Dr. Howard Bergman MD, FCFP, FRCPC
Primary care in Quebec at the crossroads: Time for open, respectful public policy discussion (May 2016)
There is no doubt that primary care is at a crossroads in Quebec. In 15 years there has been a major paradigm shift in clinical care, that recognizes family medicine as the foundation of our healthcare system. Yet accessibility, continuity, coordination, accountability and patient and population experience are clearly a focus of a great deal of dissatisfaction.This year has been challenging and unsettling in many ways for those involved in primary care in Quebec with Law 10, Law 20 and the last minute compromise with the FMOQ, as well as 2 new management frameworks that are not widely known to the public. We have yet to understand the full impact of these policy changes on the practice and the teaching of family physicians and most importantly on the quality of patient care.
This is why the McGill University Department of Family Medicine hosted a major policy symposium on Friday May 6, 2016: “Towards a common vision for primary care in Quebec”. Our key partner is the McGill Institute for Health and Social Policy (IHSP) and its Director Daniel Weinstock. Other partners include the St. Mary's Research Centre of the CIUSSS DE L'OUEST-DE-L'ÎLE-DE-MONTRÉAL, the McGill faculties of Medicine and Dentistry, the McGill School of Nursing and RUIS McGill. The goal of the symposium was to contribute to the development of a comprehensive vision and roadmap for primary care in Quebec through engagement with the public, including patients, health care professionals, health system managers, students and residents, as well as key decision makers in a discussion on key ideas and strategies that should underpin the future of primary care in Quebec. The symposium generated a great deal of interest. In fact, 300 people filled to capacity the venue with over 20 additional participants joining by webcast. We are particularly excited that a third of the participants were medical students, family medicine and other specialty residents, as well as MSc and PhD students. Our future practitioners, professionals and academics recognize that they have a real stake in designing their futures. Many of you also joined the conversation by following us on Twitter @McGillFammed, or #McGillFamSymp.
The Symposium was opened by McGill Principal and Vice-Chancellor Suzanne Fortier and closed by Dr. David Eidelman, Vice-Principal (Health Affairs) and Dean of the Faculty of Medicine at McGill. The stellar line-up of invited speakers included three former Quebec provincial cabinet ministers and healthcare commission chairs, Claude Castonguay, Dr. Jean Rochon and Michel Clair. Speakers from Quebec, Ontario and England as well as vigorous participant discussion emphasized that successful policy and its implementation require developing and promoting a shared vision in the population and among those working in the front lines. Successful implementation also requires iterative improvement through accountability and population input. A certain number of key problems were identified including lack of respectful public discussion, and a top down approach based on union negotiation with excessive centralization and even micro management. This has led to cynicism and discouragement not only among front line workers but also in the population. Yet the room was filled with a great deal of energy calling for solutions based on a certain number of key elements including patient, population and community engagement; population responsibility through local governance of primary care based on transparency and accountability; change based upon user-centered design process; innovation and entrepreneurship promoting diversity and pluralism rather than a one-size-fits all approach; quality is fundamental with quality improvement based upon peer-led process; a collaborative clinical model based on the partnership between the primary care team (physician, nurse and other healthcare professionals) and the patient.
The results of the conference will be synthesized. The summary as well as the link to the webcast will be made available through our website. The Department of Family Medicine and IHSP plan to publish newspaper op-eds as well as academic papers. Most importantly, this symposium must be seen as a first step in widening the conversation and in proposing solutions for wider public policy discussion. It is fitting that this year, the Department of Family Medicine at McGill celebrates its 40th anniversary. On May 5 on the eve of the symposium, 150 people attended the Gala Homecoming Dinner at the Musée de Beaux-Arts de Montréal with the launch of the Friends of McGill Family Medicine. The keynote guest was David St Jacques, a graduate of our family medicine residency program and a Canadian astronaut!
