The Insider Breakdown on Alberta Health's Latest Proposal with Dr. Samantha Myhr & Dr. Jon Hilner

About the Episode

In recent years, the healthcare landscape in Alberta has been marked by controversy and uncertainty. Family doctors have been at the forefront of these challenges, advocating for better support and resources to provide quality care to their patients. However, the recent announcements and developments in the healthcare system have left many family doctors feeling disappointed and unheard.

Dr. Samantha Myhr & Dr. Jon Hilner, two family doctors who have been actively involved in advocating for change in the healthcare system. We will explore their insights and analysis on the Maps report, the implementation of team-based care, and the proposed Locum Funding Program (LFP). By examining these themes, we can gain a deeper understanding of the current state of family medicine in Alberta and the potential impact of these developments.

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Objectives and Discussions

• Recent healthcare announcements do not address the needs of family doctors in Alberta.
• The Longitudinal Family Practice (LFP) model is a more effective and sustainable payment model for family doctors.
• Team-based care is essential but not adequately supported in the current system.
• Lack of transparency and accountability in the healthcare system hinders meaningful change.
• Advocating for change at the community level is crucial for improving healthcare.

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More Resources:

LinkedIn: https://cherryhealth.co/linkedin

Facebook: https://www.facebook.com/cherryhealthinc/

Instagram: @cherry.health

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 1]:  Dr. Jon Hilner

[Speaker 2]:  Dr. Samantha Myhr

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Jordan Vollrath (00:01.693)
All right, today we are joined by two incredible family physicians and health care advocates. Dr. Samantha Myhr is a rural generalist who spent the first four years of her career managing a busy full scope practice in Pinscher Creek, Alberta. Since 2022, she's been working as a locum and sundry and was the president of the section of rural medicine at the Alberta Medical Association for the past three years.

Samantha has fought to improve rural healthcare through numerous primary care tables and initiatives, including serving on the Executive Oversight Committee for MAPS, we'll chat about that a little bit, and co-authoring the proposal for a new payment model for family doctors here in Alberta. And Dr. Jon Hilner is a family doctor working in a team-based community clinic established in 1966 that provides primary care to about 20,000 people in St. Alberta.

He's been a vocal advocate for family doctors as the sole representative of the section of family medicine executive at the MAPS strategic advisory panel. Jon recently resigned as president of the section of family medicine at the AMA in October. So thanks for joining us. It should be a good conversation. We've got a lot to cover. I know there's been a lot of controversy, a lot of announcements coming out recently in the media and things here in healthcare are getting spicy and I would love to get that insider scoop just.

what you guys have been experiencing behind the scenes and what your thoughts are.

Sam Myhr (01:24.47)
Thanks Jordan. It's great to be here. Um, I don't know how spicy they are, but I like to see a bit more spice, maybe. I think, uh, you know, the recent announcements were, um, disappointing from our standpoint, having been involved heavily in maps and, and having it tied, you know, to the agreement as really something that's going to change the game for family doctors. I don't think that anybody watching that press announcement would have.

Jordan Vollrath (01:27.424)
Yeah.

Sam Myhr (01:54.31)
would have seen that as a sign of hope that things are really going to change for us.

Jordan Vollrath (01:59.101)
Jon initial thoughts.

Jon Hilner (02:00.623)
Yeah, thanks for having us Jordan. You know, it's been, it's been tough. You know, MAPS itself was a very isolating process. You know, it was, it was locked behind non-disclosure agreements and wrapped up at the end of March, six months of hard work and many hours. And then there was this, this pause, right, as a result of the political change in the election. And, and finally we're, we're hearing about, or getting the report and starting to...

to be able to see behind some of what happened at the process. But I agree with Sam. You know, this has been a long wait for not much. And that's not for lack of trying. You know, as you mentioned, we've put together proposals and ideas to try to give government or equip government with what they need to help support family medicine in Alberta. And that announcement just didn't capture that at all.

Jordan Vollrath (02:54.441)
But I mean, what else do you do right from the inside of medicine other than advocate and work with and then it, you know, at some point becomes out of our hands. And then at that point, the advocacy just needs to get louder.

Sam Myhr (03:07.25)
Yeah, exactly. And I think that's a thank you for having a podcast like this where people can come in and speak publicly, right? Because I think that's, that's where we're at is we, we did a lot of the behind closed doors stuff, we're in all sorts of rooms and all sorts of initiatives through the AMA outside of it, right? Income equity, uh, PCN reform, uh, funding tables, MAPS was a huge project. As, uh, Jon alluded to, you know, we, we do work with compensation.

Jon Hilner (03:07.539)
Yep.

Sam Myhr (03:37.382)
in the AMA and I guess we just realized that none of those things that were promised as, you know, going to change things tangibly for those on the ground are actually going to do that. And so, you know, it's we actually, I think during maps we had the thought of should we be writing an parallel report of things we actually need and putting that out, right, and, you know, didn't know what kind of traction that would get and...

And in the end just decided to ask for what we needed with the LFP and the stabilization plan, like you mentioned.

Jordan Vollrath (04:10.621)
Yeah, and so I'd love to chat about the LFP as well. That seems, sounds like it's sort of the, you know, more realistic picture of what's needed and, you know, your work on that I'm sure will actually be incredibly valuable. So we'll chat on all these. Let's start with the maps report then. So recently this just came out. I mean, the top line announcement there was the task force in conjunction with the AMA in terms of primary care. What are your thoughts there? Let's break that down a little bit. Like,

time delay and lip service or valuable group with lots of good things to add to the equation.

Jon Hilner (04:47.487)
I'll say I was confused. You know, I mean, MAPS was itself a task force, right? It was a task force in a few parts. And I will say, you know, as part of the announcement, I was encouraged to hear what sound like tangible commitments coming out of the Indigenous panel. It sounds like there is some meaningful change that potentially could happen to help represent a population that really do need support and where the health system is really not keeping up.

from my perspective, having been at the strategic advisory panel, we've seen task forces come and go. We tried to draw on the task forces that have come in the past from 2014, 2016. And it just seems like the interval between task forces is getting shorter, but we're not seeing any action come as a result. And so I would say, you know, while I hope that this time, you know, maybe we'll see a difference that's tangible, it's hard to believe in it.

And it does seem like it's just going to delay what we really need.

Jordan Vollrath (05:47.737)
What's the intent of the new task force? Like there is, they have to have some clear vision for what they think this will do that would be differently. What was the intent on the side of pushing this out?

Sam Myhr (05:47.819)
Yeah.

Sam Myhr (06:01.854)
I mean, the stated intent is to go through the LFP model that Jon and I had put forward and a stabilization plan and then work on things like administrative burden that we know are plaguing, you know, all physicians, but particularly family physicians. And so, you know, whether it amounts to...

to tangible outcomes is another story, right? Because my feeling is, is if you wanted to do that collaborative work, we could have. We put something in front of the minister, we talked to the premier, we've run the AMA board through this, we've been through the MAPS process, we've had conversations with the minister of health about the MAPS process too, and given feedback on that and to bureaucrats as well. And so.

what is the task force going to do differently than not keeping those people out of the room or isolated behind NDAs in the first place. Like we could have been there already. And so it does feel like it's a delay in many respects, right? It kind of takes you out of the budget cycle for this year.

Jordan Vollrath (07:12.634)
Mm, okay. I was trying to play. Yeah.

Sam Myhr (07:13.662)
We were working really hard to get this stuff in the summer, right? So that they had time to analyze it ahead of the budget process, which usually wraps up, you know, in November, December.

Jordan Vollrath (07:26.237)
Mm-hmm. We're trying to play devil's advocate here. Is there any tangible valid reason that a new task force would bring something to the table that couldn't have been accomplished already with all the minds and brains around the table?

Jon Hilner (07:43.608)
I'm trying Jordan. I mean, so yeah.

Jordan Vollrath (07:43.617)
Hehehe

Sam Myhr (07:46.226)
I mean, we've asked ourselves that a lot, right? The fact is we're not even involved in this task force, right, as the people who put all this work together and got in front of government, which is, so to me that looks like a step backwards in the first place. You're not starting with the people that know it through and through, so.

Jordan Vollrath (07:49.237)
Yeah.

Jordan Vollrath (08:01.19)
Damn.

Jordan Vollrath (08:04.529)
Okay.

Jon Hilner (08:04.551)
Yeah, I think that's what I feel is, you know, it's a lost ground in a way, right? Because you've got people who have the context of going through discussions, and MAPS included allied healthcare workers, patients and public, right, experts in different areas. And going through that process and having the opportunity to hear those different perspectives and try to incorporate them into something that's going to be meaningful and make a difference, which is what we did.

And then hearing that there's going to be another task force set up that essentially rolls things back for people who weren't involved, right? Who who have the context only of a three hundred and seventy seven page report that doesn't, you know, doesn't necessarily capture the discussions and the thought processes that went into developing it. You are inevitably going to slide back a bit. It's like, why, why reinvent the wheel and redo the work when you've already got something in front of you that

you can use that's meaningful and people who understand where it came from.

Jordan Vollrath (09:04.757)
So in terms of the things that they have put forward that are tangible then, so the announcement of the $57 million over three years to provide family doctors and nurse practitioners with supports to help manage costs. What are your thoughts on that?

