The following is a transcript of the podcast discussion between Dr. Phillip van der Merwe and Alberta Doctors' Digest Editor-in-Chief, Marvin Polis. The full story and audio podcast can be found here: Transforming primary care
Marvin Polis: I understand that you have been doing a lot of advocacy work for primary care and Primary Care Networks, tell me what you’ve been up to…
Dr. van der Merwe: I’ve been busy in the primary care world for probably 11 years now. For six of those years, I was co-chair of the PCN Leads Executive and that ended about 18 months ago. Then for a year I was the AMA’s liaison to Alberta Health. But even though you are officially out in the back lane you never stop advocating for what you firmly believe in.
Marvin Polis: Tell me about the advocacy work you’ve been involved in lately. I understand that you’ve been attending various conferences across Canada.
Dr. van der Merwe: Yes. Certainly over the last year or so, there have been many invitations from other provinces who generally see us as leaders in Canada when it comes to primary care reform and health care system reform. I have been out to British Columbia twice, most recently to give a keynote address in Vancouver to their General Practice Summit. I’ve been out to Saskatchewan, where they are embarking on a similar pilot in Prince Albert. I’ve been to Manitoba and also to the CMA two years ago.
Marvin Polis: Tell me about some of the messages you’ve been sharing and what is it that has been impressing other provinces about Alberta?
Dr. van der Merwe: We are probably the only province where we have all the pieces lined up to truly set us up for success in health care system change. What I mean by that is that there is overwhelming worldwide evidence showing that the only health care systems in the world that have managed to increase their quality – truly become integrated and bend the cost curve down – are those systems that have embraced and robustly supported primary care reform. The backbone of that is primary care in the form of the family doctor.
We have managed to change the hearts and minds of our colleagues in Alberta, and family doctors in the community have come together as grassroots, non-profit organizations to become part of Primary Care Networks. By doing so, they have embraced a paradigm shift in how we practice which is called the Patient’s Medical Home (PMH). The two cornerstones of the PMH are:
- accountability and;
- team-based care.
Not only have they embraced PMH, they have also embraced the fact that in order to achieve system change, we have to link those grassroots systems with zonal and provincial health care delivery systems. We did so by creating a PCN governance framework which was ratified last year by an overwhelming turnout of family doctors: the highest in recent AMA voting history. The really impressive part about that was that this vote was not about money.It was about health care system change. It was about ideology. It was about everyone’s child and not just one’s own.
Marvin Polis: Tell me how all of this makes the health care system more efficient and effective.
Dr. van der Merwe: Well, we know that we don’t really have a health care system; we have islands of care. We’ve known for a very long time that they have been isolated in the community. Not only did they not know who each other were, they also had very poor support and access to diagnostics, to specialty advice, etc., while we were trying to provide the best to care for our patients. So the first step was to connect all of us in the community and realize that there is a different way of doing this. You don’t have to be everything to everybody, and if you work in a team, you can actually provide much better care. And you don’t face the burnout that so many of my colleagues have faced, which either means we lose them to the profession or, at the very least, we lose them to comprehensive care when they go into specialty niche practices. This is really not a great return on investment for the taxpayer.
Marvin Polis: What does a really high performing practice look like here in Alberta?
Dr. van der Merwe: For a bunch of scientists, we are pretty anecdotal and lackadaisical about measurement. Any doctor will tell you that he or she is a good doctor and then if you press the point and ask, “How do you know that?” pretty soon the conversation ends because where is the real evidence?
So it’s all about measurement. It’s actually about fractions, numerators and denominators. It starts with knowing who your patients are, which we call a panel. In other words, who are those people that really use you most of the time for their primary care? It’s interesting that most doctors don’t know that. So the first thing you need to do is know who your panel is.
Then you can start measuring really cool and neat stuff. You can say, ok, how am I doing, for instance, in managing the care of my diabetics? Am I achieving the targets? When we did this six years ago, only 40% of our diabetic patients were treated to target which was really quite a letdown because we thought we were doing a better job. But, like all self-reflection and measurement, once you know the true status of affairs, then you can actually do something to change it. Within six months of that finding, we were up to 80% of our diabetic patients being treated to target. Then of course you need to make sure there is no attrition, and you need to maintain that performance.
