What is a dangerous idea? It’s a concept or worldview that moves us from the way we traditionally do things to a new paradigm. Dangerous ideas usually are inspired by unstable environments and/or recognition that following tradition beliefs and/or practices is untenable. As discussed by John Brockman, in his book, “What’s Your Dangerous Idea?” these ideas force us out of our comfort zone. Despite the name, dangerous ideas often improve our lives and help us more clearly understand the world. Dangerous ideas may be disruptive for a time but are only truly dangerous to the status quo. Over time dangerous ideas often become accepted as truth, as the conventional wisdom (Copernicus putting the sun in the centre, Darwin opening our eyes to evolution). Some dangerous ideas, such as the notion that individuals might benefit from “personal computers”, are enabled by new technologies. However, many dangerous ideas do not require inventions or devices. They are new social constructs and are enabled by changes in the way we govern ourselves or the value-system we espouse (i.e. the emancipation of slaves, the vote for women, the charter of human rights, legalization of gay marriage).
The idea is that instead of relying on a somewhat overwhelmed and underfunded academic hospital system as a home for ambulatory care, academic physicians and our patients are best served by moving a portion of our outpatient practice to centers in the community that we operate (and perhaps own). This dangerous idea is a modest proposal for change in the practice of ambulatory Medicine by members of our Department of Medicine. This idea challenges some of the generally accepted concepts regarding “academic” ambulatory care (i.e. that patients come to clinics in our hospitals and that the hospitals provide us adequate space and staff support to perform testing and assess all of our ambulatory patients in a timely manner). The “run your own offsite clinic” idea may force us out of our traditional comfort zone. However, I believe, it has potential to achieve positive change (for our patients and trainees, as well as for the faculty). Properly implemented and run through our Departmental practice plan I am hopeful it can be understood for what it is: an integrated extension of the ongoing hospital-based ambulatory program. With proper planning and discussion, I believe the vision for a doctor-directed, off-site clinic can be realized without alienating partner hospitals, inspiring mistrust or jealousy from colleagues or being misunderstood as a “get rich quick” scheme.
The environment that spawned this idea is one in which the capacity to provide timely, modern outpatient care within designated academic hospitals is inadequate to meet patient needs. This notion of a “second campus” for Queen’s University physicians in the Department of Medicine is not entirely a novel idea. Precedents exist in Ontario for physicians leaving the hospitals in order to provide patient-centred ambulatory care. However at Queen’s we would be entering terra incognita. According to this idea-the patients would not come to the University hospital; we would go out to them. I am not proposing a complete departure from the hospitals. The inpatient presence would remain as would out current volumes of outpatient care. We would simply move selected services and a portion of new patient care from the hospital to the envisioned clinic.
A variety of circumstances have conspired to force academic physicians, even those paid through an Alternative Funding Plan, as exists at Queen’s University, to consider establishment of an off-site practice. What are the forces moving us out of our comfort zone? Why add a new practice venue at little financial benefit to individual physicians? What are the risks and benefits of such a move?
Traditionally, Ontario hospitals have been funded to provide us with both inpatient facilities (operating rooms, cath labs, intensive care units and ward beds) and outpatient clinics. However, of late, acute care hospitals and Emergency Departments have become congested with patients many of whom are elderly, have social/mental health issues and/or require an alternative level of care (ALC), limiting patient throughput. In addition, hospital budgets have failed to increase to keep up with actual costs of care. As a result, even though the Department of Medicine increasingly has adequate numbers of physicians and has ensured that they are working effectively, as judged by rigorous accountability metrics, patients are waiting too long for care. In addition, convoluted labor agreements have unintentionally resulted in challenges to hospitals’ abilities to staff clinics with the multidisciplinary teams necessary to provide optimal care. This has resulted in unacceptable wait times for access to many specialists both for outpatient consultation and certain outpatient procedures, notably colonoscopy and certain cardiac and dermatologic services.