Over the past four decades, the Department of Family Medicine has grown from one of the smallest academic departments in the Faculty of Medicine at McGill, to the largest. Our Department, functioning in both English and French, spans 6 Family Medicine Units (now known as Groupes de Médecine de Famille universitaire (GMF-U)), in Montreal, Chateauguay, Gatineau and Val D’Or as well as a satellite site in a “GMF hors-établissement.” At the government’s request, it is expected that the number of residency slots will increase to 250 in the coming years. Most significantly, in the past 4 years, we have consistently filled essentially all of our spots. In this last CARMS match, we filled 100% of our slots. In the past several years, we continued to attract a record number of graduating medical students from McGill as well as a significant number of students from the 3 Quebec sister universities as well as other Canadian universities. This past year, forty-one McGill medical students matched to our McGill Family Medicine residency program and another 25 to other Canadian Family Medicine programs (many in Quebec): 38% of the class. Compare this to 2008 when only 13 McGill students matched to family medicine and we had 20 slots remained unfilled. Our Family Medicine Units care for very diverse communities and patient populations with over 100,000 registered patients offering interdisciplinary comprehensive family medicine, as well as innovative services in chronic disease management, infant and maternal health, adolescent health, care of older persons, care for refugee and immigrant populations. Beyond the borders of our Family Medicine Units, our teachers and preceptors are present in almost every region in Quebec (including the far north), looking after very diverse populations including indigenous populations. Our research and graduate study programs with over 20 PhD and clinician scientists as well as over 50 MSc, PhD and post doc students in our MSc and PhD programs (unique in the world) also reflect this commitment to improving the health of the population and our healthcare system through a community and patient-centered approach.
We are excited to celebrate this milestone with an exercise that exemplifies the heart of family medicine: reflecting on actions that take us from evidence-informed practice to policy, and back again, to collectively co-design our future.
May 13, 2016
McGill Family Medicine: 40 years of innovation in care, teaching and research (September 2015)
This year, 2015-2016, our Department is celebrating its 40th year anniversary, 40 years of innovation in care, teaching and research. We have a lot to be proud of. Forty years ago, we began as a small teaching program with units based in several McGill Montreal hospitals. From those early pioneering days, our Department has progressed to become one of the biggest, if not the biggest, department in the Faculty of Medicine. And, we are now a fully recognized and appreciated academic partner in the Faculty. Our Department spans 6 Family Medicine Units (now known as Groupes de Médecine de Famille universitaire (GMF-U)), in Montreal, Montérégie, Outaouais and Abitibi; and including a satellite site in a “GMF hors-établissement.” We are now a department that functions in both English and French. Our Family Medicine Units care for very diverse communities and patient populations with over 100,000 registered patients offering interdisciplinary comprehensive family medicine, as well as innovative services in chronic disease management, infant and maternal health, adolescent health, care of older persons, care for refugee and immigrant populations.
Beyond the borders of our Family Medicine Units, our teachers and preceptors are present in almost every region in Quebec (including the far north), looking after very diverse populations including indigenous populations. From a training point of view, our residency program with over 200 residents is the biggest residency program at McGill. At the government’s request, it is expected that the number of residency slots will increase to 250 in the coming years. Most significantly, in the past 3-4 years, we have consistently filled essentially all of our spots. In this last CARMS match, we filled 100% of our slots. We attracted a record number of graduating medical students from McGill as well as a significant number of students from the 3 Quebec sister universities. Forty-five McGill medical students matched to our McGill Family Medicine Medicine residency program and another 25 to other Canadian Family Medicine programs (many in Quebec) in the first iteration: 39% of the class - a record! We are heavily involved in undergraduate teaching. I am particularly proud of the McGill Longitudinal Family Medicine Experience. In this pioneering program, all first year medical students spend one half day twice per month in the office of a family physician. It means that we recruit about 190 family physicians each year, most of whom are practicing community based family physicians outside of our Family Medicine Units.
Our Department has a unique and flourishing graduate studies program with an accredited MSc and a soon to be accredited PhD program. This fall we have close to 50 MSc, PhD and postgrad students in our department. Our twenty PhD and clinician-scientist professors in our department are leaders in research in family medicine and global health and hold approximately $40 million in peer review grants. Our international health program extends to Latin America, Africa and Asia and continues to grow. Our newest pioneering development is the development of our distance and blended learning programs, which will make our masters and PhD programs available for a wider range of students, including practicing family physicians. It will also enable us to work and support the development of primary care internationally. It will be important for faculty development and for training our own residents who are scattered through the whole province. So we really do have a lot to be proud of. Yet this year has been unsettling in many ways with Law 10, Law 20 with a last minute compromise with the FMOQ and the two «Cadres de Gestion». We have yet to understand their impact on the practice and the teaching of family physicians. There is a cliché that says: “threats create opportunities”. As we struggle through this difficult context, it will hopefully stimulate our own organization and practices. Even before Bill 20, our units have been implementing ways of improving accessibility for our patients: extended hours on week-days and weekends, walk-in clinics and more recently advanced access. One of our units was a pioneer in implementing advanced access, which is now being implemented progressively in all of our units. Five of our 6 units are already GMFs and the 6th is looking to increase its patient registration to become a GMF. Several of our units have EMRs (Electronic Medical Records) and the others have accelerated their implementation. Our residents already have their own patient population of between 150 and 200 patients preparing them for a GMF type practice. Our Department has consistently and constantly insisted on the importance of quality: quality of clinical care, quality of proactive chronic disease management, and quality of meeting the needs of the patient population in the community we serve. There is no doubt that primary care is at a crossroads in Quebec. In fact, we can see the same debates and issues in other Canadian provinces and other jurisdictions in North America and Europe. Our Department can and must play a leading role in elevating the present debate beyond negotiations, finger pointing and questions of «productivity».
