How can we better prepare future physicians for the realities of a broken primary care system? In this episode, Dr. Oandasan dives into the gaps in health professions education and why they may leave primary care providers ill-equipped to tackle today’s challenges. From clearly defining what primary care means to setting standards for practice and accountability, we explore the steps needed to strengthen the foundation of healthcare in Canada.
Learn why training future physicians must go beyond clinical skills to include practice management and interprofessional collaboration.
Join us as we uncover how rethinking education can address the primary care shortage and improve healthcare access for all Canadians.
6:55 – Defining Primary Care and Community Care In this segment, we explore the importance of clearly defining what primary care and community care entail, and how these definitions impact healthcare delivery and policy-making in Canada.
15:46 – Challenges in Implementing Team-Based Care Dr. Oandasan and Dr. Vollrath discuss the obstacles faced when introducing team-based care models, including funding issues and the existing fragmentation within the healthcare system.
23:55 – Professional Identity and Trust in Team-Based Care We delve into how professional identities influence collaboration among healthcare providers and the role trust plays in effective team-based care.
32:36 – Training Future Physicians for Team-Based Care This section examines the need for medical education to include practice management and interprofessional skills to prepare new physicians for collaborative environments.
44:58 – Interprofessional Collaboration and Training We highlight the importance of interprofessional education and training in fostering effective collaboration among different healthcare professionals.
51:35 – Learning from Innovations in Other Regions The conversation turns to successful healthcare innovations in other regions, discussing how these models can inform and improve Canadian primary care practices.
1:01:48 – The Role of Leadership in Healthcare Reform Finally, we underscore the critical role that strong leadership and community engagement play in driving systemic change and reforming the healthcare system.
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Transcript:
Dr Jordan Vollrath (00:01.186)
Today we're talking to Dr. Ivy Oandasan. She's a professor at the Department of Family and Community Medicine at the Tamer T Faculty of Medicine at the University of Toronto and was an active family physician working at the Toronto Western Family Health Team until June of this year. She's a scholar and a leader in advancing interprofessional education and team-based healthcare for over two decades, leading initiatives provincially and at a pan-Canadian level and abroad internationally. Recently, she was the co-lead of the Team Primary Care, Training for Transformation federally funded project that brought together 20 health professions
and 14 primary care teams to implement better access to primary care for Canadians through team-based care. She's also the Director of Education at the College of Family Physicians of Canada, supporting the training of learners and teachers in advancing the discipline of family medicine. Dr. Oandasan, thank you so much for joining me today to chat more about primary care. I'm excited for this one.
Ivy Oandasan (01:18.574)
That's great. Thanks for the invitation. I'm really looking forward to it as well.
Dr Jordan Vollrath (01:23.052)
So kind of just like taking a look at the state of the union currently, like how would you describe primary care and community care system in Canada?
Ivy Oandasan (01:34.286)
Well, people are talking about it as a crisis, right? That it's not a good word. It's not a good word at all. But I actually think it actually is telling in terms of where we are. And knowing that we knew we were going to get here. 20 years ago, we knew we were going to be in a workforce crisis, particularly in primary care, hospital care. We knew that.
Dr Jordan Vollrath (01:39.02)
That's not a good word. That's all over.
Ivy Oandasan (02:03.834)
The governments knew that. And I was doing this work on team-based care. I did a study for Health Canada in 2004 looking for the evidence for us to move forward with interprofessional care as a solution for the health system crisis that we were going to be facing. And we knew at that point in time, we needed to actually have, or we had enough evidence to say we should move in this area. Things didn't move.
And now we have six million people in Canada that don't have a primary care provider or family physician or nurse practitioner. And the challenge is that the retirement ages right now of all of the main family physicians that have been out there, we've got a huge retiring population going out. And so the people who are most affected are in fact are elderly.
the elderly people who don't necessarily have a primary care provider, they're going to emerge. They're going to walk in clinics or they're not going anywhere at all. And that number is going to be worse. So do we have a crisis? I know a lot of people don't like using that word. I actually think we have a primary care crisis and we need to do something about it and we need to do something about it now.
Dr Jordan Vollrath (03:27.114)
And where does crisis begin? guess like how many million people need to be devoid of having a primary care doctor? Like at what point does it become more, okay, this is the advocacy body drumming up and making noise versus like, okay, where, where does the rubber hit the road if we have a serious problem here? And then how do you reconcile sort of that inaction over the decades? I mean, it sounds like the forecasting in terms of our
HR and just staffing in the healthcare field anticipated this a long time ago, but yet nothing really changed.
Ivy Oandasan (04:03.374)
Yeah, the challenge that we face is that we have a universal healthcare system that's supposed to guarantee access to care. Interesting that the Canada Health Act actually really refers primarily to access to a physician and access to hospital care. Doesn't really talk about primary care, right?
And so when you think about universal access to primary care, well, what does that really mean? And right now, when people say universal access that every Canadian should have access to a longitudinal primary care provider, be that a family physician or a nurse practitioner. In the past, it was a lot of the rural areas, right? That were the places where rural and remote didn't have.
the family docs that were available to them. But now you're seeing it in the cities. Now you're seeing it in every population group are not having this longitudinal care. And we know that the best care by evidence is those that actually have a primary care provider, a family physician that's longitudinal continuous care. So if Canada is saying that we're supposed to have universal healthcare,
the pride of our country, right? And people are not getting it. Then where does it begin or where does it end? It begins there. We are not fulfilling the promise of what we were supposed to be giving to our healthcare, to our population.
Dr Jordan Vollrath (05:28.93)
That's what we're known for.
Dr Jordan Vollrath (05:43.584)
What were they looking at decades ago when they saw this coming?
Ivy Oandasan (05:48.612)
They're looking at numbers. So I remember in 2004, were talking about this, World Health Organization was talking about this in terms of the health workforce was going, we weren't going to have enough in terms of the health workforce in total. And that was because they were predicting the elderly populations, the complexity, et cetera, that was there. And you know,
It's interesting how you have to get to a crisis before someone's going to look at it. And it took 20 years for people to actually recognize, my gosh, we're here. And yet there was an opportunity to actually begin to make the changes.
