During a single academic year, DFCM consists of more than 1500 faculty, 440 residents, over 700 unique medical student experiences, nearly 100 certificate, fellowship and graduate students and thriving Research, Education Scholarship, Faculty Development, Quality Improvement and Global Health Programs.
Like all medical schools and departments, DFCM has had to think differently about how it educates the physicians of the future. Predominantly, it has understood that it needs to mentor its educators to inspire them to become excellent educators.
Over the past several years, thanks to faculty leaders and teachers, both how and what the Department teaches has evolved, whether through developing a competency-based curriculum for residents; becoming the voices of various facets of care; revamping MD education to be more holistic; integrating technology into teaching; or expanding the limits of what it teaches.
Every year, through the lens of education scholarship, DFCM faculty members are always challenging themselves to find new and innovative ways to build the family physicians of the future. They are continuously creating resources for training better clinicians, better educators and better learners with the aim of improving care for patients.
“I’m interested in how to nudge people toward better habits, healthier lives and better disease management.”
—Dr. Mike Evans
DFCM Faculty influencing health care system delivery
Ontario’s LHINs (Local Health Integration Networks) are working to strengthen the primary care system, and the Toronto Central LHIN is at the forefront of the movement.
“It’s about helping patients to navigate the system better, and with regard to primary care, it’s about organizing the sector,” said Dr. Philip Ellison, primary care adviser to the Toronto Central LHIN and a faculty member with the University of Toronto’s Department of Family and Community Medicine (DFCM). “It’s a giant change management project and a great way to build primary care leadership in the system.
“Eighty per cent of patient services can be provided outside the hospital, but we have to be organized to operate more efficiently.”
All LHINs have established sub-regions -- smaller geographic planning regions to help them better understand and address patient needs at the local level. With at least one Primary Care Clinical Lead identified in each of the Toronto Central LHIN’s five sub-regions, these physicians play a key leadership role through collaborative planning; engagement of local primary care providers; and advancing goals of improving access, service integration and system efficiency.
The goal, says Dr. Jocelyn Charles, faculty member and primary care clinical co-lead for the North Toronto sub-region, is to place family physicians and primary care providers at the centre of the care delivery system where they collaborate on behalf of their clients with other providers – i.e., specialists and other health-care services -- to ensure clients get the right care in the right place at the right time.
“We are moving toward a collaborative model of addressing patient-based needs and we are building connections with specialists and home and community care so we can work together, rather than in isolation,” said Charles, who is also medical director of the Veterans’ Centre at Sunnybrook Health Sciences Centre.
Charles, one of 231 family physicians practising in the North Toronto sub-region, is one of the authors of a program called TIP – telemedicine impact plus – that is designed to assist her colleagues in supporting clients with complex needs. TIP allows the primary care physicians to reach out to outstanding interprofessional teams with specialists for a virtual case conference and consultation with the patient participating.
“Getting them to use these strategies can reduce the isolation of family physicians and help them to be better integrated with the health-care system,” Charles said.
Dr. Pauline Pariser, primary care lead for the Mid-West Toronto sub-region and associate medical director for the University Health Network, is working to connect more than 500 family physicians working across the sub-region. She is guided by a Primary and Community Care Committee in defining what is needed in the sub-region and working toward these goals. One initiative has been to bring together primary care leads from the three area hospitals – Mount Sinai, the University Health Network and Women’s College – to discuss ways of collaboratively supporting primary care. As a result, the hospitals are creating a central intake mechanism for various specialty areas of care.
Pariser has also developed SPIN, or Solo Physicians in Need, a program that is also underway in the North Toronto sub-region. Through SPIN, community health centres are offering solo practitioners access to a range of ancillary services such as foot care for their most complex cases. The program has already generated 900 referrals, with many more anticipated as the project expands to involve all 17 community health centres and family physicians across the Toronto Central LHIN.
“A lot of our work is figuring out where the need is and making connections,” Pariser said. “We get representatives from all health sectors sitting at the same table and problem solving ways of meeting the needs of our populations with LHIN support”.
“My job is to make sure the programs are based on good evidence, have a sustainable infrastructure and really meet the needs of family physicians. So often, institutions get grant money that doesn’t involve family physicians in program planning. We want to enhance the patient experience but also make it easier for providers to deliver quality care.”
Both Charles and Pariser are experienced leaders who have built strong networks of connections during their primary care careers. They hope that as they reshape the care model, they can also work to develop leaders among their younger colleagues.
“Primary care hasn’t had a leadership system, so we have to build those roles,” Charles said. “There are huge mentorship opportunities here.”
Pariser agreed, noting that succession planning is an additional benefit she can offer to her profession.
“I would love to mentor younger colleagues so they could learn to address barriers you face as a leader,” she said. “It would be a unique opportunity for them to work with the community and learn experientially how to effect change management “
Their efforts will take time, but they should yield a system that serves both clients and family physicians better.