The academic hospitals and their clinics, where most doctors are trained and most tertiary care is provided, are tightly regulated and budgets are constrained by the Ministry of Health and Long-term care (MOHLTC). This limits their ability to adapt to societal expectations for health care access. Ironically, colleagues in private practice are not as constrained by ministry policies and labor agreements which dictate hours of operation and case volumes. While their life is very demanding, they tend to be more adept at responding to change. The idea that academics need their own off-site practice does not devalue the private practitioner-both town and gown are needed. However, the complex outpatient care provided by academic physicians is important both for the actual advanced care provided to the patient and for the relevance of this outpatient population to our research mission and to the training capacity of the academic centres. In addition, academic centres often are ultimately asked to see patients once they have passed through the private practitioners practice. We increasingly find our academic gastroenterologists, who are permitted limited volumes of colonoscopy, receiving referrals for long-term management of patients who have undergone endoscopy in the community. This often results in fragmented care, has negative financial implications, impairs training of young doctors and often results in duplicate testing (particularly in the absence of a unified electronic health record or image archiving system-PACS).
At Queen’s acute, inpatient, tertiary care medicine is practiced at the Kingston General Hospital while outpatient care is provided at the Hotel Dieu Hospital. Chronic care and rehabilitation is provided by a third hospital, St. Mary’s of the Lake (Providence Care). These hospitals are each exemplary institutions but governed by separate boards, CEOs and held accountable by the MOHLTC for their independent budgets. This siloing creates an artificial division of responsibility for the global care of the patient and limits the capacity for flexible resource allocation between ambulatory care, chronic care and inpatient care.
The Academic Hospital in 2015 is a place for advanced surgery, complex arrhythmia ablation, transplantation and the like. It is not the optimal home for ambulatory care, or at least not the only home for ambulatory care. The modern ambulatory facility not only needs easy access to highways, good parking and easy accessibility, it also requires a different staffing model which includes Doctors of Pharmacy, Advanced Practice Nurses and Physician Assistants-all professional in short supply in the South East Local Health Integrated Network (SELHIN), where Queen’s University is situated. It is ironic that academic outpatient facilities that are part of the academic medical centre, lack access to funding for modern electronic health records that have been provided to practitioners in family medicine and in private practice in the same community.
While we struggle to keep the academic institutions running and manage our wait lists, private practice groups (many from outside the city) are eying our referral base and considering moving into the community. Recently it has been proposed by the Clermont group that they develop an 80,000ft outpatient facility on a new 14 acre medical campus for outpatient care be built in the east end of Kingston (see below). The proposed tenants are to be determined.
This type of accessible and modern ambulatory medical and commercial complex is likely needed but the question for academic physicians at Queen’s is: Should we be running these clinics or do we relinquish the opportunity to colleagues from Toronto, Ottawa and other universities or to more entrepreneurial local groups? In my experience, it is unwise to divest practice volume and ambulatory capacity when you are responsible for training the next generation of physicians and for providing patients with timely outpatient care. This announcement challenges us in academia to ask-if it is to be built why should it not be built by and for us and our patients and trainees?
In my view it is time for us to do the experiment and open a new practice site, perhaps partnering with entrepreneurs in Kingston to better serve our patients and preserve/grow our Academic medical centre. This dangerous idea does not envision moving staff or existing patients from KGH or HDH and would not be subsidized by Queen’s University, the Hospitals or SEAMO (our alternative funding plan). Rather, a new Queen’s Medical Arts Ambulatory Centre would allow new patient cohorts to be care for by our academic physician group in a new, off campus medical arts facility. Imagine a modern, accessible, purpose built, clinic staffed by the Department of Medicine’s 14 medical specialties and supported by appropriate allied health professionals: sounds like a great place to give or receive health care!
Let’s briefly review the local and provincial forces that are driving us toward this dangerous idea:
1) Need to shorten specialist wait times. The Department of Medicine has dealt with this in two major ways. First we have ensured every physician has a role description and an accountability agreement which ensures they are delivering optimal service (whether in clinical, research or educational domains). Second, we have increased the number and technical capacity of the faculty through recruitment. In the past 2 years we have recruited ~25 new faculty, created a Division of Dermatology, reinforced our Endocrinology Division and enhanced our ability to provide the highly technical care that can only be offered at a University hospital, from advanced epilepsy care through procedural care (such as Moh’s surgery, TAVI and Peroral Endoscopic Myotomy (POEM)). This recruitment has helped, but now our ambulatory practice is constrained by access to clinic space, lack of advanced practice nurses and Doctor of Pharmacy (PharmD) support, and the lack of a modern ambulatory electronic health record. To enhance our agility we need additional clinic capacity and a staffing model that is agile. In the modern era the physician and patient are supported by a team, consisting of technologists, nurses, pharmacists and volunteers. In a past life colleagues and I implemented just such a program at the University of Alberta, called Cardiac EASE. This clinic, which continues to run today, used a single point of entry referral strategy and the talents of nurse practitioners and pharmacy doctorates to accelerate intake and testing of cardiac patients using evidence-based algorithms. EASE managed to double the volume of cardiac consultations seen while reducing the waiting time by 50%. Unfortunately, programs of innovation struggle for support in the Ontario health care environment, where support for hospital based program and physicians are under continuous downward pressure.2) Need to grow our capacity to train medical students and residents: The medical school and residency program is always looking for more clinical training sites. Failure to provide care locally forces us to place more trainees further out of the city and SELHIN. A local academic medical arts clinic staffed by academic physicians providing care in specialties ranging from Allergy to Rheumatology would be a superb, additional site for training our medical students and residents.
