Editor’s note: This interview with Tara Kiran, the Fidani Chair of Improvement and Innovation at the University of Toronto and the lead in the OurCare project, was first published in MedicsVoices.
Tara Kiran: What I love about my job is that it gives me the freedom to think big about what it is that we need to do to make our Primary Care system better and work for everyone.
I spend some of my time at the University of Toronto overseeing the Quality and Innovation program at our Department of Family and Community Medicine.
So, what do we do there? We try to support our teams to measure and improve quality of care. We have 14 Family Medicine teaching units in the Department of Family and Community Medicine, all varying in size and location but we now run the same patient experience survey and we do it in the same way, and our department helps to coordinate all of that, analyze the results, and gives it back to the practices to make it easier to understand what they’re doing, the type of care they’re providing for patients, and how they could do better.
Patient experience is one kind of data that we work with. We also work with electronic medical record data and data from administrative sources that we try to give back.
Another big focus for us is capacity building; we want people to have the knowledge and skills to improve quality in their practice. So, we do a lot of teaching of quality improvement, but we also teach more broadly in continuing professional development. We’re thinking about how people keep up to date on a long-term basis. We’re starting to experiment with ideas like peer-to-peer coaching for example, and we’ve also started to do more forums for family doctors across our province. When COVID began, we started hosting, together with our partner the Ontario College of Family Physicians, a bi-weekly virtual series called the COVID-19 Community of Practice for family doctors. Every two weeks, we now have anywhere from 600 to a 1,000 family doctors join our webinars to learn about the latest on COVID.
A big part of it is learning from each other so it’s become a safe space for people to share their own knowledge and gain knowledge from their peers.
MedicsVoices: Let me take you back a little because you have a lot of experience with Indigenous populations and this is something that is particularly important in Canada. Tell me how that’s influenced your own career.
TK: Trying to advance equity and close equity gaps has been a running theme in my career. It started with me trying to do that as a practicing clinician; I worked in many community health centres in inner city Toronto that worked with more marginalized populations. I also worked in many remote and rural communities, including First Nations reserves in Northern Ontario, as well as Indigenous communities further afield. And I think that shaped my own thinking and ways of understanding health early on and it led me to want to do more.
I ended up doing a Master’s in Public Health that allowed me to understand the concepts of health equity and influence them. I acquired skills in Health Services Research and, in the beginning of my research career, a lot of my work documented inequities between groups.
Moving forward, I’m trying to do more and more, to go beyond just documenting the inequities but trying to close them. And I’ve learned a lot over the last 10 years about how much I don’t know about our own history in Canada when it comes to Indigenous people. When I think about the work that I did with Indigenous people as a young clinician, I think about so much of my own ignorance of the history and legacy of colonialism, and how it shaped the health of the people that I was serving at that time.
Since then, I’ve had the opportunity to take part in Indigenous cultural safety training and learn through other ways that have changed the way that I understand the issues. And what I’ve learned also is that for us to really address it, it’s about me being an ally and trying to amplify the voices of Indigenous colleagues and populations that I work with and serve; working with them to support them to have self-determination about the solutions that would work for their communities.
MV: For clinicians listening to this, what is your message for them in looking after Indigenous communities.
TK: I think it starts by unlearning and relearning what you think that you know because chances are we all have biases that relate to how we learned about Indigenous people growing up. Some biases are so deeply entrenched that we are not even aware of them. So, for clinicians it’s about unlearning and then learning about the history of Indigenous people and how that relates to the current state. When we see an Indigenous patient – first of all, many of us may not even realize it’s a patient who’s Indigenous because for very good reasons they may not want to disclose that for fear of racism and discrimination – but even once we do know someone is Indigenous, how we treat that person is ultimately informed by our own biases, and the life circumstances of that person is informed by the colonial past of our country.
MV: You’re a tremendous advocate for primary care in the wider sense and I know you’re concerned about the future of primary care and how we can strengthen primary care.
TK: When I first became a researcher, a lot of the work I did was trying to understand how reforms that have been enacted in the last decade have influenced the quality of care that is being provided. If, for example, you organize care differently, if you bring in teams, if you pay physicians differently, does that actually change whether people are getting the right treatments, the recommended care, whether they’re going to the emergency department.
