy and pathophysiology and pharmacology and stuff. In the end, why not think about either changing family practices in a major way to take into account the specialization forces that are happening and that will happen, or just phasing it out and let's have more interns.
pediatricians and so on and so forth.
Dr Jordan Vollrath (57:08.376)
It's a fascinating way to look at it, you know, from that team based care perspective, right? It's like a fully admit, right? It's like if a patient is able to see and can afford to go to a psychologist, they're probably going to get a lot better of therapy around their anxiety compared to myself, right? If somebody can afford to get in to see the chiropractor or the physio, their back is, you're assuming it's, there's something not needing like a.
Keith (57:09.014)
This is the next writing rule.
Keith (57:36.076)
Yeah.
Dr Jordan Vollrath (57:37.002)
antibiotic to treat it or a surgical fix. You know, they're probably going to do a lot better with their MSK pain compared to if they see me, but it's, you're sort of, that's where the family medicine role has anchored around is you're the triage point, I guess, perhaps not necessarily the end point for treatment and what's going to happen, but more so just the director to resources. And how do you necessarily get the patient in touch with
what next as opposed to always having to feel that pressure of, I myself have to sort this one out.
Keith (58:15.03)
Well, that could be done by anyone with six months training to triage in the emergency rooms. That's right. But it doesn't, know, to bring it back to the College of Rural Medicine, this type of, you need broad-based generalists in a country like Canada.
Dr Jordan Vollrath (58:22.882)
Yeah, phone 811, call the HealthLink line.
Keith (58:42.9)
And you need a different kind of a primary care team in rural Canada, because that primary care team often works as well almost hour by hour at the secondary and sometimes at the tertiary level, the team itself. So that type of procedural, the heavy and shifting between levels of care.
Why not put it in the Royal College? Why not make rural medicine a specialty as well? But one which is reflective of what's really needed in rural Canada and one where we can get skill sets from the specialists as they acquire more and more of them from primary care and have the permission to use them.
Dr Jordan Vollrath (59:42.136)
Do you envision anything drastic like this happening any point in the near term here? Like it seems like the system itself is not set up to step back and ask itself of these bigger picture questions of just radical change and reassignment of duties and definitions of roles. Like, is it possible that we get out of this?
Keith (59:42.834)
I'm definitely saying that's it.
Keith (01:00:02.38)
Yeah.
Dr Jordan Vollrath (01:00:07.614)
kind of continuous cycle of small changes and little iterations into just a style of governance or where things completely kind of go back to questioning the underlying fundamentals from the get-go.
Keith (01:00:25.462)
I mean, that's a very good question. And it gets to the heart of the whole, how does change happen when there are vested interests? And there are a lot of vested interests in healthcare. And Canada is not alone because we're attached to the United States and to the rest of the world too, in terms of how healthcare is dispensed.
and how much of our budget do we want to give over to it? So, you know, if I were a politician and said, you know, healthcare needs more money, but we also need, I don't know, nuclear submarines or F-35 fighter jets, or we need a dental care plan. It's interesting that when I started off, I thought that I could bring a lawsuit
eventually to the Supreme Court and take the federal government and the provincial governments to court in terms of access to care. That is that if they don't provide proper access to care in remote areas and people actually die because of that, maybe I could make a challenge under, say, the Charter of Rights.
And it turns out that healthcare is not a right.
and is specifically excluded from the Charter of Rights. So we all think that it's a right to have a family doctor or it's a right to get care, but it's not a right at all. And the only way to maybe challenge them would be on another clause called Peace Order and Good Government. so there's a lot of vested interests and healthcare is not a right.
Keith (01:02:25.292)
So you can't do the change legally.
I used to think, well...
things are getting, are just going to have to get so bad that everything breaks and then we get to reconstruct it. But the same people who are reconstructing primary care now, which is considered a crisis in Canada, access to primary care, are saying the same ideas as in the late 90s or as in the late 60s. There's been no change and they're not taking into account
What I think are two basic forces. So the specialization and the projection. So yes, you could reaching admissions to medical schools. And I know I listened to one of your other podcasts where someone was suggesting you just got to admit different type of people into medical school. At least 30%, I think they say were.
inappropriate to becoming doctors and I my ears perked up at that but I don't know how you go about that and even when those doctors graduate there's a thing that happens in medical school there's a concept of medicine called clinical courage and it's an old old medicine but we it's old old concept
Keith (01:04:04.022)
that goes back thousands of years. But clinical courage is not being a cowboy, but it's actually just grasping the thistle and having to do something. And it's not heroic like amputating a limb when you don't know how to do it or anything. It could be something like just taking on an HIV patient when you haven't been trained in HIV because they don't want to travel three hours to a clinic.