3) Need to better serve our referring physicians: Every physician group must attend to its referral base. This means providing timely care for patients and prompt feedback to referring doctors. We believe we can improve this by having a facility where endoscopy, dermatology, cardiology and infusion therapies can be delivered in a timely manner. In recent weeks I have been contacted by universities in other cities offering to do our cardiac imaging. Likewise, other hospitals are doing endoscopy on patients from Kingston leaving our gastroenterologists to do follow-up on patients who they have not themselves investigated. This fragmentation exposes Queen’s, Kingston and the SELHIN eroding local care and compromises our research and educational missions.
1) Tainted money: One of my former bosses at the University of Alberta, Dr. Lorne Tyrrell –responding to the allegation that money from the pharmaceutical industry was tainted money and should be eschewed-famously quipped, “Your right, it is tainted-t’aint enough of it!”. Likewise, when it comes to money to build an expanded and modernized outpatient service in Ontario there t’aint any money. Hospitals have had their hands tied by flat-line budgets, rising labour costs and an increasingly proscriptive funding model which dictates case mix, case volumes and specifies case costing. Health care funding in Ontario is being aggressively constrained by the MOHLTC. This is the fourth year of putting the squeeze on health care in an effort to eliminate the province’s $8.9 billion deficit within 2 years. The zeitgeist is that everything can be done on an outpatient basis and that the wisest investment is in outpatient primary care practice. Unfortunately, this approach does little to deal with hospital-supported ambulatory clinics, particularly those that are run by academic physicians and focused on tertiary care patients. Hospitals have received no increase in their annual budgets and, with mandated annual increases in labour costs, this translates into an annual deficit. This environment makes it difficult for them to provide the type and amount of staff support required to grow the ambulatory enterprise at the tertiary and quaternary care medical centres. In fact, many academic centres in Ontario have been dealing with this leading to cut backs and layoffs, such as this announced at The Children’s Hospital of Eastern Ontario (CHEO). There have been major cuts in nursing across the province as hospitals struggle to balance their budgets. The Ontario Nurses’ Association CEO Marie Kelly reports loss of 409 registered nursing jobs in 2015 and notes that Ontario has the second lowest nurse-to-patient ratio of any province.
This is not just my opinion. In a recent Globe and Mail article by Kelly Grant quoted Anthony Dale, the president of the Ontario Hospital Association as saying, “I don’t think there’s any question that the year ahead and absolutely the year after are going to be very challenging times for hospitals. There’s a lot of innovative change right now that’s happening to improve efficiency and improve quality, but, at the same time, we’re into new territory here.”
Although the government now proposes a modest 1.4% increase in hospital sector spending this does not deal with the increase in patient volumes or known and projected population growth in Ontario. There is no end in sight to the health-care austerity: Overall funding is expected to rise, on average, by just 1.9 per cent a year in the four years leading up to 2017-2018, when the Liberals have promised to balance the budget. Although the family physician remains the centre of the outpatient services network, our aging society and increasingly potent medical capabilities means that patients often expect and require access to specialists and specialist interventions in the ambulatory setting.
So what is Medicine’s Dangerous Idea?
- Start an offsite clinic for ambulatory care that is not currently conducted at the Kingston Hospitals
- House it in a site with good parking and patient access
- Staff it with a multidisciplinary team
- Provide excellent patient care and educational opportunities
- Operate it in compliance with our existing academic practice plan
I’d love to hear your thoughts on this idea.