Dr Jordan Vollrath (06:31.242)
And what do we need to actually start looking at going forward? How do you define the role of primary care, access to a family physician and comprehensive care like that, like, or versus being able to access an NP, for example, or a different allied healthcare provider? Like, where do we draw the line for, okay, this is universal access to healthcare?
Ivy Oandasan (06:55.538)
So I like to think about it as care that's outside of the hospital, right? Any care that you require outside of the hospital consists of primary and community care. So that's a nice kind of easy definition in that way. And the people who work in that kind of context are anybody who has contact with you in the community. So that could be a paramedic, that could be the physiotherapist, that could be your pharmacist, that could be your physician, right?
And what we're trying to say then is that the move towards shifting to a patient or a person, actually having a healthcare team who knows them is the way we go. The reality is the way that our system has been designed is it's a bunch of entrepreneurial solo businesses.
pharmacist here, a physiotherapist there, a family physician in their office here, and none of them are connected. When we had COVID, when we had SARS, in fact, we saw SARS was one of the first ones where, I was working at a community care access center as a home care advisor, and there was no information that was coming to connect home care and primary care and the hospital care. It was a disaster. It got better.
when we got into COVID. But you have to recognize that the primary community care system is broken. There's a bunch of individual silo buildings not connected with any particular communication mechanism. And those people who are the primary care providers, as I said, paramedics, physiotherapists, pharmacists, they actually don't have a way to share information.
And if you can't share the information or if you don't know who your team is that's working with you, how do you get coordinated care? How do you make sure that you're not falling through the cracks? How do you make sure that a referral is sent in a timely way? Or if I'm coming out of hospital, that my providers have the information that I need. And if you don't set it up from the beginning in that way, which is where we are right now,
Ivy Oandasan (09:20.346)
you get into the problems that we're facing. So, you know, for me, primary care is any care that's outside of the hospital setting. It's about care that requires anybody who has contact to ensure that they understand that they are part of the delivery of comprehensive care. They're part of the delivery of coordinated care. And they see this as part of continuity care of the patient themselves.
And with that, you actually need somebody who actually can see the whole, because often patients move from one sector to another. And you're kind of needing, you need the coach. You need the coach and you need the team that's able to have an opportunity to work together to make the goal happen.
Dr Jordan Vollrath (11:04.148)
Okay. So when it comes to that team-based primary care model, like how do you reconcile sort of, again, the big obvious elephant in the room being that the physician side of things is funded versus, unless you have access to a physiotherapist or a behavioral medicine specialist through your primary care network or...
you know, a local initiative in your region specifically paying for the patient to have access to these people. How do you put together like a cohesive model that can be rolled out across the country where that team is the central unit for that community care?
Ivy Oandasan (11:45.272)
I it goes into the design from the very beginning. And I was just in Singapore and I was really, really taken by their, their primary care reform. What they did was they, they looked at their population and recognize that, gosh, our population is getting really older and these are really complex patients. And so when we design our primary care reform, let's set it up so that one primary care settings are in the community, their neighborhood.
let's set it up so that the kind of providers that are required fit the kind of needs of the population. And so they would have physicians, nurses, physiotherapists, pharmacists, and they were all salaried. They're all salaried in one building. And the kind of care that they even have an acute care setting so that if you need it to be seen because you have chest pain or you're having shortness of breath, they have an acute
acute care office that's there where they can they can stabilize you and the ambulance drives in the back picks you up and brings you to the nearest hospital. And so it's like a one-stop shop they have the pharmacies in there you have the x-ray labs are in there and so imagine that that you we were able to restart designing the kind of system that we have because the system that we
have designed now was a young population going in and out of hospital. The population now are older, complex, requiring more than one provider. I mean, needing multiple, multiple people that are dealing with multiple issues. And our system isn't supporting that. Our system isn't designed for the kind of population and the issues that they face right now. So, you know, how do you do that?
It's and I know that they want easy solutions. I know that people want the easy solutions. But I think it comes to thinking about what does our population need? It takes courage from our politicians to say they're going to. And you look at Alberta, I mean, they're making some significant changes like you live there. So you're seeing a lot of the significant changes and people are not loving every single change. they move to a primary care.
Ivy Oandasan (14:13.671)
office. They're changing the ways in which they're delivering the structure of it. Will it work? I don't know, but I think it's a courageous and bold move to think about what does our populations need.
Dr Jordan Vollrath (14:28.578)
Well, and so having it sort of, I guess, tailored to the local demographic, right? Whatever the smattering of different professionals that's going to actually be required in that area, it sounds like a really good, kind of like from a philosophical perspective plan. But when it comes to putting it into action, I think that's where people wind up really kind of struggling to see the connecting the A to B. And then especially when you think about the funding model,
being disconnected, right? And then when you follow the incentives, which are all discrepantly put out geographically by the provinces, it starts to get very, I don't know, challenging for some people to kind of imagine how that actually comes into practice. Like how do you guys see this coming to fruition over the-
Ivy Oandasan (15:16.9)
You know, one of the things that I do, I'm working at the College of Family Physicians of Canada, I help support the new graduates, right? The residents that are coming out. Over 95 % of them all want to work in teams, and yet they don't have the models. They all train in team-based care, and when they come out, they're being given solo-based practices, which they don't love.
Dr Jordan Vollrath (15:39.906)
Yeah, sort of the reality of, okay, I'm not in an academic, well-funded collaborative center anymore. Now you're like, okay.
Ivy Oandasan (15:46.266)
Exactly. And so you wonder why people are not wanting to become family doctors. You wonder why people don't want to go into those solo practices and they're just doing locums right now because we haven't created the environment for which they would want to practice. So we need to shift the practice environment. There's a whole bunch of retiring family docs that are out there. Why not start there and group?
some of the create some team-based practices where there is a high need gaps. We know that the models are there. We know that it needs to be salary based. We know that we need to do them primarily geographically as much as possible in some regional sites. So Jane Philpott's book talking about the neighbourhoods kind of school-based model, which has in itself some challenges as well. But if we can think about the infrastructure that's required.
