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Dr. Annette Hay

“Eliminating Wait Times”: Medical Grand Rounds featuring Dr. Annette Hay

Trinity Vey, MSc Candidate (Translational Medicine)

Last week’s Medical Grand Rounds were led by Dr. Annette Hay, a Hematologist and Senior Investigator with the Canadian Cancer Trials Group, on the topic of eliminating wait times. The existence of long wait times for specialized services in Canada has been well-documented, with wait times to see specialists significantly longer in all Canadian provinces than the international average (1). In 2020, the Canadian median wait time between referral and specialist consultation was 10.5 weeks, which has increased by 184% since 1993 (2). Such long waits can delay diagnosis and treatment, leading to chronic illness, disability, and other adverse outcomes (3,4). Patients have reported mental distress, stress on family and friends, pain, and loss of work associated with wait times (5).
 

To address wait times, primary care management pathways (PCPs) have been developed by Kingston Health Sciences Centre (KHSC) specialists in collaboration with family physicians. PCPs are online evidence-based tools designed to empower primary care physicians to manage non-urgent conditions while identifying high-risk patients necessitating referral (6). In Calgary, implementation of a gastrointestinal (GI) disorder PCP reduced routine wait list volume by 99% within 12 months (7).


Dr. Hay explained PCPs through the hematological lens of Monoclonal Gammopathy of Undetermined Significance (MGUS). MGUS is an asymptomatic condition in which low levels of monoclonal protein (MP), either whole immunoglobulins or light chain components, are detectable in the blood or urine (8). MGUS is common and prevalence increases with age. MGUS has a low risk of conversion to myeloma, which is plasma cell malignancy, at 1% per year (9).
 

The MGUS primary care management pathway supports family physicians in the screening and monitoring of MGUS. The PCP specifically outlines when MP presence should be tested for, such as when patients present with unexplained anemia, hypercalcemia, or renal failure (10). The document lists the tests that should be performed, including complete blood count and serum protein electrophoresis, and how frequently testing should be repeated based on results. The PCP also describes risk factors that put patients at higher risk of progression to myeloma, such as MP >15g/L, an abnormal free light chain ratio, and non-IgG type MP, who require closer monitoring (11).
 

Importantly, the MGUS PCP defines “red flag” symptoms that require urgent referral to a hematologist, including unexplained bone pain, hemoglobin levels <100g/L, or a deterioration in kidney function (10). PCP implementation has allowed KHSC’s hematology wait list to drop this month for the first time since 2018. Rounds also featured Dr. Al Jin in neurology and Dr. Melissa Kelley in GI, who discussed the development of PCPs for Parkinson’s Disease and Alcoholic Fatty Liver Disease, respectively. More information regarding KHSC PCPs can be found at: https://kingstonhsc.ca/refer/
 

Rounds highlighted that PCPs are driven and informed by the needs of family physicians, such as Dr. Matt Dumas. For Translational Medicine (TMED) students, the PCP model is an excellent example of how collaboration across and beyond healthcare providers can improve efficiency and coordination of patient care. By promoting ongoing management of certain conditions by primary care providers, specialist resources can be allocated to the most at-risk patients. While application of PCPs could reduce wait times across the country and various specialties, considerations and adjustments will certainly need to be made for local contexts and systems.
 

Along the theme of eliminating wait times, Rounds also featured data scientist Mr. Alex Hamilton, who discussed how natural language processing (NLP) technology could be integrated into the MGUS PCP. The NLP pipeline can extract information from referral forms and generate predictions, thereby holding potential for more rapid triage (12).
 

Following Rounds, the TMED Graduate students joined Dr. Hay for a fascinating discussion ranging from her career path to usage of artificial intelligence in cancer diagnosis and prognosis. Dr. Hay revealed how her medical training in the UK, where there is more equitable clinical trial drug access, has influenced her research interests as a Senior Investigator in Canada. She also provided insight into the medical community’s shift to becoming more thorough, and potentially “over-investigating”, explaining the continually rising referral numbers. A key takeaway from our discussion was the need for balance in medical testing. In addition to contributing to wait times, unnecessary tests can potentially harm patients due to exposure to radiation or inducing anxiety (13). Dr. Hay also emphasized the necessity of working in a supportive team and celebrating the small wins.
 

On behalf of the TMED class, I would like to thank Dr. Hay and other contributors for their time, insights, and substantial contributions to patient care.
 

References:

  1. Canadian Institute for Health Information. (2017). How Canada Compares: Results from The Commonwealth Fund’s 2016 International Health Policy Survey of Adults in 11 Countries — Accessible Report. Ottawa, ON: CIHI.
  2. Barua, B. & Moir, M. (2020). Waiting your turn: Wait times for health care in Canada 2020 report. Studies in health care policy.
  3. Sanmartin, C., Pierre, F., & Tremblay, S. (2006). Waiting for care in Canada: findings from the health services access survey. Healthcare policy2(2), 43–51.
  4. Barua, B., Rovere, M. C., & Skinner, B. J. (2010). Waiting your turn: Wait times for health care in Canada 2010 report. Studies in health care policy.
  5. Harrington, D. W., Wilson, K., & Rosenberg, M. W. (2014). Waiting for a specialist consultation for a new condition in Ontario: impacts on patients' lives. Healthcare policy9(4), 90–103.
  6. Arain, M., Rostami, M., Zaami, M., Kiss, V., & Ward, R. (2020). Specialist LINK and primary care network clinical pathways - a new approach to patient referral: a cross-sectional survey of awareness, utilization and usability among family physicians in Calgary. BMC family practice21(1), 86.
  7. Mazurek, M. S., Belletrutti, P. J., Heather, G. S., Swain, M., & Novak, K. L. (2019). A22 Routine Gastrointestinal referral wait list reduction via an enhanced primary care pathway. Journal of the Canadian Association of Gastroenterology2(Suppl 2), 42–43.
  8. Kyle, R. A., Therneau, T. M., Rajkumar, S. V., Larson, D. R., Plevak, M. F., Offord, J. R., Dispenzieri, A., Katzmann, J. A., & Melton, L. J., 3rd (2006). Prevalence of monoclonal gammopathy of undetermined significance. The New England journal of medicine354(13), 1362–1369.
  9. Kyle, R. A., Larson, D. R., Therneau, T. M., Dispenzieri, A., Kumar, S., Cerhan, J. R., & Rajkumar, S. V. (2018). Long-Term Follow-up of Monoclonal Gammopathy of Undetermined Significance. The New England journal of medicine378(3), 241–249.
  10. Rajkumar, S. V., Dimopoulos, M. A., Palumbo, A., Blade, J., Merlini, G., Mateos, M. V., Kumar, S., Hillengass, J., Kastritis, E., Richardson, P., Landgren, O., Paiva, B., Dispenzieri, A., Weiss, B., LeLeu, X., Zweegman, S., Lonial, S., Rosinol, L., Zamagni, E., Jagannath, S., … Miguel, J. F. (2014). International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma. The Lancet. Oncology15(12), e538–e548.
  11. Rajkumar, S. V., Kyle, R. A., Therneau, T. M., Melton III, L. J., Bradwell, A. R., Clark, R. J., ... & Katzmann, J. A. (2005). Serum free light chain ratio is an independent risk factor for progression in monoclonal gammopathy of undetermined significance. Blood106(3), 812-817.
  12. Todd, J., Richards, B., Vanstone, B. J., & Gepp, A. (2018). Text Mining and Automation for Processing of Patient Referrals. Applied clinical informatics9(1), 232–237.
  13. Taylor, P. (2017). Why Unnecessary Medical Tests may do more harm than good. Your Health Matters Sunnybrook. Retrieved from: https://health.sunnybrook.ca/navigator/unnecessary-medical-tests-harmfu…

Comments

Name
Kiera Liblik

Mon, 11/01/2021 - 11:19

Dear Trinity,
Thank you for your thoughtful discussion and summary of last week's MGR! The discussion of wait times often going hand-in-hand with the public versus private healthcare system debate. In fact, you could argue that Canada already had a hybrid system due to our lack of coverage of certain medications, dental care, and psychological care. What are your thoughts on increase the amount of private healthcare in Canada by allowing for some private outpatient surgery clinics, for example? Still mandating that physicians do a certain amount of public work but allowing them to work in these places in their off-time to reduce some of the wait times for those who cannot afford to go to private centers? Although international precedent suggests that this may actually not be the 'time-saving' solution we think it is. (1). Additionally, do you think that we could benefit from having people pay for services based on their income level?
Warm regards,
Kiera

Name
Kiera Liblik

Hi Kiera,

Thanks for your comment! You have raised some interesting points about alternative solutions to approaching the wait times issue. As you mentioned, it seems that the assumption that increased private sector support can reduce wait times in the public sector has not shown to be the case internationally. An expansion of private healthcare in Australia caused an increase in wait times in the public sector (1). Similarly, a study of OECD nations with hybrid systems found that increased private care results in increased wait times and decreased resources in the public healthcare system (2). It seems that as more people use private systems, there is less incentive and political will to work towards addressing public wait list times. This study suggested that decreasing wait times is best achieved by increasing investment and focusing resources into the public healthcare system (2).

I think this topic also broaches on an equity issue – the fact that there are already medications, procedures, and tests that are not broadly covered by health insurance in Canada means that wealthy people inevitably have increased access to diagnostic tools and treatments (and increasing private healthcare would likely exacerbate this). As was discussed in Rounds, when tests are not covered by family physician ordering (as was the case with certain GI tests including AST or celiac serology), oftentimes patients end up accessing specialists or emergency rooms where tests can be ordered for free (again increasing wait times). KHSC was beginning to address this issue by creating special standardized lab requisitions for family physicians. Specialized testing and uninsured treatments may also represent an area where having people pay based on income may be a more equitable solution. However, I’d imagine that such a system would require time, money, and human resource investments to implement. Ultimately, I think continuing to invest into the public healthcare system and developing organizational and management strategies such as the primary care pathways may be our best bet for addressing Canadian wait times!

Best,

Trinity

References

1. Duckett S. J. (2005). Private care and public waiting. Australian health review : a publication of the Australian Hospital Association, 29(1), 87–93. https://doi.org/10.1071/ah050087
2. Tuohy, C. H., Flood, C. M., & Stabile, M. (2004). How does private finance affect public health care systems? Marshaling the evidence from OECD nations. Journal of health politics, policy and law, 29(3), 359–396. https://doi.org/10.1215/03616878-29-3-359

Name
Trinity Vey

Name
Alyssa Burrows

Mon, 11/01/2021 - 15:41

Hi Trinity,

You brought this up in class, but I am hoping that we can continue the conversation here:

Nurse practitioners (NPs) and physician’s assistants (PAs) are both health care professionals that can be implemented to improve patient care and decrease wait times. Additionally, these highlight the team player aspect needed in health care teams.

NPs were established in the US in the 1960s and the first NP school was introduced at Dalhousie in 1970s. Currently, 12 of the 66 nursing schools offer NP programs [1]. Depending on the province and the jurisdiction regulations, NPs can autonomously diagnose and treat illness, order and interpret test results, prescribe medications and perform medical procedures. The nursing approach involves treating the whole person with significant consideration for understanding how the person’s illness affects them and their family [2]. During our talk, Dr. Hay highlighted that the NPs in the hematology clinic focus on managing a patient long-term in a subset of conditions within hematology, which allows them to become experts and helps with patient continuity. From TMED 800, we also heard Dr. Lougheed discuss an NP-run biologics clinic. Several studies have found that NPs reduce weight times, reduce the length of stay (in the emergency room context), and have high patient satisfaction [3, 4].