Sam Myhr (09:21.086)
I mean, the immediate thought is that government saved $204 million, according to the information that we had access to in 2021 alone, off the backs of family docs because of cuts, right? And largely because of virtual code inadequacy.

Um, and that was at a time that we know that doctors were providing more services for that much less money. And so that's one year, 204 million versus 57 million that you're giving over three years and spread, you know, very thin to, right. It's 10,000 up to 10,000 per provider. And it comes, it sounds like with strings attached, right? Like with the requirement of more access and

Jordan Vollrath (10:02.663)
Mm-hmm.

Sam Myhr (10:08.81)
more attachment at a time that we've been telling government and anybody who will listen that the docs are stretched, right, they're tired, they can't do more. And so you've asked them to take less and do more at the same time. It's just, yeah, so it's a bit demoralizing, I think, for people. It's disappointing because we said, you know, it's almost better to announce nothing than to announce something piddly because that shows a lack of understanding of the problem.

Jordan Vollrath (10:37.867)
Mhm.

Sam Myhr (10:37.886)
and the magnitude of it. And it's also not congruent at all with what we proposed.

Jordan Vollrath (10:44.269)
Who was that to satisfy then? Is that like a big shiny number that looks good to a patient or member of the public when they see it in the newspaper, but anyone on the inside of the healthcare system sees it as a drop in the bucket?

Jon Hilner (10:58.287)
Yeah, I think I mean, I've had this experience with my patients coming in to see me who are who are excited on my behalf, right? Saying, you know, it's great to hear that there's a primary care announcement that they're finally investing money in family docs. And maybe this will keep you around, right? And keep the keep your clinic running as must be working and and, you know, taking the time to explain that that, you know, as somebody who has a full patient panel that I've built up over 12 years, my ability to take on people at this stage, especially with the increased

Jordan Vollrath (11:13.281)
So it's working.

Jon Hilner (11:28.179)
challenges our patients are facing. The complexity of both their health and social situations have become much more difficult. And so the care that we're providing is becoming more complicated. The same panel now that I had years ago, it takes more time to look after because of the administrative burdens and the care burden. And so I don't have the ability to take on patients. Our clinic is getting many, many calls a day asking for patients to...

to be signed up and we just don't have the space. And so knowing that none of the announced funds are going to support what we do, and then hearing in conjunction with this that family medicine is in crisis and that we are the cornerstone or the foundation of the healthcare system, it's incongruent and it feels like gaslighting. It feels very difficult to keep putting in the effort when you know the support's not coming.

Sam Myhr (12:26.422)
And I think it's hard Jordan, because we know what we asked for too, right? We set it to the Premier and to the Minister of Health. We asked for the tune of 250 million, right? 246 to be exact, and that was based off of getting meaningful dollars to people who are currently looking after a panel of patients in Alberta, because that's the longitudinal family medicine that we need to support that

Jordan Vollrath (12:30.442)
Mm-hmm.

Sam Myhr (12:55.998)
you know, and you know this well, but, you know, for the listeners, it's cost saving to the system to invest in that area. And it's also, it saves lives, right? Save from a morbidity standpoint, mortality keeps people healthy for longer. It's what we're calling the foundation, but it's not what we're supporting. And so we had a way to get money that actually tangibly does something, right? It would be the tune of one staff person, potentially per

per doc, right? And that's what it was based on, at least, the number. And it would go exactly where we needed to go. And we can track that, right? So that's the accountability piece for government. And they said, you need to make this kind of investment in order to retain what you have and not make the problem worse. And that's what we're trying to do with that funding while we get something like the LFP going.

Jordan Vollrath (13:48.413)
It doesn't sound like they're interested in going that way, I guess. I mean, I don't know. Oil's doing all right now. You'd think that there would be like a little bit more, uh, deep pockets on the side of the government, but still a lot of reluctance to just kind of go for the what's, what's the lowest possible number.

Jon Hilner (14:08.999)
Yeah, and I think, I mean, go ahead, Sam.

Sam Myhr (14:09.346)
Yeah. And why would you, yeah, sorry. Go ahead. I was just going to say, I don't understand that either. Like I don't understand the, like, why would you invest so little in, in what is already such a big budget item, right? Because it matters to so many people. So why not invest in the places that it's going to save you down the line?

Jordan Vollrath (14:30.045)
Well, on the other hand, then, you hear some people make the argument that Alberta physicians are one of the highest paid across the whole country. What's the actual reality of the situation?

Jon Hilner (14:42.355)
So I think from the perspective of government, when you look at this, every year we have physicians graduating. So in appearance and in terms of licensing, the number of doctors that are registered looks like it goes up every year. We have an expensive system, right? And it looks more expensive when you think about it as we're pouring money into family medicine and we're not seeing a difference. But I think the nuance of it is looking at how many

family doctors are actually providing that cradle to grave long-term relationship support with their patients. And that number is decreasing every year because the incentive structures that exist currently push us into more of a selective or niche practice, right, to focus on certain aspects of care because that's maybe more manageable and much better supported often. And so, yeah, better paid, right? So from a government perspective, you know, that this...

Sam Myhr (15:33.414)
And better paid.

Jordan Vollrath (15:37.854)
Guilty of this myself, yes.

Sam Myhr (15:40.349)
Hehehe

Jon Hilner (15:40.787)
So there's not a congruence, right? And so I can understand some reluctance in putting money into the system, which is why with the model that we built, we tried to be very intentional with how that funding was going to be applied, that it would go to the places that matter. And so I think, you know, we hear often that we're, no, yeah, totally.

Jordan Vollrath (15:56.042)
Hehehe

Sam Myhr (15:58.302)
Not that you don't matter, Jordan. But you know, you know what we're saying though, like to go to the place that they say that they need to invest in, but haven't been.

Jon Hilner (16:06.843)
Yes. Yeah. And so I think the piece that, you know, we keep hearing about being paid better in Alberta, but the reality is, you know, compared to other provinces, we've had a very slow investment over time. And we're now seeing in Canada, a context of other provinces meaningfully investing like in BC and Nova Scotia and Manitoba in primary care and recognizing that when you do that, as Sam mentioned, you hold the whole system up.

Jordan Vollrath (16:36.889)
What about the dollars and the plan for implementing nurse practitioners to have more of a role? The team-based care seems to be the common ground that everyone can get behind currently. What's your stance on that and how the MAPS committee actually thought they would help implement this?

Jon Hilner (16:41.877)
Thanks for watching!

Sam Myhr (16:56.422)
I find this part of the conversation so frustrating because we keep hearing that team-based care is the solution, yet we practice in teams and we have been for years, right? And that's what's not recognized and supported is that we do it off our own backs, right? It comes out of our bottom line and that is what makes it.

less viable to be a comprehensive longitudinal family physician compared to somebody who doesn't need a huge team to support their patient panel, right? Like, especially in rural, right? Like, if I'm in eMERGE, I need to be able to trust that my team is functioning and taking care of people while I'm away. And, you know, I've worked in practices where we're spending 50% of our clinic take-home pay and overhead because

it matters to have that team to look after the patients so that we can do all of it. For the clinic building rate, and so some of that is offset by the time in the hospital because again, our incentive structures align such that you get paid better to work in AHS or in the hospital system than you do outside of it. Whereas that's where the majority of the care happens. So it's like, it's not that we suddenly need teams and physicians need to figure out how to integrate them. It's like,

Jordan Vollrath (17:47.799)
You're at 50%

Sam Myhr (18:11.71)
we actually just need support for the teams we have for starters, right? And then also for interacting with them. Like it's, you don't get paid to do the leadership piece within your clinics, right? To do the training, to make sure things are running smoothly or to help people work to the top of their scope. And then when they do, it actually pulls money away from the physician earnings, just the way their system's set up. So it's, uh, you know, I find that very frustrating. And

And that really wasn't addressed at maps either or any of these other places. But go ahead, Jon, you look like you had stuff to say.

Jon Hilner (18:49.367)
Oh, yeah, I was gonna say, like, I mean, for my part, I'm really proud of the team we have. So, you know, our group of physicians, there's 13 of us, but we work alongside nurses. We have an in-house pharmacist. We have mental health nurses who really do make sure that people are well looked after, right, and provide that full support for the people that come through our door. And the rest of our team, you know, we have this sense of the traditional...

quote unquote, doctor receptionist who greets you at the door and brings you in. But their role is so much bigger, right? They've they often take on additional roles and try to help with screening counseling and things like that. So our team has grown and evolved both in number and in scope ability over time. And that's taken an investment of time and attention.

Sam Myhr (19:34.14)
Mm-hmm.

Jon Hilner (19:38.751)
from physicians and from the team members to do that, because we value it and we think it matters, right? We see it as something that we can provide to people that will change their lives, give them the opportunity to live healthier. And so I'm proud of what we do. And so hearing that it's important as if it didn't exist before is challenging, because it's something we've been doing for many years. And knowing that it isn't fundamentally supported in our system.

Sam Myhr (19:54.306)
Thank you.

Jon Hilner (20:07.051)
again while being held up as an important future aspect, makes it difficult to buy into that this is somehow going to solve the problem. The investment needs to happen in family doctors and in care of patients at that level.