There is a gap of a number of people in a particular community that have these kinds of healthcare issues. We need to give monies to provide the kind of care in the community for them and then tailor it. So they're going to need family physicians. They're going to need nurse practitioners. But what about one of our projects from Team Primer Care was with our Indigenous elders and our knowledge keepers.
and traditional healers. And if you look at the Truth and Reconciliation actions, we said that for Indigenous peoples, should actually have traditional healers should be part of their healthcare team. But you said earlier, what about that model? They're not considered part of the team. And so when we get back to who funds, fund what and who and how,
it needs to get back to the needs of the community and then to define who are the primary care providers. Right now, we basically say, here, design your model. And most people are saying, OK, I need one family doc and two of these and X of that, without actually really thinking about what do we really need and what is the kind of care? And with family doctors and nurse practitioners and pharmacists, they all have overlapping scopes of practice. How do we leverage
Ivy Oandasan (18:10.136)
the use of their skills. So we're not just looking at them as individual kind of robots, but we actually can integrate their skills in a really innovative way. And that takes, as I said, takes courage, takes innovation, and it takes opportunity. And yet there are many across the country that are doing this. There are places that are doing some
great stuff right now. And yet we don't even know where they are because nobody's actually capturing where they are and what they're doing.
Dr Jordan Vollrath (18:46.786)
And what would the day to day look like for a primary care physician then practicing in a team based model? we have, you hear the analogy of, you're the quarterback of the team, but like in practice, what does that actually look like? Like how much time are you seeing patients just one-on-one versus how much time are you seeing group counseling or like group sessions with multiple other providers versus liaising just sort of.
through the EMR or verbally in the hallway about a patient with these other providers? Like how does that actually start to take form?
Ivy Oandasan (19:22.714)
So my dream, because I actually worked in a family health team, right, or worked in a family health team and it wasn't working in this particular way. First, I would want to have a cadre of primary care providers in my team. I actually would prefer to have more nurses, RNs, that would be working with me and a number of family physicians that we would say, okay, we are going to guarantee for our practice roster cradle to grave care.
those of us who are going to be here, we need to make sure that we all are trained to understand how to deliver primary care. Most of our nurses and pharmacists and social workers, they never train in a primary care context. They're all work, they all train within the hospitals. And so one of the challenges when we get them into our practice is, is that we have to find a way to re to help tailor their, their work to primary care. And that takes a lot of work as well.
for us as family docs, right? And part of Team Primary Care was we created curricula for the other 19 health professions to say, what do you need to do? So now if you have a team who kind of knows all how to play baseball, right? We all have various different kinds of roles. I would like to, as a family physician, I want to be able to see some of my patients as well. I want to see, I have a shared patient roster. I'm seeing patients, the nurses are seeing patients, the pharmacists are seeing patients.
And most of my patients, may be, I'm hoping that I still see babies, et cetera, as well. But most of the time, those babies could probably be seen by the nurses. Some of the non-acute things could probably be seen. Pharmacists might be able to see somebody as well. But I'm working co-located. And so if something comes up with somebody who
says they have a cold, it might actually be a pneumonia. And the person might say, you know, the nurse at seeing that might say, I'm not sure. I'm going to go knock on the door to Dr. Waddeson because she's working right now and I'm going to get her to see you. And I know that particular patient because she shared. My afternoon though, because I actually have training in palliative care, let's say. I don't, but let's say I have extra training in palliative care.
Ivy Oandasan (21:42.754)
I know that my practice actually wants to have palliative care as part of the delivery of services. So for the team, I'm going to do palliative care and I'm going to be there. But those nurses and pharmacists and social workers sharing that patient population with me, they know they can get a hold of me if they pick up a phone or they know that and I'm doing, I'm doing enhanced care in a particular area because the practice population needs it.
the team tailors who does what, maximizing who can do what because they have the skillset and they're adaptable and flexible to fill in when there's a need. And to do that requires a special kind of, like I think it requires a new kind of mindset, a new kind of training that can actually get you there.
a willingness, a real willingness to share the load. And as family physicians, so you and I, we're trained as generalists. We're trained as generalists that are supposed to do everything. One of the biggest challenges for us as family physicians is sharing and trusting that other healthcare professionals can do it, maybe not like us, they'll do it like the way that they do it, but
But I think the notion of us never training with the other healthcare professionals necessarily, we don't really trust them. We don't trust their knowledge base. We don't really trust their skill set. And then there's the fear that, I'm liable. If something happens as the physician, I'm the one that's going to be liable. And that's not necessarily all true.
particularly with all professions having their own regulated scope. But there are nuances related to that. So I think the liability issues within the team are challenging. And that is something that we're going to need to think about as well.
Dr Jordan Vollrath (23:55.186)
I wonder how much of it is sort of an ego roadblock there. Like you mentioned a bit about, know, apprehension to relinquish some of that power control, I guess, over, okay, this is sort of the beginning and the end of where the diagnosis and the treatment happens is in the doctor's camp. But obviously, I mean, that's very, you know, short sighted way of looking at it. Obviously the diabetes educator.
is gonna do a better job at counseling the diabetes patient than I am. They do this for a full time thing. Obviously the psychologist is gonna do a better job counseling the mental health patient than I am. The pharmacist is gonna do better medication reviews. And so some of it is perhaps the liability, but like you mentioned, right, these people are professions regulated. They have their own like practice and insurance and restrictions and.
all the credentialing that goes along with it. So the liability perhaps is a bit of a misconception, but maybe more so just on the doctor's end of, okay, I need to start delegating. I need to be in a little bit more of a almost like managerial role as opposed to just boots on the ground, one-on-one patient care.
