On May 16, the Honourable Jane Philpott, MD, former federal Minister of Health and current Dean of Faculty of Health Sciences and Director of its School of Medicine for Queen’s University and CEO of the Southeastern Ontario Academic Medical Organization, in Kingston, ON, will deliver the 2024 Victor Dzau and Ruth Cooper-Dzau Distinguished Lecture in Global and Population Health, titled “Constructing the Future of Health Care.” Dr. Philpott took some time to answer some questions for us ahead of her visit.
What underlies Canada’s crisis in primary care?
There are several intersecting factors that led to this dilemma. When medicare was envisioned, it was expected to include more than just insurance for doctors and hospitals, yet it was never fully developed that way. Primary care happens almost entirely outside of hospitals and requires more than just doctors to deliver it. However, given that we don’t have a national insurance program built with this in mind, our health systems are not based on the foundation of interdisciplinary primary care. On top of that, we don’t have enough health human resources dedicated to primary care.
The biggest issue of all is that we’ve never intentionally designed a system with the idea that every single person in the country would have a place to go for primary care. We depended on an ad hoc process whereby family doctors set up practice based on their personal and professional interests rather than a plan with the whole population in mind. And we haven’t supported family doctors with the infrastructure and interprofessional teams to meet the needs.
What is the challenge in Canada in ensuring those entering the health professions see the front lines as a priority?
The funding models for primary care are challenging. There is very little public support to pay for primary care nurse practitioners or social workers or dieticians, for example. Medical students look at the conditions of work for family physicians and they see how difficult the specialty is. They see a huge administrative burden, and many feel they would rather choose something easier and where they will have the public funding to support their work’s infrastructure. As a result, we have fewer and fewer medical students choosing to enter family medicine.
What are you doing in your leadership role at Queen’s to address the crisis?
We’ve launched several initiatives that will make an impact, but the best example is our new campus and program designed to train family physicians in the Durham Region of Ontario. We welcomed the first cohort of students in September 2023 and chose students who are determined from the outset to become family physicians once they complete medical school. They have a modified curriculum that is focused on family medicine, and many of their teachers are family physicians in community practice settings from whom they learn. Another feature of the program is that they can transfer directly from medical school into a family medicine residency. Early indications are that it’s going to be a big success and it’s a model that others might adopt as well.
What advice would you give to current students wanting to help address this crisis?
It delights me when I meet students, particularly first- and second-year medical students who are interested in family medicine, and they recognize this social need. It’s encouraging when we hear students that want to help address the gaps in access to primary care. I advise them to get early experience in family medicine and to persevere in their dreams despite the challenges ahead. It is the hardest specialty of all, but it is also, in my view, the most rewarding.
Drawing on your experience, including your time as Canada’s Health Minister, in an ideal world what roles do you see the federal and provincial governments playing respectively, when it comes to healthcare in Canada? What changes would you like to see to the current system?
All governments need to collaborate on this issue. The health and health care of Canadians are too important to play partisan or jurisdictional politics. We’ve seen progress on health and social issues in this country when the federal government along with the provinces and territories have worked together for the best interests of Canadians. The federal government can set the national standards for what Canadians should expect. They can provide specific funding earmarked for primary care and then the provinces and territories have the task of operationalizing a standard of health care where every Canadian has a primary care home.
The biggest change I would like to see is that all governments in the country commit to 100% attachment to a primary care team. Currently 22% of Canadians do not have a family doctor or any other primary care provider. In Quebec the number is as high as 30%.
How do you think Canada should address the fact that it is poaching health workers from Low- and Middle-Income Countries to address its own health workforce shortfall? In answering this question, it would be great if you could draw on your own experience providing health services in Africa in the 1990s.
This is an interesting question because there are a lot of Canadians, including politicians, who think we can solve the health workforce crisis by taking doctors and nurses from other countries. On one hand, there should be a relatively straightforward way for internationally educated doctors and nurses who are already living in Canada to have their credentials recognized so they can practice in this county. However, that is an entirely different issue from poaching physicians from countries who need them even more than we do.
I spent about six years working on developing a family medicine training program in Ethiopia which is a country that suffers hugely from ‘brain drain’. They have a fantastic medical education system, highly skilled physicians graduate from their medical schools, but they are very quickly scooped up by other countries around the world, including Canada. It’s unconscionable and contrary to international agreements and commitments we’ve made. There should be no net poaching from other countries and instead we should be able to train enough physicians and nurses here to respond to our own health needs.
Can you tell us, briefly, about the implications of your work on global health? What are some of the common lessons and actions?
I am thankful that I had the opportunity to spend the first decade of my career living and working in Niger because I saw how challenging it is to deliver high-quality health care in a severely resource-constrained environment. Niger is among the poorest countries in the word, and of course their people deserve the opportunity to achieve the highest attainable standard of health. While working there, I learned a lot about the social determinants of health, recognizing that while we could do a lot at the rural hospital where I worked, the things that were making people sick were largely related to their poverty and lack of access to adequate nutrition and housing. The big lessons are that we need to address the deep foundations of health, which are found in our social structures.
Your new book “Health for All” puts forward the idea of “primary care homes”: can you explain this and tell us how it might improve health for all Canadians?
One of the key proposals in the book is the concept that every Canadian should be attached to an interdisciplinary primary care team. I use the term ‘primary care home’ in the book to describe the concept of everyone having a place where they belong, where they feel at home, where they will go for most of their health care needs, where they have a regular provider—who might be a family doctor or nurse practitioner. On any given day, it may be that the care they need is better provided by another member of the care team, and this team will work together in an integrated way. They’ll share an electronic record and address a broad, comprehensive range of health services for people who belong to that home in that geographic region.
We need to develop a system so that every single person has a home like that to which they’re attached, in the same way that every child in this country is attached to a public school for elementary and secondary education. There is an opportunity for multiple partners who are working in health to demonstrate what this model could look like. We are doing this in Kingston where we’ve pulled together our local hospitals, our academic medical organization, public health unit, the city, a community health centre, and the local Ontario health team to develop a primary care home model that responds to the needs of patients in a geographic region who don’t have a family doctor. We’ve called it the Periwinkle model and it’s described in more detail in my book. We hope it can be a template to be reproduced elsewhere. If we do that everywhere, we could finally become a country where everyone has a place to get the primary care they need.
For more information, or to register, for the Victor Dzau and Ruth Cooper-Dzau Distinguished Lecture in Global and Population Health, click here.