Health Committee on April 28th, 2009

[Nicolas Dufour, Bloc, Repentigny, QC]

I believe Mr. Ouellet has something to say.

[Dr. Robert Ouellet]

Debt is obviously an important factor, but in spite of everything, many young people nevertheless want to study medicine.

Many people can be good candidates for medicine. At a dinner at our clinic, about 15 of us were talking and said that, if we had to meet today's criteria, no one around the table would go into medicine. And yet there were specialists and general practitioners who were excellent physicians.

That means that perhaps we have to review some of our criteria. A number of people can become doctors in Canada, but unfortunately there aren't enough or capacity to train them. And yet there is a major shortage of physicians. That's why we need help.

[The Chair, Conservative, Joy Smith]

I think Dr. Kopansky wants to make some comments on that too, Monsieur Dufour.

[Dr. Deborah Kopansky-Giles]

You actually had two questions. One was about research capacity and funding for research and the other was about the debt load. I also wanted to say earlier that chiropractic students graduate--as there's no real funding or subsidy for chiropractic education--with a debt load of $120,000 to $150,000 as well. But it doesn't entice people to go into research because researchers make very poor money.

So we actually have residency programs where we're training researchers, and it's really hard to entice our chiropractic students to go into research residencies. We have three residency programs. We can only accept five students a year, and of those students, about three of them will go into research. But because of the way research projects are funded, we can't fund a salary for a researcher under a grant anymore, and you can barely get administrative costs covered under research grants. This is an issue I'm facing every day in the research I'm doing.

So I'd like to comment that not only do we have problems with students with debt loads, but they're not going to choose research careers because they can't pay their student loans off that way.

[The Chair, Conservative, Joy Smith]

Ms. Fréchette, you also wanted to make a comment on that, did you not?

[Danielle Fréchette, Director, Health Policy and Governance Support, Royal College of Physicians and Surgeons of Canada]

Thank you very much.

Dr. Ouellet said that the debt level upon graduation definitely deters people who come from disadvantaged socio-economic backgrounds from choosing a career in medicine. They cannot contemplate spending 10 years at university. Clearly this is a major barrier to the recruitment of a number of physicians who could meet the needs of various patient categories.

[The Chair, Conservative, Joy Smith]

Thank you.

Ms. McLeod.

[Cathy McLeod, Conservative, Kamloops—Thompson—Cariboo, BC]

Thank you, Madam Chair. I certainly appreciate all of the presentations.

Before I proceed, I just can't let one comment go unremarked. I am also from British Columbia, and last year I attended an amazing conference about health care innovation and the projects that were happening that were funded both federally and provincially. I just wanted to reassure Ms. Murray that great work continues even to this day.

I had to actually just make that particular comment.

I think there are a few things that have stood out for me. One, I really appreciate Dr. Valade's comments around the opportunity within the federal government and where we're going with alternatives, whether it be chiropractors or other services. I think those are very valuable.

I really like the comment around a special fund for rural and remote. At some point we need to do some uptake on that. But there are two areas that I would really like to focus my five minutes on. We hear about--and I think I'm hearing the same--great innovation happening across the country. How are we going to bring it altogether and create that actual change?

We talk about collaborative care. We know we have pockets of great work. What do we need to do to actually make that a reality?

The other piece I can focus on--and I'll open this up to everyone, both of these questions--is the potential use of physician assistants. But I also appreciate that in our primary health care system, the way we pay doctors doesn't really allow for any kind of collaborative care. It's very difficult for nurse practitioners, nurses, to work in a primary care environment with family physicians by virtue of our payment model. So would physician assistants add value, or do we really need to look at a collaborative primary care team? Someone who knew that we were doing this study, who is a physician, said we should have the foreign-trained doctors be physician assistants as a pilot project.

I want to throw all those comments out and open it up to everyone. Again, it's around innovation and how do we actually create change with all the good things that are happening, the interdisciplinary team, and where we go.

