Physician services in Canada

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Physician services in Canada

• Universal health insurance
• Most physicians are paid by fee-for-service
  funding
• Health is a provincial responsibility
• 50 of physicians are family doctors
• Now 50 of family medicine residents are female
• In Calgary family physicians deliver 50 of the
  babies and care for 50 of those hospitalized for
  internal medicine
• 95 of Canadians have their own Family Doctor

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• Calgary Health Authority
• 4 acute hospitals
• Longterm care
• Community care
• Medical departments
• Health of the people in the Calgary region

• Faculty of Med UofC
• Medical students
• Residents
• Basic science students
• Research
• Medical (and basic science) departments
• Social responsibility to southern Alberta

In all medical departments except Family Medicine
the heads of the two departments are the same
FM have co-heads.
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How our clinics run

• We get a grant of about 500,000 per year for
  each urban clinic to pay rent, nurses, supplies,
  support staff and supply academic space. This
  comes from the Health Authority who want service
• The professors work in the clinic about 40-50 of
  their time supervising residents and students and
  seeing patients. Each patient contact generates
  a fee-for-service payment for the professor which
  is taxed at 17 by the university
• The professors spend the rest of their time in a
  mixture of research, lecturing and
  administration. They work about 56 hrs per week
  not counting call.

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• Each clinic patient has a unique professor and
  the patients think of that person as their doctor
• The residents carve out their practice from
  their supervisors practice over the two years
• The clinics take care of a disproportionate
  percentage of those patients in Calgary with
  multiple chronic illnesses including palliative
  care
• The professors salary is, on average, about
  120,000 Can. and is 50 from the university and
  50 from fee-for-service billings
• The clinics serve as demonstration sites for new
  programs, laboratories for family medicine
  research and sites for public health work in the
  community

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The effective family physician brings a unique
set of qualities and skills to a unique practice
setting, keeps these up to date, and applies them
by using the patient-centered clinical method to
maintain and promote the health of patients in
his or her practice.
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The Four Principles of Family Medicine 1. The
family physician is a skilled clinician

• competence in the patient-centered clinical
  method
• an understanding of patients experience of
  illness and of the impact of illness on lives
• expert knowledge and skills for common health
  problems in the community and of less common but
  life-threatening and treatable emergencies
• based on the best scientific evidence available
• understanding of human development and family
• providing information to patients in a manner
  that respects their autonomy and empowers them to
  "take charge" of their own health care

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2. Family medicine is community-based

• based in the community and significantly
  influenced by community factors
• mobilize appropriate resources to address
  patients needs
• problems are not preselected and are commonly
  encountered at an undifferentiated stage
• skilled at dealing with ambiguity
• chronic diseases emotional problems acute
  disorders complex biopsychosocial problems
  palliative care
• the office the hospital other health care
  facilities or the home
• part of a community network of health care
  providers and are skilled at collaborating as team

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3. The family physician is a resource to a
defined practice population

• views the practice as a population at risk
• organizes the practice to ensure that patients
  health is maintained whether or not they are
  visiting the office
• requires
• the ability to evaluate new information and its
  relevance to practice
• skills to assess the effectiveness of care
  provided by the practice
• the appropriate use of medical records and/or
  other information systems
• the ability to plan and implement policies that
  will enhance patients health
• effective strategies for self-directed, lifelong
  learning
• wise stewardship of scarce resources

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4. The doctor-patient relationship is central to
the role of the family physician.

• understand and appreciate the human condition,
  especially the nature of suffering and patients
  response to sickness
• aware of their own strengths and limitations
• recognize when their own personal issues
  interfere with effective care
• the relationship has the qualities of a
  covenanta promise, by physicians, to be faithful
  to their commitment to the well-being of
  patients, whether or not patients are able to
  follow through on their commitments
• cognizant of the power imbalance between
  physicians and patients
• provide continuing care to their patients to
  build on their relationship and to promote the
  healing power of their interactions

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Our Changing Role in the Canadian Health Care
System

• We see less of the traditional model which
  involved
• Office practice
• Hospital practice
• Obstetrics
• Longterm care
• House calls
• Surgical assists
• 24/7 365

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What is evolving

• Family physicians with special interests this
  has been called boutique medicine
• Examples include
• Low risk obstetrics
• Hospitalists
• GP psychotherapy
• Sports medicine
• Occupational medicine
• Etc.