Ivy Oandasan (25:06.17)
That's a good question and how much of that is professional identity, right? And I think from the very day one when you get to med school, you are the leader, you are the most responsible, you're ingrained that of that mentality that the buck stops with you, right? And I think we need to be curious about the kind of professional identity that we want to give to our physicians.
Currently I'm also advising with a new medical school, Toronto Metropolitan University's medical school. And one of the things that I've been helping with is their interprofessional education curriculum. And this is a group of new medical students that are gonna come in and I think we actually need to focus on professional identity, give them an opportunity to think about who are being curious? Who are the other health professionals that I'd be working with?
Huh, wow, what's a traditional healer? Holy cow, they do stuff that's not in my evidence-based medicine. How am gonna actually manage that kind of piece? Like, what is that? And I, again, I think we need to be thinking about, you know, what is the future? What do our patients really want from us? And how do we create a professional identity that is open?
open to work with others, knowing that by working with others, it's probably going to give us and we know by evidence that it gives us better professional satisfaction and it certainly helps us with our wellness. It's really hard to do the work that we're doing solo and yet our systems, the fee for service is the incentive to actually just see people.
one visit at a time, one issue at a time. And it may not be as efficient as what we could. And it's not very, I would say it's probably not as healthy for us as physicians.
Dr Jordan Vollrath (27:15.394)
So let's say people are bought in on the idea, you know, most new grants have probably trained in a fairly large academic setting with most likely a team-based care model or about as pretty close to it as you're describing here. But then there's sort of that discrepancy between, okay, all these clinic owners are basically entrepreneurial doctors who get out there, take a bit of risk, start a clinic. How do we get to that point where they're willing and able to sort of see the
incentive of how do I actually launch a clinic with a team-based care model? Because it seems like that's sort of where there is this gray zone of, okay, well, this exists in like a publicly funded government created organization, but how many of these successfully running community care clinics are out there with the team-based model? And how do we start giving people a blueprint to replicate that versus sort of the
copy and paste model that people, you know, okay, we'll use a little bit different of an EMR or a check-in kiosk, but it's fairly similar across the board for how to create your own solo or group practice. How do we start shifting the culture towards, I want to create and build that team-based care model versus what a lot of the new grads are doing now is they're just putting their hands up in the air saying, I don't know what to do. I'm gonna locum for a whole bunch and kind of just join on with somebody that's out there as opposed to.
signing up or doing a whole lot of anything on my own independently that's new.
Ivy Oandasan (28:44.684)
Again, it really gets back to the funding model, right? And are there innovative funding models that are out there? So there's the government ones that are here in Ontario, the family health teams, although they've capped it in terms of the numbers. And again, being part of a family health team, I'm not sure that we are working as a team and actually have been able to fulfill the needs for the practice population and change the way that we practice.
Having said that, there's a lot of good things related to that model. I was just at Founding Medicine Forum and there were examples on the ground of physicians coming together and fee for service, but putting their money together and hiring the teams, hiring other healthcare professionals. And so there was a model that way. That's a little bit fuzzy too, because now you're an employer when you're with the team.
and what are the issues related to be the employer. There are others that are there, I just wonder about, are there, I see models like in Alberta, there was one that was looking at the community that was funding the clinic, right? And the municipality was paying for the rent of the clinic itself. And then they took monies from the government for the...
the some of the funding for salary based components of it. And so there was ways of putting monies together. I just think that we as physicians, we're not really good business people. I'd love to see some really innovative models from the business world to come in and talk to us to say, here's, here's how you could do this. And I'm not talking about privatization necessarily. But most of us as physicians, we don't want to do these new grads.
And we don't get practice management. They don't get any practice management really. So you're expecting them to go out there and set up their own entrepreneurial practices when they don't even have the training to do that. And they don't want to do that. They want turnkey operations. How, what would it look like to have turnkey operations that would allow us to offer, let's say in 2030, I've got all of these grads that are coming out and they want to have team-based care.
Ivy Oandasan (31:07.566)
Who can create that? Who can create that and help them walk in to deliver the kind of care that they want with the teams? It's a dream for me. But I actually wonder whether or not we've talked to the business folks. Have we talked enough to think about really different kind of models of care? And have we looked at other countries to see what's actually working with them?
Dr Jordan Vollrath (31:38.306)
I mean, is this something that the CFPC would consider putting in as part of the education in the curriculum is kind of the, the facet of business and how to run a clinic sort of regardless of what the model is, because right now it's pretty much an overlooked part of it, right? I feel like a lot of the clinics that have been started out there is, you know, a combination of ambition and naivety. Like you mentioned, we're not business people. Like when it comes to putting together a
profit and loss statements and finagling an Excel sheet and like all these things that we have literally zero training on or at least the vast majority of us that went through a science background get to that point. And then there's sort of, okay, we've got the dogma of you graduate and start a practice, open a clinic and away you go. And a lot of people do well figuring it out on the fly, but there really isn't a lot of training going on to actually set us up for success on this side. And it is very, very difficult.
Ivy Oandasan (32:36.378)
Well, the curriculum is full, right, for family medicine. And I don't know if you heard last year, there was a move to try to say extend the training to three years because of the recognition that there are all of these areas that they may not be fully trained or have those experiences. And so the extension of training was to deal with this. The third year was supposed to be, and I was there kind of as part of my role at the college.
was supposed to be a transition into practice here. The vision was that third year was going to be more of the family medicine residents being more independent. They could have actually been in a lot of these practices that actually don't have any care right now for access to care. We could have set up clinics where our residents whom we actually have more control over in terms of saying, here's where you can go, here's where you...
could have put them in various different kinds of clinics with teams where they could be providing care and learning the business aspects of it, learning the practice management component of it, and having supervision maybe by phone, maybe by video so that you're not necessarily, but we were going to give them a more autonomy and be able to transition them into practice.
Albeit that that was paused, so well not paused, it was stopped. So the college is not going to mandate three years of training. So where do you fit in practice management? Well, you fit it in after hours, you try to fit it in when they're in clinic and the whole idea is in the first five years of practice. And we're trying to find ways in which we can offer those kind of practice management kind of training.
in the early years of practice. Is that sufficient? Most first five years in practice would say it's not and it's something that they continue to actually want more of. I think we also need new innovative models that they could actually try to practice within. And right now it's just easier to say I'll just take a, you know, there's a hospitalist role that is going to pay me a lot of money.