PAs are also an advanced practice health care providers trained under the medical model rather than the nursing model and can perform histories, physicals, order and interpret tests, formulate treatment procedures, and work under the supervision of a physician [5]. PAs were first introduced to the Canadian Health Care system in Manitoba in 1997 and is a recognized role in 4 provinces (Manitoba, Ontario, New Brunswick, and Alberta), and most recently, Nova Scotia is piloting a PA project [5]. The PA role is more prevalent in the states and has been shown to reduce wait times both in specialist and primary care settings [6, 7].

How can we increase NPs and PAs in the health care system and better utilize them to reduce wait times? Do you think a combination of the PCPs and the addition of advanced health care providers could help with wait times in the Canadian setting?

Looking forward to hearing your response,

Alyssa

1. Worster A Original Article Article original. 6
2. Nurse Practitioners. https://cna-aiic.ca/en/nursing-practice/the-practice-of-nursing/advance…. Accessed 1 Nov 2021
3. Carter AJE, Chochinov AH (2007) A systematic review of the impact of nurse practitioners on cost, quality of care, satisfaction and wait times in the emergency department. CJEM 9:286–295
4. Steiner IP, Nichols DN, Blitz S, Tapper L, Stagg AP, Sharma L, Policicchio C (2009) Impact of a nurse practitioner on patient care in a Canadian emergency department. CJEM 11:207–214
5. Dang A (2017) What is a Physician Assistant? Canadian PA
6. Slade K, Lazenby M, Grant-Kels JM (2012) Ethics of utilizing nurse practitioners and physician’s assistants in the dermatology setting. Clinics in Dermatology 30:516–521
7. Interventions to reduce wait times for primary care appointments: a systematic review | BMC Health Services Research | Full Text. https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-017-…. Accessed 1 Nov 2021

Name
Alyssa Burrows

Hi Alyssa,

Thanks for your thoughtful comment! Regarding physician’s assistants (PA), I do think this role holds the potential to alleviate the burden on the healthcare system - particularly as the Canadian population continues to age! However, as you noted, the PA role is much more established in the States, and the growth of this profession in Canada has been moderate, despite historical success with PAs in the Canadian Forces (1). To further establish this role, it seems that more empirical evidence about the positive effects of PA practice is needed to inform policy-maker action (2). A greater investment of the government into PA education programs and legislation may increase the incorporation of PAs into the Canadian healthcare system in the coming years (2).

I have also been very intrigued by the concept of Nurse practitioner (NP)-led clinics, particularly since Dr. Hay mentioned the success of an NP-led lymphoma follow-up clinic at KHSC. Interestingly, the Ontario Ministry of Health and Long-Term Care invested into the establishment of 25 NP-led clinics in 2007 with the goal of reaching more patients without primary care providers (3). An early study at the first NP-led clinic in Canada, the Sudbury District Nurse Practitioner Clinic (SDNPC), found positive outcomes including significant patient satisfaction, decreased wait times, and NP’s being able to work to their full scope of practice. However, a concern from the Sudbury clinic was the need to increase public understanding regarding the roles of NPs and NP-led clinics (3). I’d imagine that limited public understanding (regarding the scope of practice of both NPs and PAs) is still an issue.

I think we could increase the availability of NP-led clinics through a similar model to that used to develop KHSC primary care management pathways – by collaboration with various healthcare professionals. By consulting with family physicians and specialists to perform a type of “needs assessment”, NP-led clinics could be informed by the need for support for specific specialities, patients, or rural/remote areas. Continued involvement of the government is certainly necessary to help expand this type of practice.

As primary care management pathways help empower family physicians to manage common non-urgent conditions, I think they could similarly be of great use to help empower PAs and NPs.

I wonder if anyone else has thoughts on this?

Best,

Trinity

1.Fréchette, D., & Shrichand, A. (2016). Insights into the physician assistant profession in Canada. JAAPA : official journal of the American Academy of Physician Assistants, 29(7), 35–39. https://doi.org/10.1097/01.JAA.0000484302.35696.cd

2.Jones, I. W., & Hooker, R. S. (2011). Physician assistants in Canada: update on health policy initiatives. Canadian family physician Medecin de famille canadien, 57(3), e83–e88.

3.Heale, R., & Pilon, R. (2012). An exploration of patient satisfaction in a nurse practitioner-led clinic. Nursing leadership (Toronto, Ont.), 25(3), 43–55. https://doi.org/10.12927/cjnl.2012.23056

Name
Trinity Vey

Hi Trinity and Alyssa,

Thank you for your excellent summary of last week’s grand rounds and your contribution to this very interesting discussion.

I agree that utilizing more nurse practitioner (NP) and physician assistants (PA) in collaboration with other healthcare professionals could be very beneficial. However, because NPs and PAs are less common and perhaps less well understood in Canada, I worry that simply increasing the number of these providers won’t be effective. Studies have found that physicians feel NPs lack a defined and standardized role which creates confusion regarding their scope of practice and capabilities (1). Anecdotally, I have heard that sometimes, when an NP orders diagnostic imaging or other tests, their requisition may be denied because the receiving physician believes this is outside their scope of practice, although it isn’t. Then, the NP must ask a physician in the clinic to order the test again. In this situation, just having an NP doesn’t improve wait times or quality of care. I think if NPs and PAs are going to be more widely utilized, this should be accompanied with education for physicians and specialists explaining the scope of practice of these health care professionals and what they contribute to patient care to avoid problems like this.
I was very interested in Dr. Hay’s explanation of NP’s in the hematology clinic, who manage long-term care for patients in remission. This allows for more continuous patient care and because the NPs focus on one specialty, they become experts. One potential downside of the pathways for primary care physicians (PCPs) is that while PCPs are empowered to manage patients with diseases that may otherwise be referred to specialists and end up on a waitlist, this may increase the workload of PCPs. Therefore, I wonder if NPs and PAs could be included in the pathways for primary care providers, so that NP-led clinics could provide continued care in a primary care setting for patients with a specific disease. This would create expert NPs in various diseases and may decrease the workload of PCPs.

