Even a child can see collaboration is essential to save the Canadian health-care system

By David Ponka, Director of the Besrour Centre for Global Family Medicine at the College of Family Physicians of Canada.

Now that international work travel has resumed, my three daughters looked at me quizzically as I frantically packed my bags on a recent evening. They were still fighting with their vegetables when my eldest daughter, Ella, took the commotion as an excuse to help me.

“Where are you going, daddy?” she asked.

“I have to talk about Canadian health care in Brussels, sweetie.”

“What are you going to teach them?” (Ella thinks that because I teach medical students and family medicine residents, that’s all I do anywhere I go).

“Well, they asked me to talk, and learn, about inter-professional primary health care.”

“What’s that?” she asked.

Good question.

It’s easy to confuse multi- and inter-professional medical care. In Canada, and in most of the world, we are either working in solo practices (mono-professionally) or, if we are luckier, in multi-professional clinics where we share space with nurses and allied health professionals such as physiotherapists and social workers, allowing us to meet the needs of our aging population and address the prevalence of complex multi-morbidity increasingly common in our communities.

But most of the time, while we work in parallel with these other disciplines, occupying the same space, we are not really working together. We typically share a medical record, but don’t always find ways to schedule and see patients either in tandem or at the same time. The idea was right, but it has not led to the efficient or coordinated level of care we had hoped to provide.

What we need instead is truly inter-professional and increasingly trans-professional care.

This becomes critical as more patients age in place and home care again regains importance. Yet, we do not yet have a geographic catchment system to deliver health care in Canada. I am a family physician in Ottawa but have patients in Kanata and Orleans (I have one that travels from Cornwall because she can’t find a family physician there). How can I efficiently provide home care to these patients? The answer is by collaborating with a whole team that can provide me with all the information necessary to diagnose and manage these patients.

This is what they do in Belgium. Not only for home visits, but primary care in general. If an average physician has 2,000 patients, there is no reason that the physician will need to see them for every one of their needs, every time. The team can help triage, see well babies, and offer routine care such as Pap smears so that the physician can devote more time to episodic illness, new diagnoses and management of complex chronic care.

At this point Ella was staring back at me blankly.

So, I said, “OK, let’s draw a picture.”

“Imagine yourself in school and you are trying to learn about a subject – say climate change. You probably want to get all kinds of different teachers teaching you different parts of it, like geography, chemistry, health. Maybe history. Interdisciplinary means taking in all those things together, rather than studying them all separately.”

I added: “There is another level that we call trans-disciplinary, where the only thing that matters is climate change and getting all the disciplines together to find solutions. That’s in the future.”

Ella proceeded to draw a picture that I have used in every lecture I have given since – a picture with increasingly confluent colors mixing into the background fabric of the canvas. It explains what is important in a way that only a child could relate, and it explains a difficult concept simply.

The pandemic has highlighted how disciplines and sectors should be collaborating better, even the delivery supply chain.

There are many examples of where trans-disciplinary collaboration is important. In some sectors, it has already happened. Take transportation, with its truck-rail-ship-plane-back to truck chain. The pandemic has highlighted how disciplines and sectors should be collaborating better, even the delivery supply chain.

In health care, as we continue to oscillate between the acute infectious waves of a pandemic and the more chronic additive impacts on individuals and community wellbeing, we need a more stable, unified approach.

Every parent remembers the torment of trying to balance protecting their children and loved ones from COVID-19 and ensuring their children’s well-being and education. We should be doing both, yet the health and education sectors remain siloed.

The health sector itself is siloed: In Canada, the communication between primary care and public health is made difficult because of the lack of established geographic catchment areas, among other factors. Then there is the obvious and ongoing shortcoming that professionals typically do not work out of the same buildings, let alone offices.

We need to create capacity and collaboration in the general disciplines to ensure nimble transitions as priorities shift and evolve and ensure the patient experience becomes more seamless.

Imagine this scenario: Mrs. A, an 80-year-old breast-cancer survivor with multiple chronic diseases including diabetes, arthritis, and pulmonary fibrosis, desperately wants to stay independent and avoid institutionalization. She visits her integrated patient medical home clinic a 10-minute walk from her apartment. This makes her feel secure, and the proximity and exercise make her wonder whether she still needs her increasingly unused driver’s license. She has a 90-minute appointment scheduled with multiple providers to monitor her use of medication (pharmacist), her diabetes (diabetic educator and podiatrist) and her mobility (physiotherapist). Her family physician sees her to maintain a long-term trusting relationship and to coordinate her care. All her providers shared her medical record and exchanged opinions ahead of time.

On this single visit, a recommendation is made to switch her puffer to a dry powder inhaler to make it easier for her and protect the environment (switching to a dry-powder inhaler could save the equivalent emissions of 54 km of driving per patient per month). She is treated for a foot condition before it can get worse, and her physiotherapist and family doctor work together to treat a shoulder injury so that she can stay independent. The family doctor notices a new mole but can get a quick consultation as several specialties have begun working out of the same clinic. Mrs. A also receives her annual flu and COVID-19 shots thanks to an integrated public health centre in the same building. On the way home, she makes her weekly visit to the school associated with that integrated health centre to interact and read with the kindergarten children.

This scenario could be reality with the proper investments and leadership. While there are many examples of innovative clinics, these remain the exception: We need more transformative models moving forward. We need to put patients first while seeking efficiencies. Above all, we need primary care and public health to join forces to prepare us for the next big challenge – climate change.

Society is entrenched in a very Cartesian, subspecialized approach to human problems. We see increasing specialization and the increasing use of technologies as inherently good, but the pandemic should make us pause and reassess. The current polycrisis in multiple sectors of society is a reminder that everything is related; solutions must once again be aligned, locally scaled and human centred.

Illustration info: A pictorial representation by 10-year-old, Ella, the author’s daughter, to explain where we are falling short in interdisciplinary collaboration in our health-­care system, and why this is important for other sectors emerging out of the pandemic.