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• This is evolving from a combination of factors
  which include
• Life style issue
• Payment issues
• Changes in our hospitals
• Lack of care and feeding of the family doctors
  by the Health Authorities
• Problem given this reality how can we move
  ahead and still maintain the 4 principles?

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Our Solution

• Primary Care and Family Medicine in Canada - A
  Prescription for Renewal in October, 2000
• The Family Practice Network (FPN) and Sustaining
  the Model - The Resources Needed
• One of the keys to the success of primary care
  renewal will be the ability of family doctors to
  work together more effectively in providing
  services to their patients
• Family doctors would be encouraged to form real
  or virtual groups, practising either in the same
  office setting or in different locations, but
  linked with one another to facilitate transfer of
  information and to share clinical
  responsibilities
• Interdisciplinary teams and collaborative
  practice
• Information technology

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Two examples

• Shared mental health
• Advanced nursing practice in diabetes

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Expert
Performance
Evaluation
Training effort ?
Competency
Knowledge
Novice
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Responsibility for CME and CPD

• For us this a major thrust
• Developing our community teachers
• Providing opportunities for practicing family
  physicians to achieve and maintain expert
  performance in their practices
• Give our residents and students the skills they
  need for lifelong learning

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The Recent Retreat in Kananaskas
Kananaskas is in the mountains and offers skiing,
hiking and the G8
100 physicians came with their families our
expense. Mornings at work in CPD and afternoons
to play with their families. A banquet for
all in the evenings. 3½ days.
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MAINPRO (Maintenance of Proficiency)

• College of Family Physicians of Canada program
• Built on understanding principles of adult
  learning

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Principles

• maintenance of effective, patient-oriented family
  practice depends on the ongoing responsibility of
  physicians to maintain and enhance their
  knowledge and skills
• Family physicians should maintain and improve
  continuously the quality of care they offer to
  their patients as defined by the Four Principles
  of Family Medicine
• MAINPRO should reinforce family medicine as a
  distinct medical discipline in Canada as defined
  by the four principles of family medicine

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• Physicians should plan their own programs of
  self-directed, practice-based lifelong learning
• All aspects of MAINPRO should be developed and
  managed by practising family physicians
• Family physicians should be at the centre of
  education for themselves and their colleagues
• Effective CME for family physicians requires
  active planning
• CME providers should follow appropriate ethical
  standards at all times

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Pearls is an example

• Pearls is a self-directed evidence-based
  practice reflection exercise.
• A self-learning activity
• Pearls is designed to take participants logically
  through a series of five steps.
• 1.Formulate a practice reflection question.
• 2.Seek the appropriate information (do a
  literature search and select key articles).
• 3.Evaluate the information (critically appraise
  the key articles).
• 4.Make a practice decision.
• 5.Evaluate the effect of the decision (at least
  two months later).
• A manual form the college contains detailed
  instructions on how to do a Pearls exercise

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• The idea is that the family physician undertake
  an exercise that is reflective and based on that
  physicians practice
• The requirement is for 10 hours of work per year
  minimum

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Typically follow a cycle
Identify improvement Opportunity in practice

• Restudy practice
• to determine if
• change was effective

Review performance in practice
Decide on and Implement change
Discover evidence For improvement
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Examples

• 10/10/2000 05/04/2002 ACNE Management Update
  Maximizing Therapies to Minimize Scarring-
  Multiple sites - 3.0 MAINPRO-C UBC Faculty of
  Medicine, Div of CME
• 01/08/2001 13/01/2003 DOVE - Doctors Opposing
  Violence Everywhere - Multiple sites
• 2.0 MAINPRO-C/workshop CFPC Alberta Chapter