HEALTH iNNOVATION: Faculty member Mike Evans Teaming with Apple
Though we’re making advances, Canada lags behind other countries, such as Denmark and Sweden, when it comes to digitizing health care and engaging the public: Faculty member Dr. Mike Evans has been working to change that.
Between his Whiteboard Med School for the Public on YouTube, which has received almost 15 million views; the Mini Med School at the University of Toronto; and his role as Chair of Patient Engagement in Child Nutrition at U of T, Mike Evans has combined creativity and summarized best evidence using the new ways we share information, such as YouTube, Facebook and Twitter. He has launched a new field called Peer-to-Peer Healthcare, where people share engaging, high-quality medical information with their social networks. This network could include their friends, people with the same health care challenges, caregivers to their patients and others.
Now he’ll be taking his efforts to the next level: Working with Apple in California while doing a part-time clinic at Stanford University. Though he can’t say too much about his role – Apple is tight-lipped about future innovations – Evans is excited to be working on worldwide health-care innovation.
“I’m interested in how to nudge people toward better habits, healthier lives and better disease management,” says Evans.
He believes the way we engage patients will change dramatically over the coming years. For instance, today, a physician sees a patient for an ailment such as high blood pressure, prescribes medication and then follows up weeks or months later.
In the future, Evans believes that after seeing patients, physicians will be able to prescribe apps that can provide them with information on their ailments, track lifestyle factors such as diet and exercise, remind them to take their medication and monitor their conditions remotely. All this provides physicians with more accurate, longterm data that both patients and caregivers can visualize. “We have such an opportunity to make it easier to do the right thing the other 360 plus days that people don’t see doctors.”
Evans says his experience as a practising family physician gives him the advantage of being able to understand the nuances and best practice regarding most medical conditions.
“Being a generalist means I’m not pigeon-holed into one speciality,” says Evans, who notes that many technology companies tend to work with niche researchers and specialists “…and many of the big learnings are just 'Human Behaviour 101' that comes when you observe average people trying to self-manage various illnesses in primary care. It's looking less at what people know and looking more about what they do every week and how they may actually use health technology in everyday life.”
Evans will continue to be connected to the DFCM as a faculty member throughout his tenure at Apple, with the hope of eventually collaborating on research or other projects. “Apple thinks a lot about the user experience and I think this dovetails well with the many efforts here at the DFCM to improve the quality of care.”
“I’m still getting my feet wet in California,” he says. “Who knows what opportunities will present themselves?”
Dr. Danielle Martin say family Docs Are Key to Influencing the Future of Health Care
Dr. Danielle Martin’s policy expertise and passion for equity has made her a well-known speaker, writer and emerging leader both inside and outside of health-care circles. In 2017, Dr. Martin, a faculty member and Vice-President of Medical Affairs and Health System Solutions at Women’s College Hospital, released her first book, bringing together many of the ideas she’s been developing over the past several years. Better Now: Six Big Ideas to Improve Health Care for All Canadians outlines six ways Canada can bolster its health-care system.
We spoke to Dr. Martin about the book and the messages she gives to family doctors specifically.
When did you originally conceive the six ideas?
In 2014, I first gave a speech called “Three Big Ideas to Deliver on the Promise of Medicare.” I kept working on that speech and all my associated writing over the course of another six months until I had what I felt was a complete set of ideas.
When and how did the idea of putting these ideas into book form arise?
With the quantity of writing and speaking I was doing, I came to a point where the amount of content I had could create a book. On top of that, I began to realize how many of the conversations around health-care mainly consisted of medical professionals, academics, policy-makers, etc., speaking to each other. What was needed was a way to engage the broader public in the conversation and encouraging them to think differently.
A lot of your book emphasizes the important role of the family physician in the health-care system. Do you think family doctors are becoming more respected in terms of their value to the health-care system overall?
Absolutely. I think that’s true among key decision-makers more than ever. The understanding that policy-makers have about the health-care system is deeper than ever; they’re realizing that a high performing health-care system is based on high-performing primary care. But our patients have always known what a critical role we play and how well that relationship works when it works well.
In the first idea of the book -- Ensure every Canadian has regular access to a family doctor or other primary care provider -- I talk extensively about the importance of the relationship between patients and their family physicians, but also about the relationships between primary care offices and the rest of the system. We deal with it every day through referrals, patient followups, etc. It has a huge impact when our office is functioning well with the rest of the system. So it’s not just a message to policy-makers and patients, but to health-care professionals across our system.
What are some of the biggest barriers to achieving your vision?
I think the biggest barrier is inertia and exhaustion. It’s easier to go to work every day and do the same things even though we know there are better, more effective and efficient ways to do things than how we’re doing them. We fall into habits. The same is true for patients: They fall into habits with their health that they know they can improve. And the same goes with health organizations. So the biggest barrier is overcoming that inertia and challenging ourselves to do things differently.
