Nov. 8, 2019

'Back to basics' at the Fall 2019 RA

A “Back to basics” 2019 Fall Representative Assembly (RA) heard the relationship between the province’s physicians and the Saskatchewan Health Authority (SHA) still needs work, two years after the formation of the SHA.

SMA president Dr. Allan Woo told delegates at the Sheraton Cavalier in Saskatoon that the RA agenda stressed panel sessions on bread-and-butter issues for Saskatchewan physicians rather than outside speakers. He called it a “Back to basics” agenda.

One area where physicians need relationships strengthened is with the SHA, Dr. Woo said. When the single health authority for Saskatchewan was established in late 2017, physicians looked forward to the benefits it could bring in terms of a more consistent, coherent health-care system, he said. Physicians entered dyad executive relationships with SHA staff at the highest levels of the organization, which meant physicians could no longer say they weren’t involved, Dr. Woo told delegates in his address, which opened the RA on Friday, Nov. 1

“But relationships are a two-way street,” Dr. Woo said. “It’s not good enough to have physicians sit on committees and not see the results they want to see.”

The two sides need to continue to work on the relationship, through better support and communications, he suggested.

The Saskatchewan Health Authority: Two years in

The first panel session continued to explore the relationship between physicians and the SHA. Host Dr. Kishore Visvanathan posed the same question to all five panelists: What would you do differently given what you know two years after the formation of the SHA?

Scott Livingstone, CEO of the SHA, noted the SHA’s creation was the culmination of a year of work by a transition team that looked at merging 12 health regions into one. Livingstone said the transition team learned from the experiences of other provinces that moved to a sole health authority – namely Alberta and Nova Scotia. Legislation gives the SHA flexibility to use staff where needed, he said, noting the SHA inherited thousands of employees with differing contracts and agreements.

However, it was decided at the time to deal with parts of the health system immediately, and leave other parts to be addressed later. Livingstone suggested the work of the SHA today would be easier if all of the elements of the system were moving forward in lockstep together, rather than a few sections at a time.

He added the amount of variation among the former 12 regions was underestimated, especially in areas such as payroll and other administrative matters.

“We are now playing catch-up as we move forward with the organization,” he said.

Dr. Susan Shaw, chief medical health officer for the SHA, also pointed to the variation in practices among the former health regions, saying it’s important to start understanding them, not necessarily fixing them at this stage.

She added the SHA should do a better job managing people’s expectations. The health system needs to show as little disruption as possible in caring for patients at a time when it is going through plenty of disruption. Better ways of listening to people and sharing information would be ideal, she suggested.

Dr. Philip Fourie, deputy chief medical officer, said one of his goals is to make physician leaders more prominent in the health system. There have been successes to date, but more needs to be done at the department level, he suggested. The issue of variation is a factor, as each of the 12 health regions had different ways of incorporating physician leaders into their systems.

When it comes time to remove variation and decide what to standardize, the SHA has to evaluate what will have the most impact, Dr. Fourie said. He told delegates these decisions need feedback from the point of care – such as from physician leaders in attendance at the RA.

The other two panellists were Dr. Woo and Dr. Siva Karunakaran, past-president of the SMA.

Dr. Woo suggested leadership and support is still missing at the middle level of the SHA structure, and looking back he said there should have been better planning to fill positions at the area lead and department lead levels.

Dr. Karunakaran said despite the change to a single health authority, it’s still business as usual as a specialist at the front line of care. There appear to be challenges for staff as to who to go to for decisions, and what that person will say, which leads to hesitancy with on-the-spot decision-making.

Dr. Karunakaran added he is worried that the SHA will become a top-down, centrally focused organization rather than have decision-making distributed across the province.

Health networks: A physician’s best friend?

Dr. Kevin Wasko, physician executive, integrated rural health for the SHA, told delegates the health network system recently introduced by the SHA arose out of the creation of the single health authority.

“At their core, they will serve as a tool to facilitate team-based care in the community,” he said, calling them the “building blocks” upon which the Saskatchewan Health Authority will be built.

In rural areas, the health networks will link medical services among a number of communities, while in urban areas they will link neighbourhoods, with the goal of a more integrated care system in which patient flow is seamless and people receive care as close to their home as possible, he said.

Dr. Rashaad Hansia, physician executive, integrated urban health for the SHA, added health networks are what a lot of patients already think the system is. Patients expect physicians to know each other and be up to date on information that affects that patient, he said. “Health networks will do that.”

Panellist Dr. Janet Tootoosis, a family physician from North Battleford and SHA board member, concurred, saying ideally, services would be better organized around patients and their communities within a health network. Team-based care will lead to less reliance on family physicians to coordinate care among members of the team, freeing time for physicians, she suggested.

Dr. Stan Oleksinski, a family physician from Prince Albert, said despite the team approach, he hopes to have a single contact person for each patient rather than have that spread among members of the team. Services will have to be well-coordinated and flexible to be of benefit to physicians, he said.

Dr. Barb Konstantynowicz, vice-president of the SMA, noted it’s early in the process of forming health networks. The physician’s voice will be important as networks are reviewed and evolve over the next few years, she said.

Rural medicine in Saskatchewan: Learning from the past; designing for the future

Rural centres that have been able to recruit and retain their physicians are often those that offer training programs for learners, especially residency training, Dr. Sean Groves, a La Ronge family physician, told RA delegates.

He was responding to a question from Dr. Visvanathan, who asked five panellists what is being done well in the area of rural medicine.