Ivy Oandasan (34:59.276)
I trained as a generalist across cradle to grave care, but a lot easier for me to go into the hospital, work my shift, get a lot of good money and not have to deal with office expenses. And so the incentivation is we're training people to broad scope, we're paying them to actually be more specialty focused in a particular area or clinical domain area like
hospitalists, emerged docs themselves, palliative care, and they're all needed, right? We need a good mix of family physicians that can actually provide all of that kind of care. But the way that the funding is set up actually drives where our family medicine grads go.
Dr Jordan Vollrath (35:52.96)
Yeah, the incentives, right? Every system is perfectly designed to achieve the results that it gets. And that's a big chunk of it is just following the finances and how does the remuneration take place?
Ivy Oandasan (36:07.322)
Exactly.
Dr Jordan Vollrath (36:09.922)
So I mean, I'm sorry, go ahead. Go ahead, go ahead. Well, I was gonna say in terms of like everything coming together, like the systems in crisis, we need reform. we're seriously as a society having to consider like kind of a bottom up refresh of how we do healthcare. Like what's actually going on behind the scenes? How do you coordinate between such a large volume of stakeholders when we're thinking like, okay, we need to go.
all the way back to the source for the funding model. We need to get the government on board. And obviously that's like a long process and budgets are tight. They've got all their other mandates they're trying to keep up with. And then at the same time, we're changing the culture of how do we practice fitting into that team-based care model. Also having to get on board all the other facets of healthcare providers, the nurses, the chiropractors, the dentists, the pharmacists, you name it, literally changing the curricula.
to start fitting with this new model. But there's no single point of authority actually like in control being able to pull all those strings. It's kind of like, how do you coordinate such a magic symphony of things coming together in unison to create that transformative change that we need?
Ivy Oandasan (37:27.13)
You know, it is the question of how do you move complex system change, right? And that's exactly what we're doing. You know, I think that, let's start from the top. The top is that I think we need a good definition of what we mean and what are the expected services that every Canadian should be able to expect to receive if they have a primary care provider and ideally a team. Is it okay that I go to see a family doc and they're doing primarily cosmetic surgery?
and I need my prenatal care and they're saying, nope, I don't do that because they have a choice, right? Right now we come out of residency training and we get to choose and that is a beautiful thing. It's a beautiful thing. But in terms of the accountability related to what should patients expect if they have a primary care provider, what are those services? Even a family health team right now, they don't define what the services are.
And I go back to my Singapore example, they define the government, the federal government says, this is what you will receive. If you actually go to a primary care team, you will be receiving this kind of care. So name them, name it in itself. Once we do that, then you begin to say, okay, well, who are those primary care providers that need to be providing that kind of care? Well, we had 20 within our team primary care project. And it was interesting, you ask them,
Do you train your physiotherapists in a family practice clinic? What about the nurses? Nurses, in fact, don't have any training within primary care family practices. They all train within hospitals. is no, there is now, now there is, but there was no training specifically for family practice nurses. They have to kind of figure it out on their own.
So if we know that this is the bundle of services that is required, then we need to train them. To train them, many of our universities are all recognizing that there is a standard of interprofessional education. So all of the health professions have to learn how to work together. What they don't have is a standard of primary care. If we were to say social accountability,
Ivy Oandasan (39:47.564)
Everybody needs to be practicing or learning within the primary care context. That's an accreditation standard that is pushed within our educational system. And we can work together towards doing that. There's a lever. Accreditation is a lever. Okay, let's move to the practice side. So we're very lucky. know, hospitals, they have accreditation standards, right? Right? We don't have to go through accreditation standards.
And if a pharmacist sets up a practice right now and nurse practitioner sets up a practice, I'm a family doctor, set up a practice, I'm not accountable to anybody. I don't need to actually show them what I'm doing. And so there is opportunities for creating standards of care, for primary care. And what if you were even participating in an accreditation visit, which is quality improvement.
which is a part of our scope and regulated scope. If I was to do that, to do an accreditation visit, having somebody come to my office to take a look at my practice, to say what are the things that I need to improve upon within my primary care practice, that is a team, I could share that with my college because that's continuing professional development. I could share that with my regulatory body and that's there, but we don't have a standard.
What if we did have standard? What if the standard was an incentive to share with government that, look, I've increased my access to care because look at my standard that I'm doing and my improvements that I'm making. And could you give me an incentive or could you give me a financial kind of remuneration to actually do this because I want to do something more.
And government, when the federal government gives monies to the provincial government, billions of dollars to improve primary care, and there is no accountability framework for that, they don't have to show anything. think people need to show something. So can we, so for me, it's coming up with what's the standard? What's the expectation? And once we have that,
Ivy Oandasan (42:03.246)
How do you train people for that? And how do you get people to practice in that way? And how do you support a funding model that allows for that to happen? Because as you said, as we both talked about, it's the funding that influences how people are gonna be working. And if we continue to fund hospitals as the bright, shiny place that people go to, if we continue to fund solo providers,
then you're not going to get what we actually really need at the end of the day.
Dr Jordan Vollrath (42:38.582)
And then when it comes to that creating the accountability and sort of that universal buy-in, putting the incentives in place to make that happen, like when you guys did the big project with the 20 other professions, what do they think? Do they want what we're talking about right now in terms of that team-based care model? Or are they kind of like, you know, a little bit lukewarm on this sort of thing. Maybe they want to do their own thing. Like what was sort of the vibe from all those other professions on working
towards such a
Ivy Oandasan (43:10.532)
think if you talk to people on the ground and you talk to educators, they're all as a want to do this. You talk about people who are, you know, who are burnt out that are in the community, they want to be able to do this, right? You talk to the associations who are, who lobby for their own profession.