I look forward to hearing your thoughts.

Thanks,

Samantha Ables

References
1. Guo, D, and Zuo, K. Nurse practitioners – an underutilized resource. University of British Columbia Medical Journal. 2012, 4(1):24-26. https://ubcmj.med.ubc.ca/past-issues/ubcmj-volume-4-issue-1/nurse-pract…

Name
Samantha Ables

Hi Trinity, Alyssa, and Sam! You all have given an excellent analysis of how PAs and NPs are potential solutions to wait-times in Canada. I spoke with one of my friends, Megan, who is currently in PA school at McMaster, about the topic. She mentioned that PAs are able to work under any MD that hires them, but emphasized that it is currently far easier to work in a specialty that has existing PAs since the MDs and nurses working with them understand the scope of the PAs role already. However, she also brought up that the PA role is currently in the process of being standardized by governing bodies, which is very exciting. We discussed how widespread standardization of the PA role across all specialties (especially those experiencing extreme wait-lists) will hopefully contribute to more PAs practicing and the reduction of workload on nurses and physicians. Standardization will ensure that all physicians have a clear understanding of a PA's training, abilities, and scope of practice (1).

Her passion for being a PA stems from helping health care professionals be able to spend more time with patients and thus treat root causes of illness. This would also promote patients' trust in the healthcare profession since the current system of appointments being as fast as humanly possible does not feel patient-centered, but rather is a result of having incredibly overworked nurses and doctors. She also mentioned that Canada's problem may not be a shortage of doctors but a retention issue, where many MDs pursue specialties in big cities which leaves a severe gap in general practice, especially for more rural communities. Thanks again for an intriguing discussion about the teamwork aspect of medicine!

Best,
Georgia

Reference
1. Legislation | CAPA - ACAM. (2021). Retrieved 4 November 2021, from https://capa-acam.ca/pa-employers/legislation/

Name
Georgia Kersche

Name
Alyssa Burrows

Mon, 11/01/2021 - 15:55

Hi Trinity,

Dr. Hay said that 10% of Kingstonians don’t have a primary care provider. Some more vulnerable individuals include homeless or unstably housed people, people of low social economic status, people in rural areas and new immigrants to Canada and refugees [1-3]. These people would unfortunately not benefit from the PCPs outlined in the lecture. From my knowledge these people may be more likely to access urgent care, emergency care or community how could we increase knowledge and awareness of the PCPs available in KHSC to these groups?

Looking forward to hearing others thoughts!

-Alyssa

1. An evaluation of access to health care services along the rural-urban continuum in Canada | BMC Health Services Research | Full Text. https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-1…. Accessed 1 Nov 2021
2. Khandor E, Mason K, Chambers C, Rossiter K, Cowan L, Hwang SW (2011) Access to primary health care among homeless adults in Toronto, Canada: results from the Street Health survey. Open Med 5:e94–e103
3. Perceived barriers to healthcare for persons living in poverty in Quebec, Canada: the EQUIhealThY project | International Journal for Equity in Health | Full Text. https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-015-013…. Accessed 1 Nov 2021

Name
Alyssa Burrows

Hi Sophia and Alyssa,

Thank you for addressing the important problem of the shortage of PCPs. This healthcare barrier is not limited to Kingston but spans across the country. I found an interesting news report by CTV that states 4.8 million Canadians are without a regular doctor and up to 25% of the population in some provinces do not not have a family doctor. As you mentioned Alyssa, this may leave people seeking care through emergency departments.

Tying this information to our recent situation, many people were afraid to access care in hospitals throughout the pandemic. Emergency visits decreased by 42% during the early stages of the pandemic [1]. Delaying interventions for time- sensitive serious conditions had dire consequences. I wonder if more people had access to PCPs, if some of these unnecessary deaths and medical emergencies could have been avoided. For example, even phone appointments with a family doctor could help to identify medical emergencies and instruct/reassure a patient to visit the emergency department instead of trying to avoid care weeks or months later until Covid cases subside.

Does anyone else have thoughts on how the shortage of PCPs affected Covid-19 related outcomes?

Best,
Bethany

CTV article: https://www.ctvnews.ca/health/despite-more-doctors-many-canadians-don-t…

1. Kim, H. S., Cruz, D. S., Conrardy, M. J., Gandhi, K. R., Seltzer, J. A., Loftus, T. M., ... & McCarthy, D. M. (2020). Emergency Department Visits for Serious Diagnoses During the COVID‐19 Pandemic. Academic Emergency Medicine.

Name
Bethany Wilken

Hi Alyssa and Sophia,

Thanks for your insightful comments. This is certainly a complex issue with no easy solution! As several other comments have touched on, increasing the numbers of family physicians, or increasing numbers of PAs and NPs as support may help alleviate some of the gaps in primary care– although these are more long-term solutions. Certainly, the primary care management pathways are not of use without access to primary care itself.

I wonder if increased engagement of community health resources can support those without primary care while we work towards long-term solutions. For example, the Kingston Street Health Centre is open 365 days a year and provides primary health care, including disease prevention and treatment services. It targets vulnerable populations such as homeless individuals (https://kchc.ca/barrack-street/street-health-centre/ ). I was impressed to see that Kingston Community Health Centres also offer dental services to those with low-income, which can reduce need to access the ER. They also offer Immigrant Services, a Transgender Health care program, and more (https://kchc.ca/weller-avenue/dental-health/ ).

