Evidence of meeting #53 for Health in the 41st Parliament, 2nd Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was physicians.
A recording is available from Parliament.
4:30 p.m.
Medical Director, Cline Medical Centre
Thank you for the question.
Yes, I am part of the provincial system.
4:30 p.m.
Conservative
Wladyslaw Lizon Conservative Mississauga East—Cooksville, ON
What you're practising, is it conventional medicine or is it not quite conventional?
4:30 p.m.
Medical Director, Cline Medical Centre
Well, it's a blend of conventional and what we would call alternative. It's blending the two together.
4:30 p.m.
Conservative
Wladyslaw Lizon Conservative Mississauga East—Cooksville, ON
I don't know whether you are familiar with an Ontario doctor—I think he retired—Dr. Josef Krop.
4:30 p.m.
Conservative
Wladyslaw Lizon Conservative Mississauga East—Cooksville, ON
Yes, and you remember he had challenges with the licensing body here in Ontario. Have you had a similar experience where you practise in B.C.?
4:30 p.m.
Medical Director, Cline Medical Centre
Yes, I have undergone three investigations by the College of Physicians and Surgeons, and just last Friday, I found out that I'm having my practice audited again. One of the barriers to branching out into integrative functional or alternative practice is that you become a target.
4:30 p.m.
Conservative
Wladyslaw Lizon Conservative Mississauga East—Cooksville, ON
I have just one more question.
I'm very puzzled by the case that you're describing here. I don't know how many cases there are on a daily or monthly basis in this country.
What's the main reason that the person you treated was not able to find the proper treatment in the places where she went for treatment?
4:30 p.m.
Medical Director, Cline Medical Centre
I think the main reason this woman wasn't able to find treatment is that the underlying disease process was missed. There were many treatments tried, but they didn't work because the underlying process was missed.
4:30 p.m.
Conservative
4:30 p.m.
Conservative
James Lunney Conservative Nanaimo—Alberni, BC
Mr. Chair, may I just make a brief remark for the record about Dr. Cline? This is only because it was mentioned that he is being investigated by the licensing board.
Dr. Cline, like many of the integrated med docs I know has been investigated by his licensing board, but Dr. Cline has been used by the Canadian Medical Protective Association as an expert witness to defend other doctors who are having issues with their licensing boards for doing innovative treatments.
Is that correct, Dr. Cline?
4:35 p.m.
Conservative
The Chair Conservative Ben Lobb
Thanks very much.
Mr. Lunney is retiring from politics at the end of this session, so I've showed him lots of leniency in the last few meetings. I hope other members don't mind, but we do enjoy his comments, and we want to make sure he gets as much on the record as he can.
We're going to suspend for a couple of minutes, and we'll come back with our next panel.
Thank you.
4:35 p.m.
Conservative
The Chair Conservative Ben Lobb
We're back in session for our second hour of meetings.
We have another witness by video conference, from the UBC Centre for Health Services and Policy Research, Sabrina Wong.
Go ahead, please.
4:35 p.m.
Sabrina Wong Interim Director, UBC Centre for Health Services and Policy Research
You asked me to come and talk about your study that you're doing. Is that correct?
4:35 p.m.
Interim Director, UBC Centre for Health Services and Policy Research
The Centre for Health Services and Policy Research is a University of British Columbia senate-approved centre. It was established in 1990. The mission of CHSPR is to produce and communicate high-quality health services and policy research relevant to the organization, financing, and delivery of health care.
It also has a mission to train students, as well as in knowledge translation and exchange through its publications, media interactions, and exchanges with local, regional, national, and international health policy and health services decision-makers. It is unique in its focus on broader macrosystem challenges and policies that might normally be relevant to just one or a few regional health authorities.
I'll open by saying there is a changing landscape. The provincially and territorially based health care systems within Canada continue to undergo major reforms in response to new technologies and to demographic changes such as an aging population, advances in health care and disease management strategies, and the recognition of the importance of social determinants of health and ensuring the health of the population.
There has been relatively little attention paid to the impact of system and organizational change on health human resources in comparison to the extent to which such changes have occurred during the past decade. Much of the past literature completed for a scoping review for a report completed for the Health Services and Policy Research Support Network discusses the impact of the major acute care restructuring and downsizing of the acute care sector during the 1990s on health human resources, primarily in urban environments.
Less attention has been paid to innovation in the use of different health professionals’ scopes of practice in the non-hospital sector. There is little work on the health human resource implications of the increasing use of multidisciplinary teams and interprofessional collaboration, the use of other types of health professionals working to their full scopes of practice, or the increased use of a wide range of technology.
As a community of academics and clinicians, we know much about how health care services might best be organized and delivered, as well as the different health professions’ scopes of practice. We know little about the interaction of these two areas. We know much less about how best to deploy our health human resources for optimal organization and delivery of health care services.