Ivy Oandasan (43:34.222)
there is some interesting politics that are going on where I'm not sure that the collective we team versus the person that needs to actually or the profession that needs to be the leader and just be the lead, et cetera. There's a spirit at the level of professional associations.
Dr Jordan Vollrath (43:38.114)
I can imagine.
Ivy Oandasan (44:03.406)
that is not team oriented. And rightfully so, because really they're there to actually meet the needs of their stakeholder who is their profession. What we don't have is our tables. So Nova Scotia, for example, has now brought an interprofessional regulatory bodies, right? So all of their professions come together and they have to make sort of collective decisions together. Where are those tables?
So if I look at how I'm training in family medicine right now, I don't have a counter group within nursing or pharmacy or dentistry that actually is training their own professions within the primary care context. There could be a table at the university that could bring us all together. And I was just speaking at in the North in Northern Ontario where there's a grassroots group.
of colleges and universities that have been, they're called the NICE Collaboration, the Northern Interprofessional Collaborative for Education. Nice, isn't it? That's great. And they have come together at the grassroots saying, we're gonna come together and just talk together about how we can train our professions together. That's a grassroots component of, they created a table. What about in the region or in the provinces,
Dr Jordan Vollrath (45:07.913)
Great acronym.
Ivy Oandasan (45:26.744)
I see BC and Alberta, actually have a table where they have the professions coming together to talk about primary care reform and then dialoguing about how are we going to make this happen. At the feds level, you know what, there was in the pandemic, you know what, we've got emergency measures, we had the mental health commission that was created that brought an FPT table together to actually talk about
the population health, we talk about the mental health commission in itself, there is no primary care table at the FPT level. So each province is going out there creating their own primary care reform, doing their own kind of things with our taxpayers' money and nobody's sharing across the provinces about what they're doing. We could create a table to actually have those conversations and we could get
the kind of research that is needed to identify the best practices. And I think if we could actually just mobilize funding in a way that actually is with a fulsome strategy that addresses education, practice, reform, research, and infrastructure, I think we could move this forward. Now, people will say, you're a big dreamer, Ivy, you're just a big dreamer, et cetera. But I think about
complex system change and the evidence for it. And system change happens with different pockets doing their things connected. And we just need to drive people towards primary care. If I'm a regulator, what can I do to improve team-based care? If I'm an educator, what can I do to do team-based care and primary care? And how can I group myself with others?
who are doing similar things. And how do I show the evidence that it's making a difference and getting that evidence to scale and spread so that other people don't have to redo the experiment? We don't have a primary care collaborative in Canada. We have a whole bunch of associations. The United States has a primary care collaborative. We don't have a nature here. I think people have been so burned by these big, these big
Ivy Oandasan (47:53.208)
groups and projects and institutes etc and they may not have been as effective in the past. I don't think that that's a reason to say no to something that you need innovation for at this point in time.
Dr Jordan Vollrath (48:06.476)
But it's definitely, I'm sorry, definitely like a challenging problem, right? So it almost feels like just with the distributed, disseminated chain of command in healthcare, almost like an ant colony, like everybody's out there doing their own thing, kind of like generally working towards the same things. We've got the advocacy bodies and associations, and then we've got the colleges, you know, just enforcing those minimum standards. But when it comes to that, like how do we actually drive and move care?
You know, that is that gap in the system of where are these coalitions and these people that are trying to actually push that through? And maybe that would be an interesting like six months plus one extended skills to program to start working in there is like, how do we start grouping up and, putting people in that captain seat, trying to drive it. Like that's, I guess one of the things the U S system does have with the private pay model is they have these bigger.
clustering of practices, right? You have these larger group practices, have these basically just corporations, which are numerous, you know, dozens of group practices. And so you have, you know, kind of a middle layer in that chain of distributed command actually helping to push things forward versus here. It's, very much kind of like ant colony. Everybody sorta knows what to do, but when it comes to step wise change, uh-oh.
Ivy Oandasan (49:36.548)
And it's not organized, right? So it's kind of, it's a here's your money go. And as I said, there's really no accountability for what we're actually getting. You know, we look at the monies that are going to the provinces now, billions of dollars, billions of dollars going to the transfer to the provinces. Is there a way that we could take that so that people from each of those provinces can learn a little bit from each other? Is there an opportunity to share some of that monies?
One of my biggest disappointments with Team Primary Care is we were given $45.3 million. That's a lot of taxpayers' dollars for a 17-month project, 17 months. And we tried, I have tried to get the sustainability afterwards. I have a call to action with over 1,000 names of people that wanted to continue the work afterwards. And one...
there was no monies from the feds. Okay, granted, I understand they put a lot of monies into it. Tried to get the provinces on board, there's no table. So we couldn't actually bring the provinces to even agree upon it. Went to the professions, to many of the associations and said, hey, could you pony up some monies and maybe we could actually come together and come up and continue this kind of work. Not sure our individual members would want us to be paying for team based care.
and
It's another innovative project that is there with a great website, www.teamprimercare.ca with lots of great work and there was not an opportunity to actually carry it forward.
Dr Jordan Vollrath (51:24.362)
Is anybody doing a half decent job of this process right now, either a specific province or another country? Like, is there somebody that's cracked this nut yet?
Ivy Oandasan (51:35.834)
So it's interesting because, so what's the evidence, right? So do we even know what we mean by has cracked the nut? What does that mean, right? Because everybody will say something different. Government will say, well, cracking the nut means you have increased access to care. So that means that you're seeing just a whole bunch of people. Cracking the nut might be reducing the number of hospitalizations, right? Because you're dealing better with preventative component of it. So what do we mean by cracking the nut? So.