Do you think increasing funding and support of community health resources is a viable solution for accessing patients without family physicians?

Best,

Trinity

Name
Trinity Vey

Thank you Trinity for your great summary of last week's MGR, and Alyssa and Sophia for the great points you raise!

Often, patients who do not have a primary care provider seek medical help elsewhere such as emergency departments or walk-in clinics (1) . Other reasons patients may use walk-in clinics relate to convenience and wait times to see their family physician (2). Considering the points that Alyssa and Sophia made about individuals without access to physicians, I wonder how walk-in clinics could be taken into consideration in the primary care pathways proposed by Dr. Hay and her colleagues. Perhaps the first step is to take time during the walk-in appointment to educate the patient on the health care recourses available to them and to connect them with a long term health care practitioner. These physicians could also be educated in the triage process involved in the PCPs helping refer the patient to the appropriate resources.

Additionally, mobile health units (MHUs) are also used by individuals to access more rapid healthcare. A study found that the primary reason individuals of a low socio-economic status used MHUs was to get access to basic supplies such as socks and vitamins (3). This reminded me of the point that came up in our discussion about how some patients cannot afford lab tests and wait to be referred to specialists so they can have tests done free of charge. It seems odd that in a place with universal healthcare like Canada for expenses to be a limiting factor in equal access to healthcare. I wonder if it would be possible to establish a type of reimbursement program for those who cannot pay for lab tests. There would obviously be numerous challenges associated with this, however, I think this could help reduce wait times by appropriately triaging more patients.

I would love to hear if anyone else has any ideas on how walk-in clinics might be incorporated into PCPs and creating more equal access to healthcare!

1) Hay, C., Pacey, M., Bains, N., & Ardal, S. (2010). Understanding the unattached population in Ontario: evidence from the Primary Care Access Survey (PCAS). Healthcare Policy, 6(2), 33.
2) Izenberg, D., and Buchanan, F. (2021) Ontario walk-in clinics: Complement to or competition for primary care? Healthy Debate. Retrieved November 2, 2021, from https://healthydebate.ca/2018/04/topic/ontario-walk-in-clinics/.
3) Whelan, C., Chambers, C., Chan, M., Thomas, S., Ramos, G., & Hwang, S. W. (2010). Why do homeless people use a mobile health unit in a country with universal health care?. Journal of primary care & community health, 1(2), 78-82.

Name
Cassie Brand

Name
Trinity Vey

Wed, 11/03/2021 - 20:22

In reply to by Cassie Brand (not verified)

Hi Cassie,

You’ve brought up some excellent points. My concern with walk-in clinics and mobile health units is that, by their very transient nature, they are not capable of providing the “management” aspect of the primary care management pathways. Taking the example of MGUS, if a patient were to go to a walk-in clinic with symptoms that prompt testing for monoclonal protein presence, they may be lost from the system in between the initial visit and their visit to Lifelabs (if they even go for blood work). Upon MGUS identification, it would also be important for a physician to fully explain the condition and risks to the patient, emphasizing that MGUS is, of itself, not a cancer. A patient with low-risk MGUS would require ongoing testing to monitor for myeloma progression, which I can’t imagine would be possible with a walk-in clinic alone. Therefore, as you mentioned, connecting patients to a long-term healthcare provider when they present at the clinic seems like an essential step in order to employ the primary care management pathways!

A reimbursement program for specialized lab tests is an excellent idea, although I do wonder if this would place undue stress on administrative stuff. Certainly, additional solutions, such as the specialized referral forms that Dr. Kelley mentioned, are needed to address this issue.

Thanks for your contributions to the discussion!

Trinity

Name
Trinity Vey

Name
Emmanuel Fagbola

Mon, 11/01/2021 - 16:02

Hey Trinity,

Thanks for your effective summary and facilitated discussion concerning last week's Medical Grand Rounds. Akin to the literature you cited and Dr. Hay’s talk, introducing primary care management pathways (PCPs) seems to relieve specialists of their overwhelming patient load. This reduced workload has clear benefits to the patients by allowing them to have swifter access to a specialist.

However, with the PCPs influence on decreased specialist workload, do you think family physicians may have a proportionately increased workload in managing patients that a specialist may typically manage? Also, with reduced wait times, do you think patients will be more willing to request specialists and family physicians will also be more inclined to send them? Finally, does this phenomena have reasonable potential in working against the positive outcomes PCPs have shown to bring?

Name
Emmanuel Fagbola

Hi Emmanuel,

Thank you for your comment – and for addressing something I had thought about deeply myself. In some ways it does seem like primary care management pathways (PCPs) are redirecting the workload downstream onto family physicians. This concern was brought up in our post-Rounds discussion with Dr. Hay, and one of my main takeaways was that PCPs have already been seen as a “win” for involved family physicians. While there does not seem to be published data yet to support this, it was mentioned that PCPs can reduce some of the workload on family physicians who don’t have to spend as much time following-up with specialists to find out when their patients will be seen or sending repeated referrals. The streamlining of specialist services could therefore reduce some stress and uncertainty on the part of family physicians.

The PCP tools were built with and for family physicians, with the goals of supporting and empowering them. It is important to note that family physicians directed the choice of PCP development, so perhaps not every specialty would be appropriate for a PCP for the reasons you identified. PCP development teams are actively seeking feedback from family medicine, which I I hope would help identify issues in a timely fashion. While PCPs hold the potential to drastically reduce wait lists, I’d imagine this will take time (likely many years). In the meantime, if family physicians are becoming more empowered to manage common conditions that used to require specialist referral, patients may be more confident in their care and less likely to request a specialist themselves.