That is why our Department will be hosting, in celebration of our 40th anniversary on Friday May 6 2016 a major policy full-day symposium in partnership with the Institute for Health and Social Policy, St. Mary's Research Centre, and RUIS McGill entitled “Towards a common vision for primary care in Quebec”. The objective of the symposium is to contribute to the development of a comprehensive vision and roadmap for primary care in Quebec engaging the public including patients, health care professionals, health system managers and key decision makers in a discussion on key ideas and strategies that should underpin the future of primary care in Quebec.
The symposium will emphasize audience engagement with invited guests from Quebec, Canada, and internationally drawing upon the best available knowledge and critical thinking on the improvement of primary care in Quebec. The results of the conference will be used for the preparation of a white paper on the vision and roadmap for primary care to be presented for wider public discussion. The second important initiative in the celebration of our 40th anniversary will be the creation of a network of our McGill family medicine residency program graduates as well as our present and former teachers. Our graduates are present in all the spheres of health care in Quebec, Canada and internationally. Some of our graduates are involved in academic programs, but most are community based practicing family physicians. We would like to draw upon their collective wisdom and their energy as our Department moves forward.
The kick-off for the creation of this network tentatively called “Friends of McGill Family Medicine” will be a homecoming gala dinner celebrating our 40 years and to be held on May 5, 2016, on the eve of the policy conference. I am looking forward to your input on the preparation of the policy meeting and the creation of this network of McGill Family Medicine graduates. I would also like to call upon you for volunteers who can take the lead in developing the network.
In the coming months, you will be hearing a lot more about these 2 major 40th anniversary events. I invite you to consult our website http://www.mcgill.ca/familymed/ I wish you all an exciting and fruitful 2015-2016.
Exciting Times in McGill Family Medicine (June 2013)
It was a little over a year ago when I first became Chair and sent out my first message to you. I must say that I am as excited and as enthusiastic today as I was last April. I have had a chance to meet many of you and to get to know the Department and appreciate even better now the time, dedication, expertise each of you contributes to the excellence of our Department.
A lot has happened in the past year for which we can be very proud.
First, we passed perhaps the most important test of all: the accreditation process. This is a process and an evaluation by our peers. Although we have not yet received the final written report, it is quite clear that we have passed this test with flying colours. While the program does not examine all aspects of our Department and concentrates on the residency training program, there is no doubt that all the programs and divisions and units contribute to the excellence of our residency training program and to our very successful accreditation. The equally important test was the recent CaRMS match. With only one unfilled spot in all the 84 spots available, we passed this test with flying colours, demonstrating our increasing attractiveness to medical students. Our research activities and strengths continue to grow in a very important manner.
Our Department has taken a leading role in the creation of the Quebec Knowledge/Research Network in Primary Care. At the same time, we are laying the foundation for our own McGill Research Network in Primary Care which will begin in our three Montreal Units and progressively expand to all our Units and in fact to GMF's outside of our university base. This year we have two new FRQS chercheurs-cliniciens. This is an extremely competitive competition for salary support for clinician and PhD scientists. We now have a total of 8 chercheurs-cliniciens and 7 PhD researchers in our Department. The new FMOQ program, which allows researchers to bill for their time in research, will further enhance our capacity to expand and increase the excellence of our research program. Ultimately through collaborative and participatory research, we want to improve the organization of services as well as our clinical interventions. Finally, our researchers have been very successful in some major team grants in the past year. In the “be careful what you wish for category,” under the new Undergraduate curriculum reform, all medical students will spend one half-day twice a month for ten months in the office of a family physician. This program, known as the McGill Longitudinal Family Medicine Experience, has been a major undertaking: we need to place 187 medical students! And thanks to the work of the Undergraduate committee and our staff, we are very close to this goal. What is most exciting about this is that most of the physicians that have accepted medical students in this program are in the community, not attached directly to our Family Medicine Units. We hope this will be the basis for a very exciting network with strong two-way communication, learning from each other how to improve care, teaching, and research.