Dr. Groves said La Ronge has been able to sustain practices with new recruits because its training program exposes residents to the community and the practice of medicine in it. He said grassroots training programs are most effective. The University of Saskatchewan College of Medicine needs to recognize this and move to a distributed medical education model, he suggested.

Dr. Crystal Litwin, an SMA board member and family physician in Wynyard, said the province does a much better job recruiting rather than retaining physicians. SIPPA grads populate rural centres and are much appreciated, but they often relocate for a variety of reasons. The physician may be happy, but often a spouse can’t find a job or children want to go to university or participate in a wider range of activities, so they move. She proposed a service that matches a community with a physician who might be a good fit, rather than the community taking the first physician offered.

Dr. Jon Witt, head of the SIPPA program, said 350 physicians have been given the opportunity to be licensed in the province in the program’s eight years. Being a physician involves lifelong learning, he said, which means SIPPA physicians should be mentored and provided the same opportunities as all physicians. Medical education should be seen as a continuum, with help extended to physicians who are often on their own in rural Saskatchewan.

Dr. Eben Strydom, a Melfort family physician and SMA honorary treasurer, agreed SIPPA physicians need to be nurtured to help them reach their full potential, especially in small communities. This involves educational, cultural and systemic support, plus a commitment to ensuring rural physicians have an acceptable work-life balance, he said.

College of Medicine: Supporting learners and teachers

The College of Medicine will be key to providing the innovative training medical learners will need as technology plays an increasingly important role in how physicians perform their jobs, Dr. Scott Adams told the RA.

Dr. Adams, representing Resident Doctors of Saskatchewan, said in the future, virtual care and artificial intelligence (AI) will be critical components of the health system. Dr. Visvanathan had asked panellists what they foresee in medical education 10 years from now.

Dr. Adams said students will require more training in new technologies and innovations. AI, for example, will reduce the need for follow-up tests, enable physicians to have more information at their disposal, reduce health-care costs and contribute to a more sustainable system, he said. Although AI is in its early days and is specialty specific, the college needs to think now about how its curriculum will incorporate AI for future students.

Daisy Ko, representing the Student Medical Society of Saskatchewan, said physician wellness – and preventing burnout – is a major concern for students in the future. She added students receive support from the college and the SMA when they need it.

Dr. James Barton, associate vice-dean of continuing medical education, said programs offered by the college will have to match and connect with the needs of physicians, moving away from expert content. New systems of learning will take a broader approach too, including elements of physician wellness.

College officials need to ask, “What is it that physicians want?” and look into providing it, he said.

Dr. Kent Stobart, vice-dean of education for the College of Medicine, said he would take it as a sign of future success when a U of S grad is known and recognized across the country. He said the college will attempt to fulfil the wants of students. If they want to learn about AI, the college will provide them with the resources they need to succeed.

Dr. Marilyn Baetz, provincial department head of psychiatry, told delegates they have to remember that today’s physicians train the physicians of tomorrow. That training should be team-based, build relationships within the medical community, and encourage physicians to get out of their siloes.

Health Minister Jim Reiter’s address

The Health Ministry logged some successes during the past year, but it also faces challenges in eliminating hallway medicine and emergency room waits, Health Minister Jim Reiter told delegates to the RA.

“The system has had some notable achievements this year,” he said, pointing to the opening of the Jim Pattison Children’s Hospital and the Saskatchewan Hospital in North Battleford – the latter being “the single largest mental health expenditure in history.”

The minister noted more addictions beds have been opened, and an additional $10 million has been earmarked to reduce surgical wait times. A surgical wait times initiative in 2010-15 was successful in reducing times, but since then wait times have increased due to higher demand.

The SHA has taken steps to address hallway medicine and ER waits, through its connected care strategy and the opening of a 36-bed medical unit at Royal University Hospital.

Reiter said the government realizes technology is changing the world and the way medicine is practised, but the health-care system hasn’t responded very well to change. He said the government is committed to examining billing codes to better reflect today’s realities.

He also acknowledged technology allows patients to have access to their personal medical records, which the government has made available through the MySaskHealthRecord patient portal. The goal is to get 10 per cent of the population to sign up, evaluate how it is working and make adjustments if needed.

Reiter added provisions of the Health Information Protection Act used by the privacy commissioner to reprimand physicians who sought patient information following the Humboldt Broncos bus crash are under review. He said he agrees with physicians who argued that once they treated victims of the crash in rural hospitals, those patients remained under their “circle of care” and therefore the physicians had a right to look at their personal health information after they had been moved to urban hospitals. The legislation does not incorporate the concept of “circle of care,” Reiter noted, adding consultations will begin soon with a goal to introduce legislation next fall that would accommodate the concept.

Other business

Delegates to the RA debated a number of resolutions, heard a report by officials with the College of Physicians and Surgeons of Saskatchewan, and discussed an update from SMA representatives on the SHA practitioner bylaws and rules review committee. An in-camera session was held on the state of contract negotiations with the provincial government. The previous contract expired on March 31, 2017.

Brenda Senger, director of Physician Support Programs for the SMA, gave a presentation entitled: “Courage to Care: Stepping up and speaking up when a colleague is in distress.”

The next SMA Representative Assembly, which will elect a new president, will be in spring – on May 1-2, 2020, in Regina at the Delta Hotels by Marriott Regina.

Relationships are a two-way street. It’s not good enough to have physicians sit on committees and not see the results they want to see.

Dr. Allan Woo

President, Saskatchewan Medical Association

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