To fix the #FamilyDoctorShortage...
how many
family doctors
do we need?

The math should be simple, right?

A 🧵 to explain
why we need a whole
new math equation
to actually
fix the problem of
equitable access to
🇨🇦primary care

1/ We only need 4400 family doctors...

2/

🩺❤️‍🩹
The #FamilyDoctorShortage in 🇨🇦 is ... bad.

What can you do to keep yourself as healthy as possible if you don't have a family doctor?

A🧵of (unofficial) ideas for "the unattached" 1/11 2/
❤️‍🩹🩺
First, let's get this important caveat out of the way...
If you are VERY SICK
e.g. issues breathing
or chest pain
or you're bleeding excessively
or another urgent/emergency condition

GO TO THE CLOSEST EMERGENCY ROOM or CALL 911

How do we fix healthcare?

A @CBCnewsbc spoiler 🧵
1/

❤️‍🩹🩺⬆️⬆️ FED & PROV 💰💰 in PRIMARY CARE

=Directly fund buildings + operations + non-MD staff

= "global funding" to CHC's-no more grant hustling to pay for community health needs

=transparent evaluation & QI

#bcpoli

https://twitter.com/sandraqsmiley/status/1572335482822086659

2/

❤️‍🩹🩺 SHIFT MD PAYMENT TO MODELS THAT INCENTIVIZE HIGH-QUALITY, LONGITUDINAL CARE

= e.g. capitation (lump sum pay based on # and complexity of patients in a practice)

≠ fee for service - it incentivizes VOLUME

🧵 1/5
Will "time modifiers"
added to family doctors fees
help more people in BC
access primary care?

🩺❤️‍🩹Probably not

2006-14, BC spent a BILLION $$ (!!)
with incentive fees family doctors for work that typically takes more time (e.g. mental health)

#bcpoli #primarycare 2/5
The new fees were "on top" of the usual "fee-for-service"

The stated aim:
💥to encourage family doctors to return to a traditional model of "full-service family practice"💥

And acknowledged that some work was taking doctors MORE TIME⌚️
@globeandmail
theglobeandmail.com/opinion/was-bc…

1/5
Today is International Overdose Day

Education is important

Whether it's
understanding how to use naloxone students.ubc.ca/health/health-…
or
proper language when speaking about substance use
fnha.ca/Documents/FNHA…

there is a lot of learning to do.

#IOAD2022 @BCCSU @CHEOSNews 2/5
Our REDONNA team has been working on educating prescribers in BC about sparing opioid analgesics for noncancer pain among opioid-naïve patients.
@ShawnaNarayan @ircoopy @JanKlimas @Drug_Evidence
ti.ubc.ca/2021/11/24/web…

The REDONNA study doi.org/10.1016/j.cct.…
began from the motivation for improved & safer opioid prescribing in primary care

We aimed to educate MDs about their OWN prescribing practices using audit & feedback letters developed by the @Drug_Evidence @JanKlimas @ShawnaNarayan 1/4 They received information about the number of new opioid initiations & how they compared to the average physician. They were provided information on the (lack) of effectiveness on pain for opioid naïve patients through an educational webinar: doi.org/10.1093/fampra… (2/3)

1/ Why I am worried about these emergency funds and why I think they probably won't help improve primary care access, a thread #bcpoli #PrimaryCare

https://twitter.com/DoctorsOfBC/status/1562557948961837056

2/ 💯Primary care is in a terrible state in BC (has been worsening for 20 years), and this money might "stem the bleeding" but it won't remedy the sharp objects causing the bleeding🩸🩸🩸

🤔
How much time should a primary care doctor
SEE a patient (direct)
v.
THINK/MANAGE a patient's care (indirect)

This recent paper looked at all the EXPECTED work of primary care providers w large #'s of patients

@BCFamilyDoctors @DoctorsOfBC @JournalGIM
link.springer.com/article/10.100… 🐘 US Study

US & 🇨🇦 primary care recommendations are similar (NOT same, but similar)

Doctor-only care = 26.7 hours/day to provide "recommended" care (IMPOSSIBLE)

In a team-based environment (few in 🇨🇦) doctors need to work = 9.3h/day (Still a v. long day)

#primarycare #bcpoli

The #FamilyDoctorShortage
Can we fix it with more walk-in clinics?