As an example, primary health care delivery across Canada is associated with better and more equitable health outcomes. However, many of the reforms remain incomplete and the potential improvement for patients, communities, and the health system has yet to occur.
A central component of these reforms was the implementation of interprofessional team-based care. Provinces from coast to coast have embraced interprofessional primary health care teams resulting in many diverse models of teams now serving Canadian communities. Despite rising demands and expectations, the primary health care system remains ill-prepared to deliver the expected benefits of interprofessional primary health care.
A major obstacle to improving primary health care through interprofessional teams is the lack of understanding team members have of the scopes of practice and potential roles of other team members. Many of the professions that are part of these interprofessional primary health care teams such as pharmacists and psychologists, and even ones which have long been a part of these teams such as nurses, have only recently developed frameworks delineating the competencies of these professionals delivering primary health care services.
As the primary health care system faces growing demands for efficient and effective patient-centred care for increasingly complex patients, it is essential that these interprofessional primary health care teams develop better approaches to assessing and deploying their team skills to improve the care they deliver and better meet their patients’ needs.
To answer your specific questions, I've drawn on our expertise at CHSPR as well as our colleagues from across the country, namely the Canadian Academy of Health Sciences, which recently re-released a report on scopes of practice.
Your first question was what the federal role is in the scope of practice of Canadian health care professionals. There are a couple of things that I have decided to come up with in terms of this.
One would be to invest in an infrastructure to measure and monitor scopes of practice of Canadian health care professionals linked to appropriate dimensions of care. A federal role is needed to implement systematic monitoring and evaluation, with a specific focus on inputs and outputs, to estimate costs incurred for introducing change and the long-term return on investments. A federal role is needed to enable a broader application of collaborative performance measures and an overall quality assurance framework through involvement of accrediting bodies.
As an example, in community-based primary health care most agree that we need responsive first contact care for emerging problems, capacity to resolve common health problems, ongoing care for most chronic conditions, routine delivery of preventive and health promotion services, timely coordination with other actors concerning specific diseases, and action on the social determinants of health. However, performance reporting in community-based primary health care is challenging because of the dearth of concise and synthesized information and because many clinicians prefer to be accountable only to their individual role and do not view themselves as elements or actors within a larger system.
That would be the first recommendation.
The second one would be to earmark research funds to address gaps in the literature and our knowledge in a number of areas. We know that payment models do not support changes in scopes of practice, so one area of research is to look at alternative funding, such as bundled or mixed-payment schemes, to include all health care professionals and to be aligned with desired outcomes. We also know that care is moving into the communities and multiple-care settings, so we need to understand the implementation and upkeep of electronic medical records, since it is essential for all health care professionals and patients to have timely and up-to-date information on treatment and status. We know there’s a lot of professional protectionism that goes on, so we need to do work to understand how there could be better representation of interests of professions in the context of collaborative care arrangements and interprofessional standards and overlapping scopes of practice.
Another area is to earmark funds for educating professionals and courts on changes to legislation that recognize the principles of shared-care models. Right now health care professionals are worried about their accountability and liability. There is a federal role in addressing currently rigid legislation and regulations. If we could expand adoption of more flexible legislative frameworks that could be interpreted at local settings, that would greatly help. As well, there is a need to support the development and ongoing implementation of umbrella health professional regulatory legislation across provinces and territories.
The second area that you asked me to address was to highlight best practices on the use of scopes of practice, both in Canada and internationally.
Did you want me to continue, or do you want to ask questions now?
4:45 p.m.
Conservative
The Chair Conservative Ben Lobb
Do you have a little more left in your presentation, or are you done?
4:45 p.m.
Interim Director, UBC Centre for Health Services and Policy Research
Yes, I have a bit more.
4:45 p.m.
Conservative
4:45 p.m.
Interim Director, UBC Centre for Health Services and Policy Research
Yes, okay.
In order to address your second point, my suggestion would be again to fund research to assess the impacts of selected key health system innovations on health human resources in both urban and rural settings; to develop a national framework for guidelines and quality standards for optimal, expanded, and overlapping scopes of practice; and then to promote best practices and facilitate subsequent scale-up and sustainability of initiatives across the country.
Your third point was to understand what the federal role is in supporting skills training curriculum development. As I have already noted, there is a federal role in addressing the current legislative frameworks to support the ongoing development and implementation of umbrella health professional regulatory legislation. Second is having a standard that allows people to work to their full and optimal scopes of practice by helping to establish standards for practicums and residencies that foster interprofessional competencies. Another is to have post-licensure credentialing. The last is to work with the regulatory and accrediting bodies to require continued professional education to cultivate team thinking and develop levels of trust around relative competencies.
4:50 p.m.
Conservative
The Chair Conservative Ben Lobb
That's great. Thanks very much. We have two guests here who are going to present. Then we'll open it up to questions. Stay tuned, if you can.