I think your comment also broaches on a larger issue with the Canadian healthcare system and ultimately, the need for more primary care providers, particularly supporting vulnerable populations or remote communities (as Alyssa’s above comment alluded to). This is particularly relevant as the Canadian population continues to age, and there are larger numbers of older patients with co-morbidities. Family physicians will continue to need more support, and in addition to PCPs, interprofessional teams including members such as PAs and NPs may represent one solution to this.

If anyone else has thoughts on this (or has found any relevant studies), please feel free to chime in!

Best,

Trinity

Name
Trinity Vey

Thank you Trinity for such a wonderful recap of last weeks Medical Grand Rounds. I enjoyed listening to Dr. Hay's talk a great deal, and her passion and energy is incredible.
Emmanuel, I was thinking the exact same thing. Although this is such a streamlined approach and fixes a huge backlog in the system, I wonder what impacts it will have on the family physicians. I also wonder the optical impacts it will have regarding specialist referrals and how likely a family physician would send their patient knowing they will be managing them anyways. I see there is a gap in the system and reducing wait times is very much the answer, but you can't help be wonder what downstream effect it will have.

Amazing job Trinity, Emmanuel, and Dr. Hay!
Kyla

Name
Kyla Tozer

Name
Kiera Liblik

Wed, 11/03/2021 - 10:54

In reply to by Kyla (not verified)

Hello Kyla,
Excellent point! It seems that it is becoming as difficult to see family physicians as it is to see certain specialists. I wonder if perhaps it would be beneficial to create incentives to expand walk-in clinic hours to offload some of this burden. As the majority of them are open during business hours (which is not always accessible to those who work), funneling money into increasing their hours may be a good temporary solution. Although, that may take away funding from something to increase the number of family physicians..
Warm regards,
Kiera

Name
Kiera Liblik

Hi Kiera,

I think expanding walk-in clinic hours is a great idea! I often notice large line-ups for clinics in Kingston and I'm sure this is not an isolated problem. Deciding whether to allocate funds for walk-in clinics or family physicians could indeed be challenging. Offering incentives to expand walk-in hours is one solution, but I am wondering what a solution would look like for increasing the number of family physicians. Would it be justifiable to offer incentives to medical students to pursue their residency in family medicine? Another question to ponder is why many students and medical professionals are drawn to specialities instead of family medicine. If we can find the answer to this question, it may help to address the shortage of PCPs we are experiencing.

Best,
Bethany

Name
Bethany Wilken

Hi Bethany,

You bring up a great point about potentially offering incentives for undergraduate medical students to pursue family medicine. This could be achieved by increasing exposure to family medicine and primary care during medical school, medical school admission strategies targeting students interested in family medicine, or financial incentives (e.g., scholarships for students committing to family medicine or low interest loans for family medicine residents) (1).

Contributing to the deficit of primary care physicians, 92% of Canadian physicians work in urban areas (2). This suggests that it is important for medical schools to recruit students who are interested in working in rural areas long-term.

Trinity

References:

1. Student choice of family medicine, incentives for increasing. (2019, December 12). AAFP Home. Retrieved from https://www.aafp.org/about/policies/all/studentchoice-familymedicine.ht….
2. Despite more doctors, many Canadians don't have a family physician: Report. (2019, September 27). CTV News. Retrieved from https://www.ctvnews.ca/health/despite-more-doctors-many-canadians-don-t….

Name
Trinity Vey

Hi Trinity and Bethany,

This is a really interesting point of discussion as I think the issue of PCP shortages in Canada is only going to be exacerbated year after year, potentially made worse by the pandemic due to healthcare worker burnouts (1). As of 2032, the Association of American Medical Colleges projects a shortage of between 21,100 to 55,200 PCPs (2).

I was curious as to why medical students are less commonly choosing to do their residency in family medicine and found that it is, unsurprisingly, a multifactorial issue. Firstly, teaching during medical school is largely done by specialists, so students are not as exposed to PCPs during the early years of their training (3). Additionally, the factors influencing a students’ choice to pursue family medicine appear to be different than those who prefer other specialties. Gill et al. from the University of Alberta found that students who preferred family medicine were older (> 25 yrs), female, and had previously lived in rural locations (4). Factors such as continuity of care, length of residency and preference for working in a rural community influenced the preference for family medicine. Medical students perceive family medicine as being neither prestigious nor affording academic opportunities, which is unfortunate, though highlights a gap that needs to perhaps be more actively addressed during training (5).

Grateful to be able to share my thoughts,

Lubnaa

(1) https://journals.sagepub.com/doi/full/10.1177/21501327211008437
(2) https://www.aamc.org/news-insights/press-releases/new-findings-confirm-…
(3) https://www.yourdoctors.ca/blog/health-care/why-medical-students-arent-…
(4) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3498039/
(5) https://ijhpr.biomedcentral.com/articles/10.1186/s13584-017-0193-9

Name
Lubnaa Hossenbaccus

Name
Dilakshan Srikanthan

Wed, 11/03/2021 - 11:39

Dear Trinity,

Thank you so much for facilitating our discussion and for this wonderful summary of the Grand Rounds. I found our discussion of utilizing artificial intelligence and machine learning in order reduce wait times very interesting. The use of natural language processing (NLP) to extract information from referral forms and generate predictions is an efficient way of triage. Recently, there has been more advances in the application of AI in the field of healthcare. A recent study by Li and colleagues in BMC Health Services Research developed an AI assisted module to help patients automatically order imaging examinations or laboratory tests based on their chief complaints (1). While this technology has shown tremendous reductions in wait time, I wonder about the implications of AI integration in general health care. Do you think that the public has insufficient trust in AI technology, or giving patients such liberty for clinical decision-making supported by AI has consequences? Do you think that AI can be applicable anywhere else where it might reduce wait times? Love to hear your thoughts.