I would also like to add that the Annual Refresher Course for Family Physicians now attracts over 400 community-based physicians. Our research Master's (MSc) in Family Medicine continues to be one of the unique programs of its kind in Canada. The number of Master's students continues to grow and we hope to be able to attract our residents into the Clinician Scholar Program and then into the MSc. As well, we hope to be able to structure the program to allow for family physicians in practice to enroll in the MSc. We have been designated as an adhoc PhD so our faculty will be able to continue to supervise PhD students. Concerning our MSc, we had an accreditation visit with the view of transforming our MSc program presently under Experimental Medicine into an independent Master's Program. In the area of Global Health, we continue to have very exciting projects in Africa and Latin America with several large international team projects. At the same time, our research and intervention program in indigenous health continues to grow. We have undertaken discussions with several places in China concerning the training of Chinese family medicine residents. Finally, we have tried to improve and simplify our administrative structures, as well as our means of communication. We are presently working on revamping the website with the help and support of the Faculty. There continue to be important challenges. And they fall into the category of “Be careful what you wish for: “Family Medicine is at the heart of the healthcare system; Family Medicine is critical to our healthcare enterprise" (Dean David Eidelman) and there is increasing recognition of the importance of primary care community-based research. These are important expectations that we need to meet. More precisely, in the next three or four years, we need to increase the number of residents from the present number of 84 to 103.
As we look to develop new sites (the Queen E. Family Medicine Group will be taking on 2 residents as of July 2013), we need to also consolidate our existing sites. This is not an easy task. With the Triple C, which we have been implementing at McGill for several years now, residents are spending more and more time in the Units. As well, the Units are helping train other healthcare professionals such as nurse practitioners, as well as taking on medical students either in the Longitudinal Experience or in the Clerkship. In that context, Faculty Development is extremely important and an essential element of our work in education. All this is coming at a time when resources are not expanding in the healthcare system or at the university. It is important that we maintain the perspective that our Department is no longer a Montreal Anglophone department. We are a department with Units in various regions of Quebec functioning in both English and French. Members of our Department continue to be very active at the university, involved in Faculty initiatives including the development of the Faculty's strategic research plan: the Postgraduate education program, the Undergraduate curriculum reform, the Faculty Leadership Council, the Centre for Medical Education, etc. Many have won awards at McGill (see annex on p.4), as well as provincially and nationally. At the same time, I would like to express my appreciation for the continued support from the Dean, as well as from the Associate Deans and the Dean’s staff in the academic development of our Department. As many of you know, we have begun strategic discussions in the Units, Programs and Divisions of our Department.
I do hope you are participating in these discussions which are a chance to step back from the usual and very important discussions on the daily operational issues that we have to deal with. This is a chance to look at some of the more strategic objectives that we want our Department to take. If you have not received the documents regarding these discussions, please let me know. I would be happy to send them to you.
In the fall, we will be having a departmental retreat. Unfortunately we will not be able to invite all members of the Department but we will need to find some way to involve all of you in the ensuing discussions. I want to conclude by telling you about two very exciting recent events in which I participated. First, the Family Medicine Student Interest Group (FamSig) dinner. FamSig brings together medical students with a strong interest in Family Medicine who in turn want to promote to other medical students the Family Medicine residency program. There were about 40 students at the dinner who were at various points in their medical student career. All of them were there because they were at least interested in finding out more about Family Medicine and many of them were already committed to a career in Family Medicine. It was for me an extremely invigorating and inspiring experience to see so many bright, dynamic, and committed medical students with very varied future interests in Family Medicine, as clinicians, clinician-educators, or clinician-scientists. Second, the Isaac Tannenbaum Annual Research Day. This day brought together essentially all of our residents from our six Family Medicine Units. The resident oral and poster presentations were of very high quality. Many were excellent examples of practice-based research pointing to how practice can be improved by research. The residents were interested and enthusiastic. While some may have an interest in a research career, many others will certainly be able to participate in practice-based research which we want to develop with the McGill Primary Care Research Network.