I did that and it turns out managing HIV as far as I'm concerned is easier than managing diabetes. There's very few drugs, there's not that many tests you have to do. So clinical courage, it can be very quiet, it doesn't have to be heroic. But in medical school, the rural doctors often say what's taught is learned helplessness.
So you actually learn it's a good thing to be helpless, to stay within your boundaries. And it's very bad to exceed them in any kind of way at all. Now, when I trained at the Montreal General, it was very much a see one, do one. I don't say that that training was necessarily better or I learned more.
And it may not have been as good for the patient or it might have been, don't know. you it cultured a kind of an attitude that you can and you must take care of this yourself in some way or another.
Keith (01:05:56.832)
I think so you could change that type of culture. You could admit different type of people to medical school and you could endanger, engender a culture of being judged on how resourceful you are and how much initiative you take.
I don't think that those are cultures now in medical school. So, but even when they graduate, they're going to differentiate. I think it's, they are, you can't, it's just a social thing. People are going to specialize. They're going to seek a place where they're less uncomfortable in some way or another.
Dr Jordan Vollrath (01:06:52.622)
I think you're probably right. mean, that's sort of speaking to me myself personally, right? So you've got on the one hand, medical legal risk, and then on the other hand, you've got somebody else's inconvenience and time and right. And so it's sort of how much does, do I as the doctor want to go out of my way to tackle something that I'm not a hundred percent comfortable with in my like training or having the credential there.
Keith (01:06:53.132)
So, thank you.
Keith (01:06:58.582)
Yeah.
Dr Jordan Vollrath (01:07:20.11)
versus saying, okay, well, you got to go on the 12 month wait list or you got to get sent two hours up the road to talk to the specialist or you have to pay out of pocket to see the person privately for X, Y and Z. So it was kind of interesting that, you know, just sort of how could we shift the culture in medicine to be a little more gutsy, I guess.
Keith (01:07:44.77)
I think it would be hard to do these days to be realistic. I mean, you could have initiatives like that. Even if they were successful, like I say, the doctors are going to be under the pressure to differentiate when they get out, not from the medical system, but from the social system and from themselves as well. know, so I think it would be.
Dr Jordan Vollrath (01:08:07.832)
Yeah.
Keith (01:08:14.454)
fun to try to teach that, but not necessarily going to be revolutionary.
Dr Jordan Vollrath (01:08:26.798)
Well, it's definitely, don't know, I'm just thinking back to my time doing rural medicine as well. And those things where you're a little more outside your comfort zone, were definitely more fun, more engaging. I'm thinking, you're learning something new kind of as you're going, right? It's a little bit outside of just that constant routine. And that definitely makes it a little bit more, I guess if you are of that thrill seeking type of person managing that.
Keith (01:08:27.362)
So, that the intro right there.
Dr Jordan Vollrath (01:08:53.72)
Fracture or that case that you're not totally familiar with it just seems a little more foreign and a little more novel
Keith (01:09:00.428)
Yeah. Well, I don't think everybody should be like this. mean, I don't think I was a thrill seeker, but I was maybe politically I was a disruptor, think. But, but medically, I don't think I harmed anyone and I wasn't doing it for thrill. You know, one thing I was just thinking that helped my anxiety a lot.
I mean, I still use it all the time, just continuity of care. so because I could use a simple example, like say there's a two year old in your office and it's nine o'clock at night or whatever. And the kid has a fever and it just looks kind of runny nose and it looks miserable.
And you examine the kid and you know the ears are okay and the lungs are fine and there's no rash and there's nothing looks like a virus. And so the easy thing to do and I've done it innumerable times is to just say well I'm going to prescribe you some Amoxyl just in case that you give some antibiotics and then you can go home and say you know so you don't have to worry about it.
But of course, the medically appropriate thing is not to give the antibiotics and just say, come back if the kid gets sick or whatever. But there, if you work in a team, you're conscious that if they come back, you have failed to recognize the pneumonia or whatever it was. And so because I had continuity of care,
I could say to the mother or the parent, know, tomorrow I'll be here and the day after tomorrow I'll be there. just get in touch with me if you're worried and things aren't getting better. So I had, by providing access, it lowered my anxiety. Yes, I was providing access. I was squeezing a patient in.