Best,
Dilakshan

1. X. Li, D. Tian, W. Li, et al., (2021). Artificial intelligence-assisted reduction in patients' waiting time for outpatient process: a retrospective cohort study, BMC Health Services Research (21)237.

Name
Dilakshan Srikanthan

Name
Bethany Wilken

Wed, 11/03/2021 - 15:30

In reply to by Dilakshan Srikanthan (not verified)

Hi Trinity and Dilaskshan,

Thank you for discussing the fascinating topic of AI in healthcare. AI is a topic I have very limited knowledge in and that is the wonderful thing about grand rounds, we get to learn about so many new and interesting topics that we otherwise would not be exposed to!

On a surface level, I believe AI does have its applications in healthcare but as a patient, I would not rely on AI to comfort and empathize with me. I wouldn't say I have insufficient trust in the technology as I know there are extensive measures taken in the developmental process. I believe some of the public mistrust is due to lack of understanding and I'm wondering if anyone has ideas as to how we can better educate the public on this topic.

Best,
Bethany

Name
Bethany Wilken

Name
Trinity Vey

Wed, 11/03/2021 - 20:58

In reply to by Bethany Wilken (not verified)

Hi Dilakshan and Bethany,

Thanks for your very interesting comments. While our rounds discussion was focused on the wait time between family physician and specialist services, it seems that wait times while at clinics and hospitals is a whole separate issue in and of itself. In terms of additional uses of AI, Lin and colleagues employed supervised machine learning models to predict wait times for patients at paediatric ophthalmology outpatient clinics (1). While this doesn’t directly reduce wait times, it is useful as patient satisfaction increases when patients are actually informed about how long they’ll be waiting (1).

I agree with Bethany that as a patient, I have some hesitations about AI in healthcare – and I also agree that AI is something I have limited knowledge about. Perhaps those two facts are connected. Interestingly, a 2020 study analyzing social media data and public perceptions found that most people hold generally positive attitudes towards the potential of AI in healthcare (2). Some common hesitations were surrounding the immaturity of AI, and distrust of companies creating this technology (2). Humanistic concerns, as Bethany outlined, remain on the forefront of people’s minds. This paper also emphasized that since medical AI has not yet become widely employed, people’s attitudes are likely to change over time as it continues to develop and become more widespread (2). I would imagine that more empirical evidence (and physicians promoting the credibility of this technology as a result) could improve the public’s trust and comfort levels over the long-term.

Thanks!

Trinity

References:
1. Lin, W. C., Goldstein, I. H., Hribar, M. R., Sanders, D. S., & Chiang, M. F. (2020). Predicting Wait Times in Pediatric Ophthalmology Outpatient Clinic Using Machine Learning. AMIA ... Annual Symposium proceedings. AMIA Symposium, 2019, 1121–1128.
2. Gao, S., He, L., Chen, Y., Li, D., & Lai, K. (2020). Public Perception of Artificial Intelligence in Medical Care: Content Analysis of Social Media. Journal of medical Internet research, 22(7), e16649. https://doi.org/10.2196/16649

Name
Trinity Vey

Thanks for the great discussion, Trinity, and the insightful comments from Dilakshan and Bethany too! As we learned from last week's MGR, AI can bring immense value to patient care, but can still be challenging to implement based on the complexity of patient needs. One way that AI is beginning to be incredibly useful is in helping guide decision making by presenting physicians with all of the data that they need to make clinical decisions but in a more comprehensive and optimized way. AI technologies are being developed to process a large amount of data on each patient in order to adequately understand where they're at and how they need to be treated. Such volumes of data are greater than what a single human physician could process for each patient and can serve as a useful tool for care decision pathways (1). While we have a long way to go to establish trust in patients, and rightfully so, we have a lot of innovation and improvement of care to look forward to in the future.

Cui M, Zhang DY. Artificial intelligence and computational pathology. Lab Invest. 2021;101(4):412-422. doi:10.1038/s41374-020-00514-0

Name
Katie Lindale

Name
Georgia Kersche

Thu, 11/04/2021 - 16:49

In reply to by Dilakshan Srikanthan (not verified)

Hi Dilakshan! Thank you for bringing up the current topic of AI in healthcare. I agree that it has the potential to be a helpful tool in reducing wait times and increasing the decision-making capacity of physicians. I think you and Bethany excellently covered the issue of public perception in regard to AI and their health. I'd also like to bring up the pitfalls of AI. Algorithms have been found to exacerbate racial and gender biases in risk assessment (1). Built-in biases from the creators of AI technology, as well as long-standing race-based categorization practices in clinical cut-offs can be reflected in AI decision making, creating even more barriers to minorities in accessing care. For example, by using healthcare costs required in previous years, algorithms do not account for financial, transportation, medical, and discriminatory barriers that can lead to some groups of patients accessing less care, therefore underestimating the incidence and severity of some illnesses (2). So, I think there is a long way to go before AI can reliably be used to significantly decrease wait times in terms of screening and diagnosis, otherwise we risk AI being a tool to further perpetuate inequality. I wonder if AI can be employed in other fields, like you mentioned, perhaps in the administrative side of healthcare. Another possibility is using AI to educate and empower patients themselves to evaluate their needs before pursuing a PCP or specialist. Perhaps, if done right, AI could even reduce personal bias in healthcare. Would love to hear your thoughts on this!
Best, Georgia

References
1. Noor, P. (2020). Can we trust AI not to further embed racial bias and prejudice?. BMJ, m363. doi: 10.1136/bmj.m363
2. Glauser, W. (2021). AI in health care: Improving outcomes or threatening equity?. CMAJ: Canadian Medical Association Journal. http://dx.doi.org.proxy.queensu.ca/10.1503/cmaj.1095838