Those students and residents are the future of Family Medicine and it was really great to see how the future is so bright! June 2013
It’s a perfect time to be in Family Medicine! (March 2012)
Dear Colleagues, I am delighted and enthusiastic about taking on the daunting but exciting challenge of working with you in leading the McGill Department of Family Medicine. In accepting the Chair of our McGill Department, I know I can build on very important strengths developed in the course of our Department’s history under the leadership of its Chairs, in particular the tenures of Louise Nasmith, Martin Dawes and Miriam Boillat, as well as the previous and present leadership of our family medicine units and programs. I have been very impressed by the competence, enthusiasm, dedication and collegiality of the members of the Department that I met in the past weeks.
Our Department can be very proud of its strengths in undergraduate medical education, resident training and faculty development, as well as in research, global and public health. We have created the first Master’s program in Family Medicine research in Canada, and are part of the development of an interdisciplinary McGill PhD program. It is a testimony to your collective efforts that this year we matched 100% in the first round of CaRMS! We live in a complex and rapidly changing environment. Demographic changes are characterized by the aging of the population and important pockets of vulnerable populations. Chronic disease, in the context of the aging population, is recognised as the main driver of mortality and morbidity resulting in increased complexity and multi‐morbidity. There is a clearer understanding of the impact of socio‐economic and environmental factors and of the importance of health promotion and prevention. Global health is no longer the health issues of others. They are shared issues of the developed and developing world.
Finally, technological developments have created new hopes and expectations in what has become to be known as personalised medicine or personalised healthcare. We also live in a rapidly changing healthcare system where care has moved from institutions to networks of care, often community‐based; from a single professional, generally a physician to many health care professionals; with increasing expectations, knowledge and involvement of patients, families and communities. There is a growing preoccupation with costs and performance leading to increased government intervention, control and reforms. Medicine and our health care system have become increasingly complex and interdependent. Through all these rapidly changing demographic and epidemiologic changes, there is one clear consensus: primary care, and in particular Family Medicine, is the foundation for a sustainable health care system capable of meeting the needs of the population.
The Family Medicine Group (FMG ‐ or Groupe de médecine de famille ‐ GMF) model, designated as Medical Home by the College of Family Physicians of Canada, has become the basis for primary medical reform in most provinces and countries around the globe. It is based on these cornerstones: interdisciplinary group practice; assuring accessibility, continuity and quality of care for an identified population; evolving remuneration; and IT infrastructure. Family Medicine and the continued development of the Family Medicine Groups have become a priority of the Quebec Ministry of Health and Social Services (MSSS). Although this has not always resulted in the addition of sufficient resources, it is clear that the support for primary medical care is very high on their agenda. The government has increased – in both absolute terms and relative to other specialties – the number of slots for trainees in Family Medicine and the number of Family Medicine Units, while increasing responsibilities in undergraduate medical education. The MSSS and the Fonds de recherche du Québec‐Santé (FRQS), in collaboration with the Canadian Institutes of Health Research (CIHR), have announced a major initiative and investments in primary care community‐based research – identifying mental health and aging, including chronic disease, as priority themes –and designated the four university Departments of Family Medicine in Quebec as leaders in the initiative. This is part of a larger Canadian and Quebec strategy on Patient‐oriented Research (SPOR). Dean David Eidelman has clearly indicated to me that, building on the existing strong base in our Department, the development of Family Medicine as a premiere academic discipline at McGill from an education and research perspective is a priority for the Faculty of Medicine. We have his support to expand our strong contribution to the Faculty at all levels and our strong presence in health care reform, education and research in Quebec. The Dean has asked our Department to play a leading role with our colleagues from other Departments in developing the McGill strategy for the SPOR initiative. A very exciting opportunity through this initiative is the creation of The McGill Primary Care Community‐based Network for Care, Education and Research based in our Family Medicine Units.
You, of course, know the expression: Be careful what you wish for! That is why a very important short‐term priority is the carefully planned integration of the increasing number of residents and sites, as well as the new undergraduate programs, recognising that this comes at a time when all the units have increased clinical and teaching loads without the necessary increased resources. In the coming months, I plan to meet with all of you and work with you in identifying the key strategic issues for the Department over the next 5 years.
I am excited and enthusiastic about working with you; so please never hesitate to contact me directly.
It is a perfect time to be in Family Medicine!