If I look at where people are doing innovations, the province of PEI, all move towards patient medical home models. Do we know whether or not it's made a difference? Again, where's the research? What are the metrics that we're all going to be agreeing upon so that Alberta can look at PEI and say, look at them, they did this and this is what actually happened? Provider satisfaction, patient outcomes were better, decreased hospitalizations. What are the metrics?
where are researchers who could come together to define what is that indicator metric that we're looking for? I would say there are countries. I mean, look at Singapore, Singapore, which is a small country, 37, 300 and whatever kilometers wide. They're a small country and they are able to innovate because one of the things that they have is they have a government that's been in power for over 30 years. They don't have to actually
shift every time we have an election and then we have sort of some ideas and then the next government comes in and we have to start from scratch again. And so that we never can move to a place of moving our innovations forward, particularly in the healthcare system, because we have these crazy government cycles that we have. And I don't know if it does as well either. So
You know, I think, is there anybody doing it? Yeah, there are. But do we know what that means? I think we need to come to consensus on what do we mean by team-based care? What is the outcomes that we're looking for? And how can we shine a light on the ones that are really doing some great work so we can learn from them? And I'd love to learn from somebody in BC. I'd love to learn from somebody in Nova Scotia. I don't know who they are.
Dr Jordan Vollrath (54:00.002)
What would you suggest would be the KPIs or how do you even assess that of dollars per boo boo fixed or number of ER visits? What do you even look at to take sort of a holistic picture of success?
Ivy Oandasan (54:16.462)
I'd love to look at the, again, the notion of access that everyone should be able to say that I have a team. So if the community health survey, you'd say that everybody would say that they have that. So that's one indicator. The second I think is, it is the reduction. So the reduction in referrals. So if I trained to be a generalist,
and I can deal with anything from cradle to grave, I really don't need to be referring to many of the specialists, particularly if I'm in a team of family docs where we can work together and there may be somebody who has an interest in adolescent health and there may be somebody else who has an interest in sports medicine. I can refer internal to my group. So could I measure the number of referrals that are going to specialists?
And do those specialists need to be seeing my patients on a regular basis when that's just a specialty code? I would be looking for number of referrals, number of hospitalizations that you have. I'd be looking for physician wellness. Numbers of burnout rate that would actually be reduced if we did this well, right? I'd be looking for...
improve access to care so yeah, you'd be seen by a team member within a 24-hour period of time. It doesn't have to be the family doc, but you're going to be seeing somebody in the team and I can guarantee that you're going to be seen within that day. So access to care. And I would want to be looking at efficiencies from the provincial funding models. I would want to be able to say to the provinces that you're saving money.
because you've got less people going to hospitals, less people going to emerge, less numbers of specialists that you're going to, because we're taking a lot more good care in an infrastructure that has been designed to keep people out of hospital. What's the metric for that?
Dr Jordan Vollrath (56:35.01)
One of the really interesting things there was just the number of referrals. I do wonder, like I've often found myself critical of like governments and just the amount of government budgets that goes out to consultants. And then the question is sort of, didn't you just hire somebody competent to do the job that was needed to be done in the first place? But yet now that I'm reflecting on it, it's like, I'm often guilty of this myself. Like I'll send a patient for cardiology. Like I'm pretty sure on this, but it's more of just a risk.
mitigation, you know, okay, I'll sleep a little bit better with reduced liability and honestly kind of just passing the buck a little bit. It's like, wonder if that, like how much, you looked at it at scale, referrals being unnecessary, how much more clog in the system and inefficiency does that introduce that perhaps just looking at the family medicine scope of practice could be able to, I don't know, improve upon.
Ivy Oandasan (57:32.314)
Well, I think about even the procedural skills, right? We train our learners to actually do procedural skills to do the lumps and bumps, cetera. So they know how to do that by the time they leave. You go out into practice, that's a heck of a lot of money to spend if you're a solo doc or entrepreneurial doc to actually get all the equipment to do the procedural skills. Am I really going to get my money back by doing those procedural skills in my practice?
Or is it easier for me to refer to a plastic surgeon that might be a year wait? Yet, if I was funded in a way that recognizes my generalist skills and actually appreciates the fact that I can do that, and I can actually have the infrastructure to actually have those kind of materials and instruments like every hospital has, but the physicians don't have to pay for it.
Huh, maybe I would do it. And maybe the care would not require a one year wait to get to plastic surgery.
Dr Jordan Vollrath (58:40.97)
That is very interesting because yeah, patients get delayed. It costs more for the same procedure for the same thing getting done. That would be an interesting KPI to look at, not just how many morphine doses did I prescribe this year, but like how many referrals did I send off? And what did the specialists think of that referral? Should I have just dealt with that or was that an appropriate one?
Ivy Oandasan (59:07.438)
And so, you know, just dealing with there's a new whole digital infrastructure that's coming down the pipe with Infoway and Kaihai working together. I don't know how you'd measure those referrals. We don't even have the capacity to be able to actually determine how we would even get that measure. That's how individualistic.
Dr Jordan Vollrath (59:30.838)
put a plug out for Ocean, I guess, and the referrals platform if we had something a little more standardized, then we'd start actually seeing these things.
Ivy Oandasan (59:38.618)
We could, we could. And so there is that notion of how do we design the system that actually can track the continuity for the particular patients. And my hope would be that Infoway can actually figure that out. But when I spoke to them about, gosh, you know that each EMR that is out there is bought individually. at least in hospitals, you deal with one hospital and you deal with their platform. In the primary community care,
you're talking hundreds to thousands of primary care providers that are out there that all have to agree upon one kind of system and agree to actually share their information. It gets back to the way that we were designed in the first place. And the fact that we have an elderly population with a healthcare system that was hospital-based and it doesn't align with what the population needs now.
Dr Jordan Vollrath (01:00:36.086)
I guess going forwards in the coming years, like, how long does it take to ease a crisis? Like, what should we realistically expect if things are going well versus how do know if things are not going?
Ivy Oandasan (01:00:50.008)
I'd love to see the smaller provinces that have already made a good start, right? So PEI has made a good start. I don't know how much of the, when we talk about, you know, what's the recipe for TeamBase to move to TeamBase primary care, people will just say, you just give them money and you put all the people together and they'll, you know, it'll just happen. No, you can't just put people together and expect that they're going to know how to re-
design their work that actually can provide the efficiencies and the collaborative approaches to care that would allow for new approaches to how we bring patients in and what they do. So if I go back to the province of one province, one is the ones that got the money, where did they put their money? Did they get the leadership? Was there leadership? Were there tables, interprofessional tables that actually helped them?