What is the role of family doctors in achieving these ideas? And what can medical educators do to help promote leadership in the next generation of family doctors?
At the individual level, every part of our hearts and brains can be engaged in the work of bettering our health-care system. There’s a lot we can do with the first idea in my book: Cultivate strong relationships with our patients and act as brokers and quarterbacks for each patient’s health journey. There’s also a lot we can do with the third big idea: Reduce unnecessary tests and interventions -- for example, by engaging with and building on the work of Choosing Wisely Canada.
But as academic family physicians, there’s also a lot we can do in the way we teach as educators and the research we do. There’s a lot we can be engaged in: For example, around improving curriculum, the social determinants of health, all the way up to being leaders in system level change and much more. We see examples of that all the time at DFCM. That work is already happening but we need more of it and we need it to be a concerted effort where we’re all pushing in the same direction.
What is the role of academic family doctors specifically?
As an academic family doctor, I’m a huge believer that when we recognize that system change needs to occur, the change that happens must be built on our family medicine values like fairness and equity. On top of that, the ideas we put forward for change need to be backed by solid evidence. What I’m trying to do with this book is to bring evidence and values together through narrative. While each of these ideas is told through stories, all of my claims and ideas are supported by rigorous evidence. I really think that when we do knowledge translation of this kind, through storytelling and narrative, that we must continue to stay on the path of scholarship and evidence.
Q&A With Dr. Joshua Tepper, Family Physician and CEO of Health Quality Ontario
Q. Is your background as a family physician valuable in your role leading Health Quality Ontario (HQO)?
A. It certainly helps, but it is not a requirement, to have a clinician in this role.
I am influenced by my ongoing work as a doctor. I continue to have a complex family practice and I also work in the emergency room. These ongoing experiences give me a hands-on view into quality issues the system is facing, what patients voice as their concerns and also the challenges that face clinicians in working on quality improvement projects.
To be clear, I am not the only clinician working at Health Quality Ontario. We are very committed at Health Quality Ontario to involve front line clinical expertise in all aspects of our work. Our aim is to have the voices of physicians and other clinicians help shape the quality agenda.
Q. What do you mean by quality?
A. HQO has adopted the six dimensions of quality set out by the Institute of Medicine:
No one quality improvement initiative will address all six, but it should influence at least one of them. I think all six apply to family medicine.
Q. Is QI changing the practice of medicine?
A. It’s a bit of a shift, but an important one. I think building a culture where we explicitly think about the quality of the care that we provide and participate in quality improvement activity is very different than before.
I often think about the parallel shift in practice when we adopted the concept and application of evidence-based (or evidence- informed) practice. It was a deliberate, skills based adjustment to how we delivered clinical care.
Q. What are the challenges of getting family physicians to incorporate quality improvement (QI) into their practices?
A. I appreciate that QI has to fit in and complement the activities of daily care providers. It cannot be “extra work” with no perceived value for either patient or the doctor. Quality Improvement also should not be seen as critical or punitive but aligned to the caring values that family physicians bring to their discipline every day.
I also know that participating in quality improvement work takes time, certain skills and other resources. Family physicians are already working very hard, and depending on their model of care, there may be very limited support. HQO wants to make sure that QI is easy to do and is seen as synergistic to practice. We want physicians to feel supported with data, tools and resources, skills and leaders. We need to listen to the challenges that face family physicians in participating in QI.
Q. What’s on your to-do list?
A. More than 1,000 organizations in Ontario have completed Quality Improvement Plans, including more than 200 family health teams and community health centres. Creating quality improvement plans is an annual effort where organizations reflect on how to advance quality care in the coming year within their organizations. We want to make sure these plans are useful exercises that support an improvement mindset.
We also want to increase the number of family doctors who sign up to receive a Primary Care Practice Report. These are produced by the Institute for Clinical Evaluative Sciences (ICES) and HQO. They offer every family physician a free, confidential, personal report on key quality indicators of their practice. It is updated a few times a year.
We want to make it easy for the QI process to be embedded into daily routines and seen as part of the practice of family medicine.
Q. How can family physicians become more involved in the QI agenda?
A. There are a few ways:
- The cornerstone of QI is data and information. That information can come from the electronic medical records, surveys of patients and other sources. I have already mentioned the HQO/ICES Practice Report as one good source for data.
- They can take additional training in QI, just as they would in epidemiology or procedural skills. There are very short courses and articles on the basics or programs that go much deeper. Quality Improvement is a set of skills and one of our roles is to provide those skills. It’s unfair to expect physicians to practise QI without providing data and support. HQO works with the medical schools and universities to offer training to physicians at all career stages
- Leadership. We have great leaders in the Department of Family and Community Medicine who take on roles in QI promotion and knowledge transfer. DFCM deserves a huge amount of credit for its leadership and investment in QI. I’d like to see every family medicine department in the country have a similar commitment to QI and QI capacity building.