Name
Georgia Kersche

Name
Pierce Colpman

Thu, 11/04/2021 - 06:46

Hi Trinity Firstly I would like to say thank you for a great summary of Dr Hay’s medical grand round talk. I think you did a great job of summarizing important points and as someone who was unable to attend due to family concerns, you did a great job of explaining PCP’s and the importance of reducing long wait times.
As I was unable to attend this MGR, my first question for you is if there were any pearls of wisdom that Dr Hay shared with us which in your mind stood out as being very important for our roles as MSc candidates. Furthermore, PCP’s seem to be, from your explanation, very effective in reducing waiting times for patients. Even reducing routine waitlist volume by 99% within 12 months for gastrointestinal disorder patients. How easy do you think it would be to implement a PCP for all avenues of care? Do you think that there would be an enormous cost associated with this? In other words, do you think there is a burden placed on the hospital in any other way due to the implementation of PCP’s? Or do you think that only benefit would come from a system like this.
The next part of my question has to do with wait times in Canada and why they are so long. In a study by Clare Liddy et al, from 2020 it was seen that amongst all commonwealth countries Canada ranked last in wait times (1). Do you think this has anything to do with our free healthcare system? Do you think that because we have access to quality free healthcare that the wait times have gotten out of control, or do you think the problem is bad in Canada for another reason? Additionally, do you think implanting these practices in other countries would be just as beneficial as here or are PCP’s specifically designed to work in the Canadian healthcare system?
Thank you for your great summary and insightful post
1. Liddy, C., Moroz, I., Affleck, E., Boulay, E., Cook, S., Crowe, L., Drimer, N., Ireland, L., Jarrett, P., MacDonald, S., McLellan, D., Mihan, A., Miraftab, N., Nabelsi, V., Russell, C., Singer, A., & Keely, E. (2020). How long are Canadians waiting to access specialty care? Retrospective study from a primary care perspective. Canadian family physician Medecin de famille canadien, 66(6), 434–444.

Name
Pierce Colpman

Hi Pierce,

Thanks for your comment! I’m glad my summary was able to provide some insight on Dr. Hay’s talk. Dr. Hay did share quite a few pearls of wisdom that are applicable to us as MSc students. One of the big ones was setting reasonable expectations for yourself and prioritizing work-life balance. She shared that she has recently taken up sailing and enjoys it as it forces her mind to be completely focused in the present. She also drove home the importance of working in a good team where everyone has each other’s backs; healthcare (and research) is a team effort, and support from a team is important to avoid burnout.

You’ve asked quite a few thought-provoking questions that were briefly touched on post-rounds – one of which about the international capability of these tools. Dr. Archer mentioned the fact that healthcare in Canada is generally driven by the “common good” in contrast to the US where it is profit driven. Physicians generally don’t “solicit business” here. In the states, due to the profit-driven system, it might be harder to implement pathways that ultimately reduce patient visits to specialists. I think part of the reason for the long Canadian wait times is certainly the free healthcare, in addition to the movement to “over-investigating” in attempts to not miss anything.

Many of the presentation contributors emphasized that while its possible (and helpful) to build off previously designed primary care pathways, it’s important to adapt them to local contexts. I know that certain healthcare systems abroad have virtually no primary healthcare providers. For example, family medicine was not traditionally recognized as a distinct discipline in Japan and therefore family physicians make up only 0.2% of Japanese physicians (1). Despite long wait-times for specialist services also being an issue in Japan, primary care management pathways are certainly not a readily accessible solution.

With the redistribution of some work from specialists onto family physicians, it’s possible that additional burden will be placed on family medicine and their administrative staff. However, as discussed in a few other comments, there will also be work such as follow-up and repeated referrals, that will be reduced. I'm not sure if primary care management pathways are the way to go for all specialities – there are certainly some specialties that provide surgery or specific therapies that cannot be provided by family physicians alone. Specialists exist for a reason! It’s worth noting that in the development of the KHSC pathways, family medicine specifically identified hematology, neurology, and psychiatry as areas that they would like to see pathways developed. Perhaps increased education in these areas during undergraduate medical training or family med residency could also help. It will be interesting to follow the evolution of primary care pathways in the coming years!

If anyone else has key pearls of wisdom from Dr. Hay’s talk, please feel free to chime in!

Best,

Trinity

Reference:
1. Yoshida, S., Matsumoto, M., Kashima, S., Koike, S., Tazuma, S., & Maeda, T. (2019). Geographical distribution of family physicians in Japan: a nationwide cross-sectional study. BMC family practice, 20(1), 147. Retrieved from https://doi.org/10.1186/s12875-019-1040-6

Name
Trinity Vey

Hi Pierce,
I hope you and your family are doing well. It was an excellent talk and truly a great shame that you were not able to attend. I thought I would take the time to respond to one of your questions. The one that really stood out to me was: "how easy do you think it would be to implement a PCP for all avenues of care."
Firstly, I think this is a great question and one that I myself am having trouble giving a definitive answer to. I think that this would likely depend on the specialty, and even on a case-by-case basis. For example, we discussed the Parkinson's disease PCP and the main thing that stuck out to me was that this pathway was requiring the primary care physician to manage the patient for the first 3-4 years before seeing a specialist. To me it seemed like many primary care physicians would be happy to take a more active role in managing their patients early on, but as the years pass and symptoms progress they may find this to be more difficult. Furthermore, ultimately, I wonder if we were to adopt this framework for every medical discipline and sub-discipline, would we end up with the same initial problem pushed off to the primary care physician. The last thing patients need is to have a wait list just to see their primary care doctor. Ultimately, however, one of the greatest take aways I had from this talk was the importance of empowering primary care physicians. Improving communication and efficiency is an admirable goal and one that urgently needs to be met.
I hope this helps and I am wondering if anyone thought differently.
Best,
James

Name
James King

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