Sam Myhr (20:23.178)
And to answer your question on the NP piece, and the focus on that, it's more about the way that they're doing it. And it doesn't address what Jon or I just explained. It's new structures. It's siloing or fragmenting the system more, instead of finding ways to better incorporate MPs into existing clinics to allow them to expand.

Jon Hilner (20:34.943)
Thanks for watching!

Sam Myhr (20:46.462)
on what they already have and have a more integrated system. Like I work with an NP, I work with two physician assistants, you know, and a handful of docs and a really great extended team. But, you know, that you learn from each other. You learn from each other, you have that ability to consult in real time and to grow your skills to the top of your scope when you're physically located in the same space or you have those, you know, those tight networks of...

collaboration communication. The way that it's been done feels adversarial, right? Like setting it up as a competition of resources. We can do what you can do or you know, it's the, there's no difference in the training, which isn't true, right? But, but people working to their scope and working supported can do much more than, than they could alone. And that's true for physicians as well.

And so I just think, you know, we're going about it the wrong way. And it's kind of making it a butt heads and a confusing situation. And one that might actually be not so great for nurse practitioners in the end either, right? Cause nobody works alone. So.

Jordan Vollrath (21:54.025)
So maybe this is a great time to sort of pivot away from the maps and chat about how your clinics are structured. Because as I understand you, and you're both in that blended capitation model with a very comprehensive team-based care structure to it. I don't know who wants to start there, but what does that look like in practice when it's implemented successfully and usefully to the patient and the care team?

Jon Hilner (22:21.203)
So I mean, I think there's a few things with blended capitation that are fundamental to understand. So one is that the model itself is still a physician payment model, right? So it doesn't include any support for administrative time. It doesn't support teams in terms of extra financial supports, but it does give you some flexibility in how you deliver your care because essentially what blended capitation does is it says,

you know, for the care of one person, you're going to be provided with X amount of dollars for the year, and you need to use that funding to support them in the way that you see fit. And so what it means for people coming into the clinic is that if they need to see the mental health nurse, they don't have to abide by the whites of the eyes rule of seeing a doctor first before they can access that service. They can come in and see that nurse. They can come in and see the pharmacist to talk about their medication issues.

And that's all wrapped up in that same sort of bundle of funding for the patient. But it does mean that you have, as a clinic, you take on more of the administrative responsibilities. And where blended cap has been challenging is, you know, in Alberta blended cap's been around since about 2017. Many of the issues that existed in 2017 still exist today. And we're now looking at it like we've got.

We've got a working group again, another task force, a working group looking at blended capitation. But for the past few years, I'd helped establish a community of practice. So throughout the province, we've been talking between the different blended capitation clinics so that we don't have to reinvent the wheel. We don't have to resolve the same problems. And so that we can highlight the areas that have been an issue. And so it's not new news, right? This is something that's been around for a long time. So it does present its opportunities, but it has substantial challenges. And one-

biggest ones is that if our patients go anywhere else for care, then some of that funding gets removed from the clinic. Oh, did I freeze? Oh no. Okay. Well, it was passionate.

Jordan Vollrath (24:16.125)
Okay, we might have to edit that part. Get it to, get them to. Oh yeah, sorry, we lost the last like 20, 30 seconds.

Sam Myhr (24:26.834)
I'm sure your rant was beautiful though.

Jordan Vollrath (24:31.613)
Right after, for the since 2017, the same problems have existed and then we dropped off.

Jon Hilner (24:36.747)
Sure, sounds good. I'll paraphrase a little. So the challenge with blended capitation is since 2017 the same problems have existed, right? And we're now looking at how to address those issues again and we have a group working on that. But we've highlighted them already. We have a community of practice across the province where all the clinics communicate on a monthly basis and talk about.

innovations, ways that we've found to make the model work better, as well as challenges. And so those challenges are well known, but they're again, like everything else in the system, it's very slow to address them. And so with blended cavitation, you do get some opportunity, but you also take on a fair bit of liability. And Sam, I'll let you speak to some of that as well.

Sam Myhr (25:26.77)
Yeah, I mean, I think the most challenging piece for people with blended cap is the external negation, right? So then the idea is that you are able with the way you're funded to look after patients so well that they don't have to go anywhere else, right? And so if they go somewhere else, that funding is pulled from your clinic to pay, you know, the person that they do see, so walk-in clinic or even if they go to emerge in most cases, right, in smaller communities in particular.

if it's being billed by a family doctor. And so there's times where you've done even appropriate referrals, and because they're seeing a GP with a specialization, on the other end of that referral, you lose huge amounts of money for your clinic. And it doesn't go below zero, right? But then essentially that patient's funding has been reallocated inappropriately, and that's something that we know have...

has gone on over and over again for years, and that's been brought to attention and nothing's been done about it. And so of course that really doesn't sell the model very well if you don't know why you're getting money taken away and you can't really predict that. And no matter how well you do, right, or appropriately you look after a patient, it's gonna be happening anyway. And then there's no voice on the other side really like listening to you and dealing with the problem.

while they're saying that they want to support ARPs. So blended models of payment are fantastic. I think we know from a lot of global research that it's the preferred method of combining efficiency and the ability to deliver care in different ways and have that predictability of funding for the government side and the provider side. But the blended capitation model as it's been

implemented here has problems and we actually have learned from those in the way that we designed the LFP, right? We took those as lessons learned and how can we make it better and therefore also make it more accessible to more family physicians to join because it's been very slow, right, to onboard to PCM.

Jon Hilner (27:44.343)
And I think, I think to expand on that, um, the LFP model comes largely or in large part from some of the work that's been done in BC to simplify blended payment models, right? To say, you know, we, we recognize that a component of your, the, the care you're providing to patients is time-based. Another component is service-based and we're going to blend those two things together in a way that's easy to access.

Sam Myhr (27:53.161)
Yeah.

Jon Hilner (28:09.423)
and that captures the full amount of time that you're spending to look after people, which is kind of what blended capitation and it's hardest trying to do in a very complicated way. Right, from the outside, it's kind of a mystery, and from the inside, there's still enough of a black box that a lot of the time, you're not really sure how things are being processed for you. So.

Sam Myhr (28:18.839)
Mm-hmm.

Jordan Vollrath (28:28.661)
And how does that integrate with that team-based care model? Like I saw one physician on one of the Facebook groups, his phrasing was, I don't need to be babysitting a pharmacist or a nurse. He just wants to be remunerated appropriately for everything he's doing and be more supported in his own work. How do you actually set up that team-based care model and how does that fit in with that blended capitation payment structure?

Sam Myhr (28:58.51)
Go ahead, you've done this better than anyone that I know. So.

Jon Hilner (28:58.547)
Sam, do you want to talk to that? Okay, fair enough. So it does take a lot of willingness to go through a change, right? And our clinic went through this to try and keep what we had actually. So we already had integrated mental health nurses, we had integrated pharmacists, right? That didn't change under blended capitation. What did change was our ability to allow them to grow in their roles. And so...

Um, you know, what we recognize is that if somebody comes into our clinic and, and there's somebody else there who's more able to look after the problem that they're coming with, um, you know, from a mental health perspective, they might need the, the attention and time screening of a mental health nurse and the supports that they can connect them to in the communities. And our mental health nurses are going to do a much better job at that than I would. Um, and so the, they can access that service right away, instead of having to wait for an appointment with me, which is taking longer to get.

as our system demands increase, and then wait again to see the person that they need to see. And so I think from an efficiency point of view, it can be really helpful. There's a cost to that though, right? And that's the piece that still hasn't changed in blended capitation. So although you are supported or funded better in many ways, you lose out on some of the things that you otherwise would be paid for, as Sam said. And in many ways, it feels like

you are the one town with a sheriff in the Wild West, right? Like you have responsibilities, you have accountabilities, but those don't exist elsewhere. And as a result, you end up essentially paying the cost for the system, even when you're trying to use it effectively.

Jordan Vollrath (30:45.237)
So the two key pieces there, like it's direct to the allied health provider that saves time and system inefficiency from you being the gatekeeper. And then what is the actual family physician's role at that point? They see them, are you now the consultant role if they need you to weigh in on something? But like you were saying, if they see the mental health nurse who's gonna do a better job than arguably the doctor would because they've been trained.

to do that stuff for years versus months, what is that fallback or that liability piece that you're accepting?

Jon Hilner (31:21.211)
Yeah, so I think, I mean, the key to that is communication, right? So our mental health nurses will communicate what they discuss with the patient. They'll let us know what the plan is. So we're still responsible and accountable to care for that patient, medical, legally. And if there's a component that falls into our side, so where, you know, we're prescribing medications and supervising the treatment and care of the patient, then they will let us know that.

that this is somebody who they feel would benefit from that or might, and then we have that discussion. And so in that way, the person who's being cared for has both sides, right? Their community supports are set up by the mental health nurse. They have the self-care and, as our nurses call it, the behavioral health side of things where they're equipped to help themselves. And then our physician side of it is if there's a medication component or.

treatment that they need to access in the system, referrals or otherwise or treatment in-house, then we take care of that piece. So it really, I mean, that is the nature of the team, right? It's literally a whole group of people looking after you for all of your needs.

Jordan Vollrath (32:33.777)
What about on the pharmacist side of things? How much can they effectively do without needing to have the doctor as a gateway or just a roadblock to them actually getting that higher level of care from the specialist?