A 🧵 about access hours
for (episodic) primary care in BC
based on our recent pre-print paper

#Cdnhealth #primarycare #bcpoli #tweetorial
@ircoopy @LindsayKHedden @UBCISU @sarah_fletch

medrxiv.org/content/10.110… 1⃣ What's the difference
between seeing a family doctor at a walk-in clinic
versus
a "regular" family doctor's office?

There are two typical kinds of "relationships" people have with a family doctor - EPISODIC + LONGITUDINAL #Cdnhealth #primarycare

Why is my family doctor running so far behind?

Another 🧵
to explore
the inner workings of
🇨🇦 care,
and
why the
#FamilyDoctorShortage
will not be fixed
by just hiring more family doctors.

@BCFamilyDoctors There are two main reasons your doctor is running late:

1) undifferentiated illness
2) primary care service funding being stuck in 1985

#FamilyDoctorShortage

What happens
when your
family doctor
orders
LAB TESTS
for you?

Another 🧵 about the inner workings of 🇨🇦 primary care (or how the sausage gets made), and how fixing the #familydoctorshortage is not just about hiring more doctors.

@BCFamilyDoctors Let's say you go to your doctor,
after considering your story (= reason for your visit), your past medical history,
the possible diagnoses/treatments
for the issue,
she decides to order blood work (=evidence-based medicine),
& you agree with that (=shared decision making).

I think Nurse Practitioners are a part of the solution to the #FamilyDoctorShortage in #BCPrimaryCare and the rest of 🇨🇦

👀 I expect to hear the following "buts"

1- see too few patients
2- spend too much time per pt, cost too much
3- have less training than FP's

And, I agree they are not 1:1 replaceable with FP's

But a "doctors only" fix to Primary Care is so 2019

I am a generalist,
full-service family doctor,
working in a clinic
that provides
longitudinal primary care,
and I referred
a few patients
to specialists
this week...

here's how and why that happens 🧵 1/9

(#BCPrimaryCare) When I see a patient, we talk about:

-the reason they needed the appointment today
-how life is going in general
-as needed, their other medical history

after I get hear the story
do a physical exam
review old information
We may decide that we need extra advice
2/9

I am on call for my primary care clinic this week...

What does that mean?

A 🧵 about how
our fee for service (soon to be "group contract") clinic
of 16 clinicians, ~15,000 patients
delivers afterhours #BCPrimaryCare

@BCFamilyDoctors Our MDs and NPs are on call for one week at a time.

Between 5pm-8am weekdays and all weekend,
we need to be ready to
support patients for
URGENT, not emergency issues
that cannot wait until the next business day

that means phone close by at all times

@DocVan_Nostrand @MariaMichelleH Putting all the responsibility/money for all the things on family doctors, is not really working out:

❗️clinical care
❗️teaching learners
❗️running office
❗ transforming primary care
❗️Leading quality initiatives
❗️evaluating system change
❗️increasing access & capacity

🤔 @DocVan_Nostrand @MariaMichelleH What is the work that Family Doctors *must* have a leadership role in... ?

And what work could we rely on skilled professionals for?

(Analogy: if I was renovating my house, which bits would I want to be in charge of v. Get advice v. contract out completely)

THREAD: Everyone gets a Family Doctor!

This new announcement by the @liberal_party recognizes the value of primary care. liberal.ca/liberals-move-…

And research shows us that access to primary care saves lives!
ncbi.nlm.nih.gov/pmc/articles/P… Details in the Libs announcement are sparse, but to my BC ears, it sounds familiar ... GP for ME
straight.com/life/630116/gp…

Great idea, pay GP's a special incentive fee to take on more patients and ... everyone gets a GP, problem solved... right?

It would be great if every medication worked 100% of the time, but they don't.

The NNT (Number needed to treat) is a way to quantify how often the medication "works"

(caveat: what a drug "working" means is a whole other tweetorial/PhD dissertation!)
#SafeMedsBC To help us get our heads around the math of NNT... an analogy...

Imagine kids learning to read.
If you have 20 kids in a grade one class, by the end of the year, you might have 10 kids who can read. By the end of Grade 3, likely almost all will be able to read.

#SafeMedsBC

How do family doctors organize themselves to deliver #BCPrimaryCare?

Seems like a simple ? right... ?

Our @MaapStudy #MAAPBC team is identifying clinics that provide community-based primary care/family medicine.

And we want to group them into types of clinics. 1/x We started out using the @cpsbc_ca list of all GP's in the areas of interest (all @VCHhealthcare regions).

We identified (by phoning & googling) only those GP's who provide community-based primary care (excluded those people who e.g.just work in hospitals, or are retired) 2/x