And when they did that, did they get the training? Did the teams get the training? And from the training, did they actually have the infrastructure with the shared EMR? Did they have those things? Because there are, if you look at the patients medical home model from that's the vision for the College of Family Physicians of Canada, it's about an infrastructure that supports. So there's a change. So do we know in PEI, where many of them have moved to our patients medical home model, they have the structure? Did the people
working in that structure, get trained, retrained to work in a new way. Is the culture incentivizing teen-based care? Because there's a cultural component of that. Are there incentives to do that as well? And are there, is there a move towards improvement, continuous quality improvement, which again, I get back to sort of standards and that you go and you open your doors and say, hey, help me understand where I can do better.
And by doing better, okay, I can actually change my practice and I'm accountable. So I'd love to see a province like PEI. I'd like to see anybody else who's doing this. So Ontario is going to be doing their own primary care coalition. Alberta is doing their own. BC is doing their own. Could you come together and just say, what are the metrics that we're going to be looking at? Could we come together even just once a year and just share?
Ivy Oandasan (01:03:18.455)
What's actually working well? And where were the stuff that you want to avoid? Could you come together once a year just to even talk about that? Who would bring us together? And that's always the question for me. Who will stand and say, I will take that leadership role from a profession, from a government, even from maybe it's our patient associations that need to move forward. I don't know.
But it's about bold leadership.
Dr Jordan Vollrath (01:03:53.538)
What about for all the community providers that are out there right now? There may or may not be access to a funding model for a team-based care. What can they start doing or educating themselves on or at least like pushing for in terms of changing the culture or trying to actually get to that point of systems change?
Ivy Oandasan (01:04:15.994)
We're all taxpayers, right? Whether we're a healthcare provider or not, we all have family members that are falling through the cracks. You know, what makes things happen is whether or not we voice to our governments what we need. And so I would say one, if you're tired and you're burnt out and you're 24-7 care,
and you're doing it by yourself because that's the way that the model has made you do it, maybe we need to think about calling for something different. And who are those people? I actually would like to say that the primary care providers, I named them at the very beginning, anybody has first contact, we're the ones that are not working in the hospital, we're the ones that have less pay than the ones that are working in the hospital. Wait a minute, most of the care is in primary and community care.
I wonder if we banded together and said we need a shift in the change across professions and across sectors. Would that make a shift in difference? I would hope so to say yes. And I think the other is, I'm hearing it from our patient provider, patient associations and our patients themselves. They are the ones that are really.
suffering in many ways. And when my parents is, my father is 89, my mom is 86, and when their family doc who I trained with retires in the next couple of years, who are they gonna go to? Who are they going to go to? And I worry about that. I worry about even if it's not you right now, it's one of your family members. And if we don't...
we don't actually make this a priority. I think it's an election issue. It's an election issue. And we can voice and there are provinces that are making differences. There are things that we don't have to actually have this learned helplessness. I think it's a learned helplessness that we have as Canadians. I don't think we need to do that. But it requires collaboration.
Ivy Oandasan (01:06:40.44)
It requires us to band together. And we can't do this alone. It is a team. It's going to require a team.
Dr Jordan Vollrath (01:06:49.372)
Does it seem right now like there's any political party specifically pushing towards this vision or is it again going to be starting with your local MLA and writing letters trying to get these specific changes on?
Ivy Oandasan (01:07:03.918)
Well, you know, the feds pledged for the primary care. So and they did increase the funding for the bilateral agreements, right? So there is monies that are coming through there. I think it'll need to be each of the provinces because the provincial governments are the ones that are managing health care. So the accountability of the provinces, we need to push for them.
to demonstrate that they are using the funding that they got from the feds and they're making a difference. And if they are not, then there needs to be some accountability. But that is every single individual province has to do it individually and they have a four year cycle and whatever comes forward, they'll start and if they don't finish, then the next government comes along and restarts it again. And we're the ones that are going to...
not move ahead very quickly.
Dr Jordan Vollrath (01:08:04.15)
I guess just being respectful of time. We've run over our hour here. Any other final things you wanted to comment on before I let you go for your afternoon? Get out of here.
Ivy Oandasan (01:08:13.826)
Yeah, you know what, I don't want to end with a doom and gloom. actually think that there are hundreds and thousands of people, and I know many of them who are actively wanting to work on this, and they are doing it. And there's lots of innovation that's happening across the country, and there's great funding opportunities that have come. I just think we need to think about how do we not make them pilot projects any longer? How do we...
move to accountability? And how do we really recognize that we're the ones on the line? No, like, I don't know if I'm going to have a primary care provider in the future if they actually are going to be retiring. And as I said, my parents and my other other family members, I don't want them to fall through the cracks. And so I think that there is voice and I think there's an opportunity for us to actually come together.
So that's my hope and I do believe that there's some great things that are happening in Canada and would encourage you to get them on your podcast. So there you go.
Dr Jordan Vollrath (01:09:22.644)
Absolutely. Well, I'm personally inspired a little more to actually start getting involved. I've been just glued to the American politics side of things recently, but you're right. That learned helplessness of we don't have to just accept mediocrity as the status quo, but actually get out there, start talking to the MLAs, start looking for the opportunities within our profession and to build up that interprofessional collaboration, working towards that team-based model and just...
Systems reform.
Ivy Oandasan (01:09:55.008)
One day at a time.
Dr Jordan Vollrath (01:09:57.692)
Dr. Ivy Oandasan, thank you so much for joining me today. Really appreciate it.
Ivy Oandasan (01:10:02.724)
Thank you for the opportunity. Take care.
About the Author
Cherry Health
Canada's Medical Network
About the Author
Cherry Health
Canada's Medical Network
About the Author
Cherry Health
Canada's Medical Network
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