Sam Myhr (32:49.074)
I think a lot of it is actually the stuff that you don't really see otherwise, right? Or that you wouldn't get the communication on. Like the pharmacist is great for doing like med reconciliations or doing all that counseling around the medications that people are using or picking up on things that like when the patient's coming in to see them, they might ask a question that triggers a pharmacist to say, oh, this is something you need to talk to your doctor about.

But then if they're in communication with the doctor, right? And you've set up those pathways or you're charting in the same system, you can do that in real time. So it's not so much, like again, the sort of overall conversation around incorporating pharmacists more in the system in Alberta has again been a siloed thing, right? Pharmacy-led clinics and like expanded prescribing and whatnot. And like that's not necessarily, that's not a bad thing in and of itself. But if it's...

fragmenting the system more it is. So these integrated pharmacists are like a huge benefit for the team, right? Cause they do have extremely high knowledge of medications that we don't get the same training in. And so they're a useful resource in that respect, but they also pick up on a lot of things that patients just say offhand or whatever, and then they can say, oh, you need to go right now and talk, or I'm just gonna pick up the phone and call your doctor. It's those connection pieces, I think that.

Majority of the systems missing and blended cap does help you to create more of. Um, but all these other fragmented solutions really don't. It gets us further from the goal.

Jon Hilner (34:25.619)
Yeah, I think where we see the beauty in that, especially as you know, Jordan, our hospital system is heavily burdened as well, right? And our emergency system. And so when our patients show up in the emergency or they get admitted to hospital and they get discharged and there's been changes to their medications and changes to their care, we have a system set up in our clinic that monitor for that. And so when they're discharged, our nurses will reach out to the patient and make sure they're doing okay.

and that they have the supports in their home, and that if they need an appointment with the doctor, that gets set up. And our pharmacists will reach out to them and find out if they have questions about their medications and we'll go through, you know, how their medications are prescribed, make sure they have enough to get them through to the doctor's appointment if they're waiting for it. And so there's that safety net, right? And you kind of, you're not just, you know, dropped from the hospital or discharged from the hospital into the community and waiting or feeling unsupported, you've got a support system.

And I think, you know, when, when we look at Alberta and the fact that there's 80,000 plus, sorry, 800,000 plus patients who don't have family doctors, who don't have a connection to, to any form of that support, um, you know, that that's the piece that's missing. Um, and that's again, what we're trying to, we're trying to say needs to be supported and, and paid for in the system, cause it, it saves more than money, it saves lives.

Jordan Vollrath (35:48.433)
And so that blended cap model, it does allow you to have that sort of leadership and administerial role while still not impacting the bottom.

Sam Myhr (36:00.33)
Well, I mean, yes and no, because you're still not getting, like you're providing the service, but like you still don't get any extra for it and you're still paying for the staff in many cases, most cases, right? And so that's why I think Jon was alluding to, it's still not a team-based model. It's a physician remuneration model, and then you're just able to do some more with it, but with that comes a huge administrative burden to figure all the complex pieces out.

Jon Hilner (36:11.775)
Mm-hmm.

Sam Myhr (36:27.402)
which is why the LFP is so nice. And we kind of saw what BC was doing. We're like, oh, we need to customize that to Alberta. And because in many ways we're better set up to incorporate it here. Like we have a lot of advancements in terms of tracking like who patients are attached to and things like that makes it easy to implement something like this. Certainly much more simply than expanding BCM.

Jordan Vollrath (36:53.469)
Now you mentioned you're paying a 50% overhead at your clinic, is that correct? That sounds foreign.

Sam Myhr (36:59.838)
So in, so that was in Pinscher, we did, you know, the clinic, on clinic billings, it was that much. We had a huge team, right? And again, it was just recognizing the importance of that for patients. And so we were doing that on fee for service. And so blended cap helped buffer that a bit, because we made a transition there too. But it was still, like it's still.

nowhere near what you can make doing so much less work, right? Less hours, less mental or cognitive load taking, you know, taking on the burden of 24-7 responsibility for a patient panel. Like you can go work a shift, right, as a hospitalist, or, you know, be a screener for a surgeon's clinic or something like that, and then just go home at the end of the day. And if, as long as you keep remunerating those types,

of care more than this longitudinal piece, you're going to get people moving into that type of care instead of the longitudinal piece. And so when Minister Legrange says in question period in the legislature, you know, we actually have whatever she said, a hundred and some new docs coming in, right? Family doctors, like she knows, as we do, as we've had this conversation, that you can't say that those are going into longitudinal family medicine.

Jordan Vollrath (38:03.399)
Mm-hmm.

Sam Myhr (38:25.558)
Right? And so, can't say that it's gonna help get anybody a family doctor. Um, it's, you know, it's a numbers game and I think we just really need to be honest about what is and isn't supported and get down to doing something about it.

Jordan Vollrath (38:42.001)
And so even at that 50% price tag, though I can imagine a lot of doctors seeing that on the job description and then just getting sticker shock and walking away immediately. But they should not be dissuaded by that because the benefits of the team-based model and all that support comes with actually was a like net improvement in just your mental health and your work-life balance. Is that what I was hearing?

Sam Myhr (38:52.749)
Yeah.

Sam Myhr (39:07.774)
Well, I mean, until it was systematically dismantled in the past few years, right? I think that's, that's part of it is that we've been fighting, like we, we had COVID to go through a pandemic, but more importantly, we had cuts at the same time and just an ongoing lack of support. And as Jon alluded to, no real responsiveness to the problems with BCM as well. And so, um, you know, as you can do the right thing on the goodwill, I guess.

great aspect, like in job satisfaction, knowing that you're doing a good job for patients, you're doing important work. But as my colleague Ed Asman, who was the president of the section of rural medicine before me, now in BC, said, the goodwill's gone. And I think that's where family physicians are at, and you can't rely on that anymore. Nobody's gonna pay a 50% overhead.

when they can go and work less hours, spend more time with their family, and take home more in the end. So yeah, I know you're focused on the 50%, because it's crazy, right? It sounds crazy. But that's what people do. People do what they need to do to look after patients. That's why people go into family medicine. And so it's pretty sad. We got so many responses.

Jordan Vollrath (40:17.845)
That sounds wild.

Sam Myhr (40:31.662)
We did a reach out survey in the spring and the answers were heartbreaking. Just people talking about why they can't do it anymore or why they've already moved out of family medicine or why they plan to. And it's like it's alarming how many, it was 53% of the people who responded were going to decrease access in some way in the next three years substantially. So moving provinces, retiring, quitting medicine.

because they don't, they want to find a different career, right, because they don't feel valued, or, you know, commonly going into niche practice. But the stories were the heartbreaking things. There were people like facing bankruptcy or stuck in leases and remortgaging their homes to keep it going, or like being delivering, or sorry, like being immediately post-delivery and going back to work two weeks later with a newborn.

because nobody's there to cover. It's a pretty awful situation, but there's a lot of optimism, I think, in what we could do with something like BC's model, which is why we keep trying to push that, because it really is, I think, a solution to a lot of the issues we're seeing, both at all these tables that we're at, where the work isn't happening and the advancements aren't coming, and just on the ground for hope.

right, that this is gonna be something that we can draw new grads into or we can fill our family men's spots in CARMS matches and keep looking after Albertans.

Jordan Vollrath (42:06.404)
So, Jon, you got a burning thought there.

Jon Hilner (42:09.211)
Oh no, I think Sam hit it on the head with the trainees as well, right? So I mean, we have medical students and residents that come and work with us in our clinics and I mean, they're not oblivious to the conditions we're working in, right? And medical students are trying to make their decisions for their careers. Medical residents in family medicine are trying to decide what kind of a family doctor they want to be.

Jon Hilner (42:37.891)
Sam was mentioning in Pinscher Creek and you see this, the clinic that really does exemplify the team model and is trying to deliver that wraparound care for their patients in a situation where that becomes unsustainable, right? The natural inclination is gonna be to say, I'm getting out of this, I need a job that's gonna have some security and stability and I don't see myself in that position. And

And that's why stabilizing is the first step, right? Like the first piece is to make sure that you can keep what you have and make it something that's viable so that the people that are graduating that are coming out and those who've put their life into it can see themselves continuing to do it or starting.

Jordan Vollrath (43:24.609)
We've seen the downstream impacts of just the situation on the CARMS program and the unprecedented number of family medicine spots that were open a couple of months ago, right? And so we're seeing that. Well, so then you guys have been working on solutionary things to these issues then. So why don't we chat about the LFP that you put together and the stabilization plans. What is needed? What was it? Why don't we start with what was the LFP? What was the goal and the intent?

Jon Hilner (43:38.025)
Hehe.

Jon Hilner (43:56.307)
So I think, you know, reflecting on what it is that keeps us in family medicine and really it's, you know, right now time and attention are really scarce resources and that's what we need to support family doctors doing. That is the goodwill in family medicine. And so the LFP was a way to try and recognize that and support it in cradle to grave care and long-term, longitudinal care for patients.

And so the model had a few parts to it. It was, you know, number one, make sure that you recognize the time doctors spend in caring for their patients, both face-to-face directly and increasingly on the administrative side. And then number two, start to recognize the increasing complexity and the need to fund teams. And so we'd broken it down into a few components that would do that in a meaningful way.