Keith (01:11:21.804)
but it was worth it in my schedule to squeeze a patient in if it made me less anxious. Now that was one thing. And the other thing is that the other thing was the natural history of disease. Now here I sound like an old fart, but disease evolves over time. And most diseases, I mean, there are very few diseases that you actually have to be instantly fix it.
Dr Jordan Vollrath (01:11:29.671)
Yeah, yeah.
Keith (01:11:51.882)
You know, you have a shoulder dystocia, you have to do something right then and there. Meningococcinia kills like nothing else. it just like you have to do something right then and there. But most of the stuff we see evolves over time. So a back pain evolves over time, a cough. So instead of feeling the pressure,
and the anxiety to get it all right in this 10 or 20 minute visit and then sort of overcompensating with tests or referring to specialists and so on. I knew that this disease can evolve over time so let's just see what happens over time and that would make me a lot less anxious as well. So hypertension, like hypertension people come in they're having home blood pressure monitors which are good in a certain way.
or going to the pharmacy and having their blood pressure, then they're rushing in because their blood pressure is 170 over 90. I mean, I still do stress tests and we're actually looking for a rise in blood pressure with exercise. It's abnormal if it doesn't go up. But hypertension plays out over 10 or 15 years for end-organ damage. people can, mean, athletes have probably blood pressures of 300 over 150 when they're at their
peak exercise level. So, and here we are, you know, trying to sort out, should I give them an ACE inhibitor or calcium channel blocker or whatever, and, know, okay, so you could also just say, well, why don't you, you know, take it easy for a little while and then come back and we'll see how it evolves over a little time or I can order a 24-hour blood pressure monitor and we'll see if it normalizes at night. There's no rush to put you on.
anything right now. So natural history of disease has also been an anxiety reducer for me.
Dr Jordan Vollrath (01:14:02.582)
It's just that access. That's where things start to fall short though. Is the patient able to get in and see you again when we're in the midst of the shortage? And probably part of the thing that's compounding the anxiety on behalf of the doctors is they're like, well, I kind of feel this time crunch. I got to sort this out now. Otherwise my next available appointment's not for six weeks.
Keith (01:14:15.842)
Yeah.
Keith (01:14:25.612)
But you have to be able to squeeze people in. I mean, I do see, have 1500 patients in my practice. I think most of them consider that they have good access, but they want to see me. And that allows it. still, you know, go away for holidays or there's somebody else covering for me who does the same sort of thing. So instead of, you just sort of assume.
that you're going to see whatever it is, 15 patients in a day, and then you have slots. And if they do come in, that's great, you get paid for it. If they don't come in, that's great, you can do whatever else you need to do or go on your smartphone or whatever. I don't, with 1500 patients, granted I know them well, but they're actually quite heavy, many of them in an internal medicine way, because I...
kept charge of them, but I can see them all in two or three days and do minor surgery too. So, and you know, in two or three days, like totally overpaid, like make more money than I ever did. And they keep throwing money at me for primary care for doing less and less and less. And I just don't see access to care.
Yeah, it's a nuisance to have a squeeze in, but it actually reduces your anxiety about things.
Keith (01:16:03.554)
So, I don't know where you're at.
Dr Jordan Vollrath (01:16:04.318)
I fully agree. No, I think you're definitely hitting the nail on the head.
Dr Jordan Vollrath (01:32:57.502)
I wish we had more time to continue chatting, but Dr. Keith MacLellan I appreciate so much you taking this opportunity to share with me a little bit about the SRPC, a little bit about your time consulting with NASA and just sort of your perspective on how things have shifted over the decades. It really is refreshing to get a little more of that perspective and the wisdom forged in time. So I do thank you so much for taking the opportunity today.
Keith (01:33:24.786)
anytime. It's been fun too. And good luck on all this. What you're doing is important. It's just to keep ideas going and communication. think we need more and more of that.
Dr Jordan Vollrath (01:33:37.24)
Thank you, I appreciate that.
Keith (01:33:37.981)
Thanks.
About the Author
Cherry Health
Canada's Medical Network
About the Author
Cherry Health
Canada's Medical Network
About the Author
Cherry Health
Canada's Medical Network
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