[The Chair, Conservative, Joy Smith]

Who would like to start with that?

Ms. Neufeld.

[Kaaren Neufeld]

Thank you, and thank you for the question.

I think when we are talking about innovation and collaborative care in professional teams, the group we need to talk about the most is the patient, the client, and the resident. To me, collaborative care includes having them as the heart of the team, at the head of the team. When you involve patients and families and residents---the community--in the collaborative care practice, I think that's when change will really start to happen. We need to be able to put in place systems that allow their voice to be heard concerning the types of system-level improvements that we need to make, not just regarding the therapeutic interaction between nurse and patient or doctor and patient, but, rather, at the systems level. I think Canadians are ready to engage in that conversation, and for the Canadian Nurses Association, collaborative care means the involvement of patients and families.

I want to speak very quickly about work that the CNA is doing with the College of Family Physicians of Canada. We are working with them to expand a model of primary care that has taken off in Nova Scotia, where nurses and physicians are working together in an innovative fashion, in such a way that they're able to increase the number of patients the practice is able to see. They're able to go from two-week waiting lists to same-day appointment services. There are a variety of very effective innovations that have been applied, through which change is happening there. So that would be an example we would look to.

[The Chair, Conservative, Joy Smith]

Dr. Kopansky-Giles, did you want to say something?

[Dr. Deborah Kopansky-Giles]

I just wanted to comment that I thought your questions were very poignant and really appropriate, especially for the audience and for the witnesses that are here today.

I also wanted to add that it's not just the funding. It's not just giving another bunch of money to people to look at creative projects. There has to be a long-term and sustainable strategy.

In my experience, in the past four years of delivering interprofessional education sessions, where eight health science learners are educated together, we see a lot of things happen. We see, actually, the falling away of barriers, and it's not just a team being plunked together and sharing space. It has to be a team that actually works together, seamlessly, without barriers, and we see that through the educational process.

When we put learners through a week-long or a five-week-long module and they're learning together, they're learning curriculum, and embedded in that curriculum are all kinds of concepts of team-based care and group dynamics and conflict resolution. You see those barriers fall away, and that's when patients really benefit. Those are the types of care and innovative strategies you want to fund. It really has to be that way.

[The Chair, Conservative, Joy Smith]

We have run out of time. I'm so sorry.

We're going to have to go to our next person.

Ms. Murray.

[Joyce Murray, Liberal, Vancouver Quadra, BC]

Thank you, Madam Chair.

I'm going to go back to one of my earlier questions about quality improvement programs based on a framework model. I think those of the witnesses who have been part of that are aware that there's a specific philosophy that brings people together to improve processes and that it's had very good outcomes.

One example that I'm aware of in the Vancouver health authority is a situation in which the number of hours between readiness to be discharged, I believe in the case of maternity, to when the person is actually discharged decreased from ten to one as a benefit of a quality improvement program in that facility.

My question is to all of the witnesses. Have you been involved in essentially a Deming-based quality improvement program, and if so, what would your recommendation be to this committee as to if and how the federal government can encourage the spread of that approach to improving quality and productivity?

Thank you.

[The Chair, Conservative, Joy Smith]

Who would like to do that?

We'll hear from Dr. Padmos first.

[Dr. Andrew Padmos]

I'll take a crack at that.

In my role in Nova Scotia, one of the jobs I held was vice-president of research and academic affairs at the Capital District Health Authority. It included the quality portfolio, so I'm familiar with, at a hospital and a health authority level, the commitment to quality that pervades the system. All staff are involved in the accreditation process that Accreditation Canada sponsors and administers. It's comprehensive and it draws all staff into regular reviews and continuous quality improvement initiatives.

In addition, at the hospital level, we participated in programs under the auspices of the Canadian Patient Safety Institute, and many of those, while they may have a safety focus, in fact are about quality. Built into leadership in the hospitals, both medical and nursing, is a commitment to these processes. Many projects, many prizes, and many programs pull out some of the best innovation that's brought to bear, and it's shared through various conferences that take place in Canada on a regular basis.