Sam Myhr (44:54.014)
Yeah, and so what that looks like in practice is that there's an hourly rate, a base rate that you get, whether you're seeing patients or providing the indirect care administrative stuff that goes along with that. So, you know, as you know, the charting stuff isn't, or all the referrals and the management of your inbox, right, all the results and investigations and consult letters that are coming.

you know, never-ending cycle that often people are sitting at home at, you know, midnight or on the weekends doing. That's the stuff that the public or the patients don't see. Like, most of that is unremunerated and so it's up to like 30% of what a family physician does is unremunerated and we wonder why it's hard to get people into the job, right? And then you pay 50% overhead on top of that. Yeah.

if you're trying to do it as best you can, right? And so it's being able to get paid an hourly rate for those things and then there's an encounter rate on top of that to recognize the service-based component because sometimes with salary we see not as much, not as much service being provided. That's just a known fact in the literature and that's not just medicine but.

And so it's a blend of those two things. And then, yeah, as Jon said, there's an aspect, like Manitoba's done a fantastic job of breaking down panel complexity. So we did borrow a lot of that, right? And that sets you up for actually knowing, you know, if you have a lot of people with depression, anxiety, which is very common these days, especially after COVID and isolation and things like that, you know, you can get money.

for the patients that you're looking after for those reasons appropriately. And then you know that you could fund more mental health with supports for that, right? Or you are more appropriately compensated for all the extra time it takes to talk through the problems that they're facing. So that's that complexity piece. And it really is exactly based on a transparent structure for the problems that your panel has. And so that allows you, if you have a smaller panel but it's very complex.

Sam Myhr (47:05.406)
it allows you to more appropriately be remunerated for that. So you're not just, you know, like you're, I hate to use the word cherry picking, but that is something that the government talks about too, right? Cherry picking easy patients. Not that any patient is easy, especially these days, right, more complex, but there's a tendency, like, what is the incentive to take on somebody who really needs the care? And those are the people who really need the care to keep them out of the hospital system. And then the team-based stuff, right? Like there's a component of it that

Jordan Vollrath (47:17.248)
Mm-hmm.

Sam Myhr (47:35.502)
that just recognizes that you may want to, like for typically now, like PCN funding, right? There's attachment-based funding that goes to the PCN for your panel, right? That you're looking after. Some of that money might come back to your clinic for some team supports, right? But often they're not co-located, right? It's just not as efficient as it could be.

and it doesn't support necessarily exactly what your clinic population or your panel needs. And so we were proposing to take some of that funding and have it be more commission service, right? So if you can get the services you need from your PCN, then you just keep allocating it there. And if not, then you use it towards the team that you do need. And so it's all like it's all together, something that would improve.

your ability to sort of track where your investment is going, because this is obviously only longitudinal family practice that this would go to. Or like you can incorporate MPs in it too. We had a consideration for that or others down the line. But it allows you to track that the money that you're putting in is getting the outcomes that you're looking for in a way that doesn't add to the administrative burden for physicians tracking it themselves. It becomes automated. So it's actually pretty neat in that sense too.

Jordan Vollrath (48:57.409)
Well, it makes total sense, right? Like the incentives need to line up with where the demand is and what we actually see as being highly valuable and what's necessary, right? And so if it's that blended model where you're, you know, accounting for the administrative time, it sounds very much like what BC's changes were recently, where they're actually paying doctors for those administrative hours and the charting and sending consults and dealing with all the labs and inboxes, which makes...

Sam Myhr (49:08.547)
Yeah.

Sam Myhr (49:20.402)
Mm-hmm.

Jordan Vollrath (49:26.817)
total sense, right? Otherwise you will see people drifting off to the, as you say, the cherry picking side of things, right? It's like one patient, one visit. Let's go set up a walk-in clinic next to a university where everybody's disproportionately healthy and young, right? So you gotta make the actual structure behind the scenes align with what's needed in the system.

Sam Myhr (49:48.842)
Yeah, and the other cool thing from your perspective Jordan, I think is like from the locum side of things like BC incorporates locums into their model by allowing them to bill under the LFP clinic and Because there's so much better supported then right because they're able to build out rate and whatnot Like you can offer a competitive overhead arrangements I think with locums like I foresee this like looking at cherry health. You just have a filter

right, to like which clinics are LLP clinics, right, and allow people to preferentially choose those places where they're probably gonna have better team supports and stuff and wraparound services too. It makes your job easier as a locum. Like there's lots, and then of course the team and the panel aspects wouldn't be applicable to the locum. Like that's the benefit of having the clinic structure. But I think you'd be able to attract locum so much easier too on this.

So it's like, there's so many wins to it. When it really was designed with government in mind too, like knowing their budget restrictions and what they need to show and that there's strings attached for the federal funds. So like all those pieces were incorporated to try to bring something that made a lot of sense with evidence-based. And it's just like really sad to see, you know, what comes out for announcements, not really matching the excitement in the room that we were showing with this.

Jordan Vollrath (51:11.017)
Well, and so I guess circling back to the map side of things and the announcements that are actually coming out, the final report, it sounds like it was a bit different than what was actually discussed with the team and what was actually put forward.

Jon Hilner (51:28.115)
So I think it's a challenge, right? Because it is a very big report. And when you have that bigger report, it's difficult to really focus in on what the discussions were at the table, right? And so I think for people looking at this and saying, well, what is the take home?

My recommendation to physicians out there is to read through at least the first two recommendations and figure out what this is likely to mean for your practice and your practice viability. I think the MAPS report in the way that it was released and came out, it took a long time to come out. The context has changed from MAPS. We've seen developments in other provinces like BC, like Manitoba.

where family medicine is, we're flipping the system and making family medicine the priority. And to me, that context matters. We need to start thinking in Alberta about how we keep attracting people to our province and keep making family medicine attractive in our province. And so the report itself, I think, is, in many ways, a general framework. There are some things, as you've seen, I'm sure, in there around governance structures

aren't really clear in many ways. But at the end of the day, the key is that without a commitment to stabilize what we have, and now looking at another task force to go and do the same kind of thing, it kind of calls into question what the purpose of that report is.

Jordan Vollrath (53:09.193)
How many people worked on the Maps reports? How many people actually worked on the LFP? How big are the teams that they're actually putting on these projects?

Sam Myhr (53:18.898)
I mean, the LFP was us, you're talking to, we had, you know, the, the sort of like endorsement support or whatever from a couple of senior AMA staff, right? So that we could get it to the board level and have them, but we did all the work, right? Is it came out of, like you said, labor of love that puts all the information that we have from various tables and takes, you know, what's happening nationally.

and puts it in one place and it's because it wasn't happening anywhere else. Like nobody was doing this work despite us saying like, look at BC, look at BC. Like we need to be doing something like this or we're going to continue to believe that way. And that's just like, so we took initiative and did that. So it wasn't like you're looking at the team there. Um, but, but it was partially because we knew it wasn't coming from maps, right? Like we kind of touched on before or any of these other.

other areas, in fact, like the PCN side or anything sort of related to that, like just everything halted in this interim with maps. It's like, oh, we need to wait for direction for maps. And so there was not an urgency on any of that side, which is with government structures, right? And so they know that they have something coming out and they're saying, hold up, don't do any work and wait for that to come out first and then we'll align with maps, which is.

as Jon mentioned, huge, and it gets bigger every time we see it. So, like, it changed the last 24 hours between, you know, like, what the panel saw and had talked about, and then what was going to be going forward to the then minister copying. And there were some substantial changes made then, and they weren't discussed. And then I think since we saw it last time, it's 100 pages more or something.

You know, it's hard to tell, it's all jumbled, whether there's a ton of changes to the structure or the components of it. But it just, I mean, I think it, if anything, it just speaks to kind of the lack of trust in the process that we assume that there has been. It's just, it wasn't really reflective from our perspective of the need that we were seeing.

Sam Myhr (55:34.594)
and didn't really feel heard. And in fact, there was dissent at MAPS that wasn't really allowed to happen. And I think from my perspective, those are the kinds of conversations that you need to have, right? Like if you have physician leaders, they're speaking on behalf of like half the membership or half the physicians in the province, right? Because we hear so many stories from them.

right, and what reality is like for them. And you're not taking that at face value. And in fact, you know, you're saying, well, we don't actually want your dissent. This needs to be a pretty consensus package. That's like, it's been hard to kind of sit and live with that, knowing that it wasn't even treated with that respect, I think that it deserves, because it is the voice of so many.

Jordan Vollrath (56:27.905)
So there was unilaterally an additional hundred pages just thrown into the report at the last minute without anybody really seeing or signing up.

Jon Hilner (56:39.687)
So, I mean, it is bigger than we last saw it. Some of that is formatting in white space, right?

Jordan Vollrath (56:45.237)
Mm-hmm.

Jon Hilner (56:48.947)
from when the report was developed. And so I mean again it comes down to you know like is it is it meaningful or is it a distraction right? So and what do we take from the report that's going to move forward? So releasing the maps report is one thing right putting it out publicly.

showing or talking about which parts of the report you plan to implement and when is the next. And I think that's like to me that's the piece is it's kind of you know as a government what is your priority right? Do you try to implement structures that allow you more ability to control the healthcare system meanwhile ignoring the components of that system that make it work and allowing them to degrade further and not be there anymore?