Marvin Polis: There is that old saying that what gets measured gets done …
Dr. van der Merwe: That is true. But we want to make sure we don’t get into the pay-for-performance world either. One of the things that we know is that continuity of care is the best care. So does your patient see you most of the time for their care? If not, where are they going and how is that impacting the health care system?
There are ways to measure that and, in my own experience in my practice, I have older and sicker patients than most people (if you look at my patient panel). My patients (Calgary zone) show up in emergency less than anyone else’s. So why is that? Is it because I am such a great doctor? Well, I hope that is part of it! But really what it’s about is the fact that we have an excellent team.
In other words, my patients don’t have to come see me for every single thing that ails them. They can access the counsellor, or the physiotherapist, or the pharmacist. They can see those people without me playing gatekeeper. They can access those people online. Patients do not have to be treated like children. They know what’s best for them and they can manage their own care. You just have to remove the barriers. Then you start seeing the improvement. I can’t give you the dollar figure, but if people aren’t showing up in Emergency, then there is money being saved.
Marvin Polis: Clearly you are getting the results, but let me ask you a devil’s advocate question: How can you be the quarterback without being the gatekeeper?
Dr. van der Merwe: There is an element of education that has to happen. There is upfront heavy lifting required, which means harnessing that relationship that you have with your patient, which is so important. We know it is important for physicians and we know it is important for patients. You have to spend some time having a conversation with your patients about this change, about what it means to be part of an inter-disciplinary team, about not going to emergency or to a walk-in clinic. And therein lies the problem.
Because those conversations are not typically supported or paid for, some doctors may not have those crucial conversations. But you have to explain to folks why things are a certain way. Let’s talk about Choosing Wisely Canada, for example. Patients may ask, “Why am I not getting my physical this year? Why am I not getting an EKG or a chest x-ray?” I have not had even one patient push back, but it takes more than a two-minute conversation. You have to explain to people what the evidence says and how you are trying to prevent harm and prevent wasting their time. I think you can be a quarterback, but being a gatekeeper should be about having conversations, not putting up barriers.
Marvin Polis: It sounds like you’re also having conversations about what each of the individual members of the team bring to the relationship and how your patients can benefit from those individuals.
Dr. van der Merwe: Absolutely. It is really important that people practice to the top of their scope. Again, therein lies the conversation and the education piece with your patient to understand what certain team members can actually do for them. I work very closely with a clinical pharmacist, for instance, who can prescribe medicine, can change medicines, can adjust dosages, etc. So why would I have a patent come to my office to have that done? Why would I have a patient come to my office every three months for a refill of a prescription when their condition is stable? Is it just to have that visit fee? It’s absolute nonsense. It’s non-defensible and I would like to see what the wider economic impact is of forcing people to take time off work, to pay for parking, etc. just to come in and have you essentially put up a barrier to something that really should be done remotely.
Marvin Polis: So you’re really seeing the big picture here?
Dr. van der Merwe: Yes! I think many people do. Of course there are still many barriers, but we’ve got to keep on pushing.
Marvin Polis: So who wins at the end of the day? Sounds like everybody wins.
Dr. van der Merwe: Everybody wins. Clearly the patient wins because their access and experience has improved. Clearly the health providers win because their jobs are easier and more fulfilling with better work-life balance and collegiality. Ultimately the system wins because it is more efficient, costs less and the quality is vastly improved.
Marvin Polis: Any final words before we wrap up?
Dr. van der Merwe: Yes, I would like to give a shout out to a stellar group of family physician leaders who have not only mentored me and supported me but have been leaders in their own right. This could not have been done by one person alone. Specifically, these are stalwarts like Drs. June Bergman, Al Bailey, Peter McKernan, Brad Bahler, Tobias Gelber and the current leaders of the PCN Provincial Executive; Drs. Jeff Bratvold and Justin Balko. Of course whenever you name people you inevitably leave someone out, so I apologize. We have been extremely fortunate to have really stellar folks.
Banner photo credit: Csaba Nagy, Pixabay.com