[The Chair, Conservative, Joy Smith]

Dr. Kopansky-Giles.

[Dr. Deborah Kopansky-Giles]

I just wanted to add, too, one of the solutions that you might consider. I'll follow up on the previous speaker's comments about Accreditation Canada.

I've been a surveyor for Accreditation Canada for the last nine or ten years. One of the new innovations I see as a surveyor is that when we go into all these environments and do the surveys, we often see fantastic examples of excellent quality improvement, and Accreditation Canada has been making efforts to create these benchmark programs, to make them accessible for other people to share across Canada. I don't think there's enough sharing of that information, because it's a fantastic resource where we see excellent quality improvement going on.

[The Chair, Conservative, Joy Smith]

Thank you.

Dr. Ouellet.

[Dr. Robert Ouellet]

I think I've said that we are trying this year to have some kind of project to integrate all those initiatives across Canada and elsewhere, to improve, first, the access, but also the quality. We have seen examples of what is going on in, let's say, the Netherlands or Denmark, where they have put a lot of emphasis on quality, not only on wait times, because they have solved that problem. Quality is a very important aspect.

This year, we want to try to bring in all the initiatives in Canada and try to spread this, again, to every possible location. Quality is very important, but maybe we need to do something else, which is to put in health goals and targets in Canada. Maybe it could be a federal role to say that we should improve work on obesity, let's say, and put in some national goals. That could be very helpful. If we put in goals, then there are some targets. We need to improve the quality of our service, but also the quality of the health of patients, so this is one aspect that could work.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Ouellet.

I'm sorry, but we're going to have to go to the next questioner because we've run out of time. Thank you for your comments.

Ms. Hughes.

[Carol Hughes, NDP, Algoma—Manitoulin—Kapuskasing, ON]

Thank you for being here. It's certainly very informative.

I'd like to focus probably a little more on remote rural and aboriginal communities. The issue is retaining doctors and nurses up there. It's often more difficult than it is in the cities, of course, and I'm just wondering if you have some ideas with respect to some of the roadblocks that could probably be removed in order to do this. On that note as well, on the locums, do you see that it would be of assistance to change the way that some of the licences are handed out?

Also, would you see the impact of a national home care program as a positive thing, such that it wouldn't be so onerous on the hospitals and the clinics if there were a national home care program with more of an intervention part?

I'd like your comments on that.

[The Chair, Conservative, Joy Smith]

Ms. Silas.

[Linda Silas]

You would have seen in our brief, on educating your own.... That comes from research, both in rural and aboriginal communities. If we're able to find education programs that are built on career-laddering programs in rural communities, they will stay there. Those are their communities; they will stay there. But if you take me and bring me to the north, I might stay there a year or two and then I'll want to come back. So it's really building those bridges.

I'll say quickly that one of the successes we could have from this committee is, again, the observatory or institute, to answer Cathy's question. There are all kinds of different programs out there, in rural, in home care, that are experienced, but nobody talks about them. If we had one pan-Canadian program led by a federal-provincial-territorial...where we all share a positive experience, we would be able to share experience in rural and northern communities, and then find solutions for the country. But we need one spot, which we do not have today.

[Dr. Andrew Padmos]

I think the attention for physician services and other health providers in the north is being gradually and incrementally improved through electronic means. I think Telehealth videoconferencing, in bringing more providers closer to the patients, is making a very significant effort.

I think collaborative education is very important here. Many northern communities are serviced by experienced nurses who work in teams with physicians, often at great distance, and they build up trust over the period of time and I think deliver superlative care.

I do think that the medical and health personnel in those areas need special support in terms of dealing with their continuing professional development. They need backfilling support for locum tenants when they're away, to get that continuing professional development. I think we just have to accept it as part of the infrastructure cost to providing northern, rural, and remote health services.