Or do you meaningfully commit to a sustainable healthcare system by supporting the practices that you currently have? And the announcement and the way that it's rolled out suggests that the latter is not the priority, right? That the supports that have been announced are not meaningful and won't sustain what we have. And so, you know, now we need to wait and see, you know, where support is going to be put. And in that process, we're going to lose a lot of the care I think that we already have.

which is devastating when you're starting at the point where so many people are already without it.

Jordan Vollrath (58:14.081)
And then how do you deal with dissent on a committee like this? Like you'd think that that's a good thing, right? You want to be leading and not just managing and dictating what's going on, but rather actually putting all the minds together to collectively problem solve. But then it sounds like that sort of gets stifled. It sounds somewhat sad.

Sam Myhr (58:22.515)
Yeah.

Jordan Vollrath (58:35.785)
reminiscent of Dr. Hinshaw dealing with the government and getting stuck in the middle on the whole COVID pandemic management, and then kind of in the middle being the scapegoat and also the like front person explaining things as per the government view, as per the actual picture in healthcare.

Sam Myhr (58:57.502)
Yep.

Jon Hilner (58:58.223)
Yep. Yeah, that's a good analogy. I think, I think the thing is too, you know, when, when maps was designed, the intention as it was stated was to have people who had experience in the healthcare system from a variety of different backgrounds who were relative experts in their area, um, come together and come up with something that would lead us in the right direction. And, and experts disagree, right? I think, you know, we have different contexts and different backgrounds and we come with different information.

Um, and, and disagreement is productive, right? Uh, you can, you can use disagreement to come up with new solutions. Um, or you can ignore it and, and I think, you know, you ignore it at your peril, right? Like a lot of, if you want to keep things going in the same direction, pretend to listen to people, um, and, and you're still going to have the same path at the end of the day that you started on. Um, and I think that's, that's where you're right, Jordan. I think that's where we, we often don't see a match between what we are.

trying to bring forward, which ultimately for the two of us, you know, for Sam is the voice of the members she represented up until recently in the section of rural medicine. And for me is the voice of the family doctors in primarily urban centers, but across the province, because my role as president when I was in it was also to represent rural physicians in family medicine. And so we're bringing that voice forward and it's not just one person's opinion, it's...

Sam Myhr (01:00:17.667)
Mm-hmm.

Jon Hilner (01:00:24.827)
somebody who's had experience in the system, but also has a lot of the information from others. And when we weren't sure, we asked, right? Like when we weren't really sure if maybe we were missing the boat and maybe there was something that was meaningful either in what had been announced at the time or what was potentially coming, we asked our members and the resounding message was, no, it's not enough. And that's the message that we brought forward is it's not enough and it's still not.

Jordan Vollrath (01:00:51.485)
And so up until, oh sorry, go ahead, go ahead Sam.

Sam Myhr (01:00:51.786)
And there. Oh, I just I just wanted to highlight that there's been an unwillingness to hear that right, like not just at the maps table, but to believe it outside of that, like within our own representative organization with other primary care groups and from government. Um, and I don't think a report that doesn't address the things that we were trying to raise, right? The reality that we're facing now, um, does a lot of

good right in that discussion or it doesn't help right to have that to be able to point to and be like well look all these experts said right or endorse this when you haven't incorporated like to answer your question how do you handle dissent I think you talk about it right you put like that there was not consensus that's how like you know the National Academy of Science or other places would do it they would put you know recommendations and then they'd say there wasn't consensus for these reasons

Um, it's not, you know, it doesn't detract, I don't think from, from your report at all. I think it actually adds to it. It shows that you thoughtfully, um, you know, work through the problems and you couldn't reach consensus, but you think that this is the direction you need to go still. But, but when it's not, uh, mentioned at all, I think that raises red flags, right? Is it, did you actually want to listen or did you just want to push your stuff through? Yeah.

Jordan Vollrath (01:02:16.142)
Yeah, they have that agenda and then anybody who disagrees with it, dude squash it with an NDA, right? Like the, okay, we've got to have a unified frontier and everyone agrees on exactly what's been published.

Sam Myhr (01:02:31.31)
Mm-hmm.

Jordan Vollrath (01:02:32.785)
And so, I mean, Jon, you were up until just very recently the president of the section of family medicine at the AMA. Can I ask why'd you quit?

Jon Hilner (01:02:45.179)
Yeah, I mean, it was a difficult decision. I think, you know, when you take something on, you kind of have to ask yourself, is this meaningful? Like, does it matter? And it certainly does. I mean, that hasn't changed. Obviously, I'm still talking about it. So it's still meaningful to support family doctors. And I would, you know, it is my hope that my family doctor colleagues, yourself and Sam and everyone else across the province can succeed at what they're trying to do.

But the second part to that is, is it manageable? Like, can you actually achieve the thing you're trying to? And for a variety of reasons, Jordan, it became apparent that really within the organization, that wasn't likely or possible. There were a number of, we obviously tried a number of different things. Part of that was the isolation of the NDAs and not actually being able to represent people. And I don't know if you know, but...

up until recently, those NDAs actually prevented the board of the AMA from knowing information about maps until a few days before the announcement, right? So it makes it very difficult to provide input and advice and to lead when you're hampered by things like that. And then when you're trying often to justify the decisions that you're making based on the information that you have as somebody who sits at all of the different places that

that Sam has mentioned, you know, at MAPS and talking about income equity, which has been an issue in balancing the relative supports and fees for sections across our profession for many, many years, for many physicians who are close to retirement for the full duration of their practice, right? And recognizing each time that these things aren't going to address what we need. Eventually, you get to the point where you kind of have to say, well, if I can't make a difference here, where can I?

And so I've chosen to leave the AMA and to go back to my clinic team where, like I said, I'm proud of what we do. And I've got colleagues who I've been drawing on the goodwill of to be able to represent them at the AMA and patients as well who've been waiting for longer for appointments to see me as I take on these other responsibilities. And really at the end of the day, that's where I think that the difference can be made is that.

Jon Hilner (01:05:08.604)
the level of the community and the clinics that need to support the people that we care for.

Jordan Vollrath (01:05:13.985)
I mean, that sounds ridiculous that the people that are leading the entire organization and the province and the AMA are not even privy to much of this information and the work that's been done because of these NDAs. Like is this a commonplace thing in healthcare? Like is the entire system just rife with sort of this lack of transparency and stifling dissent? Is that anything you've seen elsewhere or heard elsewhere?

Jon Hilner (01:05:40.959)
Well, I think, I mean, at the, yeah, I think, I mean, if you think about, about how you feel, right, as a, as a, as a doctor practicing in, in the community, right. And you're, you're waiting and you're, you keep saying, you know, this is what I need. This is where, you know, like I need these supports and you're not seeing them. There's something that's not connecting, right. And, and when the messaging is, you know, we have a much more positive relationship with

Sam Myhr (01:05:41.916)
I shouldn't laugh, but yes, the answer is yes. It's hard.

Jordan Vollrath (01:05:44.53)
Yeah.

Jon Hilner (01:06:06.803)
with government or things are great, we've got an agreement that's gonna solve the problem, we've got a maps process that's gonna solve the problem, we're tackling income equity, we're gonna see that balanced out and the meaningful change isn't happening, right? Something's missing, right? There's something that you're not seeing and yes, I do think that that's a big part of it is if we had more transparency, then at least we could decide whether this was the way we wanted to be supported.

Sam Myhr (01:06:35.146)
And I mean, I just like, I can't not say that, like we personally been excluded from tables for raising dissenting opinions that are in line with our members feedback, right? Just because they're hard things to hear, they're, you know, like they're meant as constructive criticism. You don't go through the time and energy to give that feedback or to raise those things if you don't care about the resolution of them.

And so yeah, we've seen that even with our own primary care groups, other leaders, right? Is it don't talk about X, Y, Z, you know, and even though it's something that impacts our members hugely. And, and if you won't stop talking about it, then, then you're not allowed at our table. And, and so that's just, it does nothing but to harm our own representation as family docs. And, and unfortunately like that, I think that's part of it, right? Is that like the, the top leadership they made to like, hasn't, has upheld those sorts of things.

And part of it is, I think, like it's systems, it's not individuals, it's how we've set up our systems, but they're not serving our people. And it's not true representation. So there's a lot of work that we need to do on transparency. But right now, given the magnitude of the situation and what needs to be done, I think the best thing to do is the kind of stuff that you're doing, Jordan, is like bringing the voice out to the public.

so that people have an idea of what they need to advocate for themselves, right? Like to their local areas, communities, groups, MLAs, you know, some of the most meaningful action that I've been part of, like back in Pinscher Creek was like a whole community wrap around of their healthcare services, you know, back in the 2020 job action for rural, right? It was like our community stood behind us because they understood how much it mattered and they could see down the line.

and know what this was going to mean for their community. And so they stood up with us and that was so meaningful. So I think, but that took a lot of time and effort, right. Talking to MLAs and to mayors and reeds and going around and spending time with town council and, and it's energy that like, if you're not, if you're spending it at your represent representative organization and you don't see it happening there, despite like the, the things that we've been privileged to be a part of.