First, we're going to have, from the Canadian Federation of Medical Students, Bryce Durafourt.
Go ahead.
4:50 p.m.
Bryce Durafourt President, Canadian Federation of Medical Students
Good afternoon.
Thank you, Mr Chair and members of the committee, for inviting me to speak to you today as you explore the role of the federal government in the practice and training of health care professionals.
Before speaking to the topic at hand, as the representative of the Canadian Federation of Medical Students, I would like to take a few moments to introduce our organization.
The CFMS represents more than 8,000 medical students from 14 Canadian medical schools coast to coast. We represent medical students to the public, to the federal government, and to national and international medical organizations. As the national voice of medical students, we connect, support, and represent our membership as they learn to serve patients and society.
I am here today in my capacity as president of the CFMS. I'm also a fourth year medical student at McGill University in Montreal.
I would like to start by reviewing the current process by which physicians in Canada are trained.
A potential doctor in most provinces in Canada is required to complete an undergraduate degree prior to being accepted into medical school. Medical students usually then complete four years of studies before graduating as doctors. They then complete additional training, referred to as residency, in their specific field of interest. Residency in family medicine is an additional two years, whereas specialty training is usually five years. Additional sub-specialty training is often required for a physician to be hired in an academic centre.
The implication of this system is that medical students can study in one province, complete their residency training in another province, and ultimately be hired as staff physicians in yet another province. As a result, there is an opportunity for federal leadership in the development of a robust supply-and-demand model for health care professionals.
The CFMS would like to commend the federal government for its ongoing support of the Physician Resource Planning Task Force, PRPTF. Through the work of this group, the government is helping to address an imbalance of unemployed or underemployed specialist physicians against a continued shortage of family physicians, especially in rural, remote, and northern communities. The CFMS believes there is a need for ongoing modelling of physician supply-and-demand projections in order for medical students to make informed career choices that best serve the Canadian population.
We support the recommendation of the PRPTF for the establishment of a pan-Canadian physician resources planning committee for continued collaboration on this issue. The CFMS also commends the Government of Canada for its support of the transformation of medical education through the Future of Medical Education in Canada projects. These programs, if realized to their full potential, will result in better physicians who are more responsive to the health needs of Canadian society and better equipped to improve health, enhance quality of care, and secure a sustainable health system.
While there has been progress towards a more equal distribution of physicians across Canada, there are still significant challenges. In 2012, the Canadian Institute for Health Information reported that 18% of Canadians live in rural and remote areas, while only 8.5% of physicians work within these regions. These distribution issues underlie the 2014 Commonwealth Fund finding that placed Canada last in terms of timely access to care when compared with 10 other OECD nations.
The Government of Canada has made positive steps towards correcting the maldistribution of physicians across the country. An example of this progress is the Canada student loan forgiveness for family doctors and nurses program. This initiative allows family doctors or family medicine residents in a rural or remote community to benefit from up to $8,000 of federal loan forgiveness per year to a maximum of $40,000. As of November 2013, this program had enabled more than 1,150 family doctors and nurses to receive some loan forgiveness.
While this program represents a positive step towards providing rural Canadians with better access to care, the CFMS believes that this program is not operating at its full potential. The barrier to maximizing the number of new family doctors taking advantage of the program lies in ensuring that they have outstanding federal government loans when they are in a position to take advantage of the program. That means that you still need to have Canada student loans at the end of your medical training.
It is helpful to know that medical trainees are required to begin payment of principal and interest on federal loans during their residency. The interest rate charged on loans through the Canada student loan program is significantly higher than that charged by major financial institutions for other professional student lines of credit. For instance, the interest rate on Canada student loans is currently set at prime plus 2.5%, whereas a medical student line of credit would be set at prime.
As a result of this difference in interest rates, most medical residents choose at the start of their residency training to consolidate their Canada student loans to a line of credit from their financial institution. This shift of debt significantly reduces the incentive that has been created to draw new doctors to rural and remote communities. Simply put, residents and family physicians who no longer have outstanding debt on a Canada student loan are no longer eligible for the debt relief program.
The program would be significantly improved if the federal government were to delay repayment of principal and defer interest accrual on Canada student loans until after the end of residency. As a result, many more physicians would be able to participate in the Canada student loan forgiveness for family doctors and nurses program, and Canadians in rural, remote, and northern communities might enjoy better access to care. Furthermore, this proposal would better align federal and provincial policies, as several provinces already offer loan forgiveness for residents who remain within the region.
The CFMS appreciates Ottawa's important role in supporting skills development of health professionals. Two areas in which the Government of Canada can tackle physician maldistribution are long-term projections of physician supply and demand, and improvements to the Canada student loan program. These solutions have the potential to be important levers to improve the federal role in skills training of health professionals.
Thank you for your time and your attention. I look forward to our discussion.