Sam Myhr (01:08:50.794)
like maps and all of these high level tables and talking to the premier and the minister directly, then you gotta go back to what has worked and where you can make a difference. And you can't do that in isolation. You need to bring your team with you and it's the team that trusts you and has the same shared common goal that's gonna take you further. So I think that's part of it too.

Jordan Vollrath (01:09:14.257)
Just keeping the dialogue running, advocating for transparency. Anything else that the doctors or the public in general should be trying to look for or steer towards to keep the system honest and moving in the right direction.

Jon Hilner (01:09:29.671)
Yeah, I think going back to, you know, we do a lot in family medicine to look after and care for our patients, but also protect them from the cracks in the system. Right? Like we try our best to, you know, especially if you have a family doctor who's known you for a long time, you know, we're often on the phone trying to set up specialist appointments where we know there's a longer wait time than that patient probably needs to get their issue dealt with, because it is a crisis, right? It's something that needs to be dealt with more urgently.

And so we put in that extra time to do it. And I think that's where we probably need to start saying no to some of the things that are preventing us from recognizing the problems in the system or really addressing them meaningfully. And if our doctors and our patients, if they value this kind of care, if they value having a family doctor and being able to say my family doctor is so-and-so, then they need to...

They need to know that there's a problem and then go and speak about it with their MLAs, go speak about it with their municipal leaders and say, you know, I value what I have now and I don't want to lose it and we need to do what we can to sustain it. So that message keeps carrying up and that no matter where they turn, our elected members of government are hearing the same thing, that the support and sustainability of family medicine is important.

Sam Myhr (01:10:56.798)
And I also think there needs to just in general be more transparency about data from government side, right? Like some of these budget announcements, despite being intimately involved in the projects or initiatives they're talking about, we can actually trace where the dollars are going. And so we don't know if they're going to be meaningful. You know, there's been re-announcements of...

We kind of alluded to before, I think, but the re-announcement of the same thing over and over again, it's like, is this new budget? Is it, oh, and like, what are you getting for it? And I think, like, the public demanding that. Like, they should know where their tax dollars are going, right, and it's painted as like, oh, we need to cap, you know, this growing budget, that physicians are paid too much or something like that, right, when really there's a lot of inefficiencies in the system, there's a lot of places where money is going, duplication of services.

Jordan Vollrath (01:11:26.877)
Mm-hmm.

Sam Myhr (01:11:49.582)
But it's certainly not going to the foundation of the system, right, that we keep talking about. And so, where is it going? What are we getting for it? So I think public report cards that don't place burden on providers that can't deal with the system problems, right? We need to be able to show the parts of the system that are failing all burdens, and so that we can keep our government accountable for what and how much they're funding.

And that's, so that's something we said repeatedly at MAPS, right? Where's the accountability on the government side to fund the things that you're asking for? And that was always kind of like met with a, oh, we don't need more accountability. Just you. Yeah.

Jordan Vollrath (01:12:32.022)
Not us, no, yeah. What are your thoughts on the new federal transfer payments structure which comes with the strings attached? It sounds like that's a step in the direction in terms of transparency and accountability and where are these funds being allocated? What are they being used for?

Jon Hilner (01:12:35.398)
Yeah.

Jon Hilner (01:12:50.739)
So I think, I mean, we know some of the strings. We don't know all of them. As you said, Jordan, some of it is information sharing. So I mean, that is positive if it's done in a meaningful way. I think the hard part is we don't know what that impact is going to be. And part of what we were hoping for was to actually be able to help governments meet, the Alberta government in particular, meet its...

its requirements when it comes to federal health transfers so that they could be applied in a way that would make a meaningful system change, but also that they could account for this without much extra work. And that was kind of built into the LFP. So I think if we knew more about it, it would be great. I think that would be the first place to start. And then the second would be that, you know, if we could trust, as Sam said, that there's going to be transparency around how that funding is allocated.

because we've had in the past few years, we've had a number of commitments that haven't been delivered on, right? And each one of those is harmful for the trust and belief that this is going to make a meaningful difference for family medicine, which as we said, affects recruitment, it affects retention of family physicians. And at the end of the day, it affects Albertans.

Jordan Vollrath (01:14:09.285)
So BC, they just signed their bilateral agreements, that things are moving along nicely there. Quebec doesn't really want anything to do with strings attached. What about here in Alberta? Is there anything that seems to be holding things up on our end or have you heard any whisperings about the actual movement of...

Sam Myhr (01:14:29.422)
Well, as far as I know, everybody has agreed to it except Quebec. And so it's just a matter of what is actually agreed to and know that's like, we haven't been privy to that information. We've tried to, you know, we've asked the minister directly because in part, we wanted to be able to design the LFP and the stabilization plans in a way that would be mindful of that, so to help them meet those requirements. And of course, trying to ask for what are the...

opportunities, I guess, for budget allocation from that to this place of great need. But, you know, I think it seemed like she wanted to talk about it maybe more and couldn't. So I think it's, you know, locked down on that end and we'll hear alongside everybody else, I'm sure, instead of being part of the ability to shape it, right, from our vantage point in the system of being care coordinators.

Largely, right, and seeing cracks in so many places, it'd just be, I think, overall, what we need in the system is the ability to work together more, right? Not just task forces that are so formal and whatnot, right? But a meaningful, ongoing dialogue and addressing problems together. Because trying to do it through largely administrative or bureaucratic channels and government and an organization as big as the AMA, it's slow, right? Same with AHS.

Jordan Vollrath (01:15:57.193)
Well, and then on the same topic of transparency and accountability, you were probably involved in attending the AGM for the College of Family Physicians of Canada last week, correct?

Sam Myhr (01:16:10.306)
Unfortunately, couldn't make the actual meeting, but yes, very involved in the discussions leading up to it, heard lots about it, and have our own opinions. I'm just going to go straight ahead and say from a rural perspective, it just blows my mind, right? So the SRPC, for instance, the Society of Rural Physicians of Canada came out against it very strongly, and the rationale behind that is that we know we're graduating.

very competent physicians who are ready to not just take on a practice but also emerge and labor and delivery and all of those areas in two years with rural programs. And so it's not so much the time but it's how the program's structured, the amount of sort of independence safely, right, independence with supervision, exposure, right, and

and really the confidence that you're putting into the students you're graduating. And so to say when it's working in two years in so many places that you need to change the whole curriculum, especially at a time where we have such a shortage, right, and there's a decreasing or waning desire to go into this because of all the other things we've talked about today, it's just it's mind-boggling. And so yeah, there was a very strong opposition to it.

And I think that's just a piece of the rationale.

Jordan Vollrath (01:17:35.605)
Why does so many places have a three year family medicine residency? What's the benefit? Like I see, I kind of see it from both sides. I'm like, okay, everything's on fire, we're in crisis. You know, if we have doctors graduating that are 50% smarter, because they have a three year instead of a two year residency, would they be able to just be that much more efficient? You know, like.

Jon Hilner (01:17:55.039)
Thanks for watching!

Sam Myhr (01:18:00.196)
Jon, are you in your 15th year of residency now? I think that's the answer, right? We're always learning and growing. You can't possibly do it in two or three.

Jon Hilner (01:18:04.324)
That... yeah.

I think that's, that's always the thing Jordan is it's, I mean, you know, we, one of the, one of the great privileges of family medicine is you're always learning something, right? Like, um, you know, whether it's standards that are changing or presentations that are new for you, right? Um, there's, there's always something new. Um, and, and I mean, like, I, I always revel in the fact that, that I am learning from my residents and students, things that I didn't know, and that, that my colleagues who are

Jordan Vollrath (01:18:09.726)
Hehehe

Jon Hilner (01:18:35.091)
towards the end of their practice, they're still pulling me into the room to ask me questions about things that they don't know. Right, I think that's one of the great beauties of family medicine is you're always learning something. And so I guess to me the question is, does the third year really equip you better to do that? Right, like if you're already willing to learn, does it really teach you a lot more and how can it be set up like that? And I think that's part of what was missing is,

I know there were comments made that this wouldn't create a gap year, it wouldn't create a loss of family doctors or a period of time where you have a refractory graduating class kind of thing. But at the same time, you kind of have to, right? There's got to be a... Either you need to double your residencies so that you can graduate one after two and one after three years.

And the big question is who do you put those people with, right? How do you, how do you find, um, uh, people to learn from? How do you find supervisors and preceptors for those residents, especially as we're seeing supports not exist. So from a practical standpoint, I just, I think the first step is you need to create the, the landing pad.

You know, you need to build the incentive structures that make people want to do this on an ongoing basis and support the people that are doing it so that they can train and support the people that are coming. And that's true for residents and it's true for teams. And it's something that I think kind of speaks to where we feel we need to start, which is sustaining what we have.

Jordan Vollrath (01:20:10.217)
Is there anything that we need to be doing internally, you know, as just the family doctors collectively in terms of system reform, you know, things that are within our power to start doing currently versus advocating and waiting on third parties and external agencies to change for us? Like, what should we be doing? Is it pushing our practices towards that team-based care? Is it, I don't know, fill in the blank.

Sam Myhr (01:20:39.166)
I mean, if you can't support it. Yeah, me too, actually. Yeah, I was trying to think of a different way to say it, but you're right. Like I think it's like Jon alluded to before, there's so many cracks in the system that we prevent or hide really from the public view by the care or the lengths that we go to provide good care. Like I hate to say it, but I think we do need to stop. We need to stop.

Jon Hilner (01:20:39.271)
The first word that came to mind for me was less. Yeah.

Jordan Vollrath (01:20:44.893)
set boundaries, just, yeah.

Sam Myhr (01:21:07.798)
Uh, like using ourselves as bridges across those gaps, right. Because that's why people are burning out, right. When they're not supported and they don't feel like they're even supported to have boundaries. Right. Like, I mean, and I know I'm preaching to the choir slash converted here, but the, you know, like if you take a vacation. Right. Are you taking any time for yourself? You're lucky enough to have coverage to do that. You come back and the overwhelming response from patients is.

Oh, like you so long to get into you to see you, right. Or I can never get in to see you and I need to, or, you know, or you're greeted at the door with a pile of forms from your staff and like, it's just, it's a overwhelming pressures from all areas. So there's, there's lots of ways that you can, you know, take a page, I think, out of the book of our specialist colleagues, right. Or, or others that have a bit more leniency to say like, no, actually I'm full right, or my waiting period for XYZ is this long.

And that's again out of necessity for access to ORs or whatever. If you know you're not going to be able to take care of the patient in the way that they need to be taken care of, then you have to say no. And that's where we're at, but we feel like we can't say no. And so you have to say no to something. So maybe it's like we've been tossing around ideas about this for a long time, right? And it's just like, do you just say, do you have a forms wait list, right? Or just say, I'm not accepting forms for the next.

You know, but and how does the college support that? We've actually had these conversations with the Registrar of the College to say like, we can't as a profession meet the guidelines in the system that we're in now, right? And so like, what can you do as the college, right, to support family physicians and to make sure that they are aware because that's another reason people drop out of the profession is cause they are afraid of all of this liability that they're taking on in a system that they can't.

they can't achieve what they're supposed to do. And it's not like we don't want to. So there's lots of, I think there's lots of places where we can find like, what are your boundaries? And if you set them, how would you be better able to take care of the people that you can in the best way that you can? And that might be saying, okay, we did six things today, we can't get through your other eight. You know, like the list have gotten so long. Yeah.

Jordan Vollrath (01:23:17.109)
Mm-hmm.

Jordan Vollrath (01:23:33.781)
Well, it's a good point, right? Like you're approaching a, I say you, I mean, we as a profession are approaching, you know, this long-term problem with a short-term solution of let's do more, let's burn ourselves out. Are we really doing our patients or the system a favor in general? Right. So you can only do that so long before you quit, you taper back, you cut down your hours, you do something else. Right. So if it was a short-term demand, perhaps the argument there would be,

It's really got worse during COVID, right? It's like, okay, let's all rally together. There's increased burden right now, but things have started chilling out a little bit, but yet that sentiment of, you know, do more and that sense of duty to the patients is still very strong. And things are just getting worse in terms of we've hit the end of the rope.

Jon Hilner (01:24:22.319)
Yeah. And I think, I think the longer we wait, the more difficult that is to recover. Right. Like, um, you know, we've, many of us have had friends of ours who have either decided to, to move out of, out of longitudinal family practice or who have moved out of the province, right. Because they're, um, they're recognizing that there are other places like BC where, um, you're at least seen for what you do and, and supported to do it. And I think that that's.

That was our hope, right? It's still our hope is to see that happen. And that's gonna start with number one, demonstrating that there is a problem because we hear the word crisis, but we're responding to this very, very slowly, if at all. And number two, how do we fix it? And that starts in our communities. That starts with people speaking up for what they need. And that's hard to do, right? Cause a lot of us are already so stretched thin that we've kind of...

We barely have the energy to lift our heads up and ask for help. And we need to create that space. And that's why I say, like, I think we have to start by saying no to things. We have to start by doing less so that we can do more to look out for what we need.

Sam Myhr (01:25:33.218)
But also saying why, right? I think that's like one of my best mentors, you know, that her approach really was, you know, I'm gonna say no to you right now so that I can be here for you in a year. And that's, and like, you can take that at face value, right? You can be angry or upset that we're not covering this today, but like recognize I'm telling you what I need so that I can still be here for you, you know, years from now.

Jon Hilner (01:25:35.036)
Yeah.

Sam Myhr (01:26:02.49)
And I think, like, unless we're honest about that, I think a lot of people in medicine put on a brave face, right? Or they don't wanna show that things aren't going well. But what good is it to patients or the province if you just burn out and leave? Or, you know, make your exit plan to a place where you feel seen or heard or valued for what you do, like Jon was saying. I feel like we're doing a lot of free advertising for BC. Very.

But it's true, it's like we should talk about it because they've done something good and they're drawing in family docs, not just from Alberta, but they're keeping their own grads and they're pulling them in from other areas of the system back into primary care and that's what we wanna see. So, I mean, kudos to them and hopefully we can do, you know, an even better job here, right? Because we had a leg up, I think, to begin with. But yeah, I think we need to be honest about what's happening.

And there's a lot of places where that, like we didn't even talk about connect care, but we call it disconnect care for a reason, right? And referral pathways that are being done, like Alberta Surgical Initiative, there's a lot of things that are, that end up adding to the workload of family physicians for no further remuneration. And it obviously wasn't designed with a medical home or primary care perspective in mind. And it should be, if we, I like to think of it as just,

simply the message is flip the system, right? Like put the time, the effort, the remuneration whatnot into where 70 or whatever percent of the care is happening in the community. That includes our specialists, colleagues who are very underpaid in the community as well. And in forging those connections and integration there instead of making a AHS based system that it's great if you're in AHS, pretty awful if you're outside of it.

and you're getting like the same thing 18 times and it's just increasing to your workload and you don't get the stuff that you need to get on your patients. You have to go track down elsewhere and it's costing the system a whole lot, right? But like these things, you would just think that you would plan in advance to have them integrated in the place where the majority of care happens, right? And patients don't know this because they're told that it's great. And so we just need to have those conversations, honestly, like you're doing.

Sam Myhr (01:28:24.598)
So thank you.

Jordan Vollrath (01:28:25.001)
We try, we try. I mean, kind of getting over time here. I don't wanna, I wanna be respectful of your Sunday afternoon. Do you have any other thoughts? Any like final wrap up comments or call outs? Things you want.

Jon Hilner (01:28:41.031)
Oh, I just, I echo Sam Jordan. Thank you for doing this. Um, you know, for, for a while, Sam and I actually, uh, worked with another colleague of ours, a urologist, Howard Evans, who, uh, we had a podcast where we talked about how if we didn't change something, this was going to hurt. Um, and, uh, our, our hope was to get the message out in advance so that, you know, we're, we're all about prevention and family medicine and, and we were hoping to prevent, um, you know, inevitable harms. Um.

And unfortunately, without a response, we're gonna see more of the same. And I think Alberta has a huge capacity to be a leader in healthcare and in primary care. As Sam alluded to, we are set up with very, very good structures if we are willing to invest in them and leverage their abilities to push us in the right direction and to make Alberta the place that...

family doctors want to work and where patients are well looked after. Um, and, and I think until we recognize and commit to that, we're, we're going to unfortunately see, um, a degradation in, in primary care, which is really is the foundation of the healthcare system. So this is a crossroads. Um, and, and hopefully someone is listening and, and many of us continue to speak up.

Jordan Vollrath (01:30:01.557)
Yeah, well, I'll say thank you for your work, you know, and the advocacy and everything that you have done and will do for the primary care system here in Alberta. And I myself am very fortunate to be in a position where I can do things like this and have these conversations and get the message out there. And so, you know, I think there is a lot going on for Alberta here. It's a fantastic place to live with a lot of wonderful communities. And hopefully by the collective efforts here, we can help.

Sam Myhr (01:30:01.748)
Yeah.

Jordan Vollrath (01:30:27.425)
tidy up and keep the system running well and make it a great place for everybody. So that, I don't know, kind of unless, Sam, you sort of jump in there and then we can end it.

Sam Myhr (01:30:37.434)
Sure. Yeah. I just, you just made me think of like one of my favorite sayings is that good ideas don't have titles and, and in going around talking to people in the province, like medical or non, like this, like the problems are complex, but the solutions aren't and they don't have to be and people get it, like when you talk to them and they have great ideas and that's not, you know.

it doesn't have to be one or two people in a room shouldering the burden, right? We just need to listen to the people on the ground doing it or listen to people from other industries who could do it better, right? They have experience from other industries and learn from that. And so I do encourage everybody, medical or not, to put their opinion out there. There's been some of the best ideas and...

just pathways forward that I've heard have come from like municipal leaders or engaged citizens in their communities.

Jordan Vollrath (01:31:31.073)
The fool does not learn from his mistakes, whereas the wise man does, yet the even wiser man learns from the mistakes of others. Thank you so much to both of you for joining us today. We'll end it there, that was prophetic. Thank you so much again for joining us.

Sam Myhr (01:31:38.642)
Ooh I love it. Love it.

Jon Hilner (01:31:39.845)
nice

Sam Myhr (01:31:44.225)
Yeah.

Jon Hilner (01:31:46.451)
Thanks Jordan.

Sam Myhr (01:31:46.926)
Great job, Jordan. Thank you.

Jordan Vollrath (01:31:50.524)
Awesome.