For health systems to work well, we need a strong primary care foundation.
The underlying premise is that for health systems to work well, we need a strong primary care foundation. If we look across the world, we see variation in how strong those systems are, and we can learn about how we can do better from other countries. And, as I’ve gotten further into my career, it’s not just doing research to understand how we can do better from a policy perspective, but also trying to directly support clinicians and teams to do better from a practice perspective.
Then, most recently, I’ve been really interested in working with, and hearing from, members of the public about their experiences in primary care and what their priorities, needs, values and preferences are for the future. More and more I’ve come to recognize the terrible situation in Canada where not enough people have a family doctor. Our latest survey, last fall, points out that about 22 per cent of people in Canada 18 years of age and over are without a family doctor. That’s more than six and a half million.
And, to realize a vision of everyone having a family doctor, we need to have a broad public dialogue about what that means, the tradeoffs that might be involved and the types of models that we might need to close the gap. We need to start thinking differently about how our systems are set up for us to achieve that vision of everyone having a family doctor and nurse practitioner.
MV: When you wrote in the Canadian Medical Association Journal, I noticed that you said, “training more family doctors is not the answer.” What do you think the answer is?
TK: There are many things that we need to do differently. We definitely need more teams. There’s lots of evidence that team-based care, when done right, can improve patient outcomes. It can actually improve provider joy in work and, importantly, it can grow clinician capacity to see more patients. We do have some teams in Canada and the way they’ve been implemented hasn’t always been with that last objective in mind. But I do think we need to expand team-based care if we are going to leverage the full potential of family doctors and nurse practitioners that we have currently because, logistically, there is no way for us to train the number that we need in time for the population that needs care now.
In addition to teams, we need payment reform. Teams work best when physicians are on salary or capitation model and not working in a fee for service setting. But we also need to rethink how our systems are structured. As a physician myself, I benefit from a whole lot of autonomy, but I think we need to start to think about whether that autonomy is really good for the system, and we probably do need more physician accountability in the system. That could also come with benefits. We’ve also heard from undergraduates that many of the reasons they don’t want to go into Family Medicine is because they have to set up their own business and they have to figure out who to cover for them if they want to take a vacation or if they want to go on parental leave. But what if we started to have organizations that employed these doctors, gave them benefits, took care of the business part, so that they could focus on the doctoring part.
And what if we started to think differently about how we set up our systems so that it was more like a public-school model where people didn’t have to go on waiting lists and call around just to try and find out if there’s a family doctor that can accept them if they move into a neighbourhood. If the local clinic has to take them on and that local clinic would provide regional after-hours care together with other clinics in the neighbourhood, then you wouldn’t need walk-in clinics. All those walk-in clinic physicians could be doing something different; they could be working in continuous longitudinal practices. So, I’d love to see us rethink what we’re doing.
MV: In addition to the reorganization, which you’re clearly very passionate about, what about the recruitment and engagement of young doctors with family medicine?
TK: It’s a really important point. Right now, and over the last decade, there’s been a slow decline in interest among medical students in choosing Family Medicine as a speciality. Even among Family Medicine residents who do train, fewer of them choose to practice longitudinal continuity-based office care, so they’re not opening up their own family practice or joining a family practice in the way we traditionally imagine. But they’re using their family medicine training and doing other things, some of which are definitely needed in the system like emergency medicine. But sometimes they’re doing other things that arguably could instead be folded into a family practice – whether that be sports medicine, whether that be fertility medicine, even psychotherapy. All of those are human resources that could be redirected toward longitudinal primary care which we know is still foundational.
So, what we see is fewer people going into the kind of care that we know our population really needs. The reasons why are multifactorial, but they relate to an outdated payment model, people not liking the fee for service system, and not seeing how it can help them meet their own financial needs.
It relates to not having the infrastructure and team-based support that they would get, for example, if they chose to be a hospitalist. They know that if you work in a hospital setup, you automatically have a team, you automatically don’t have to pay rent or set up your practice.
It also goes back to the amount of pay, and even the amount of respect that family doctors are accorded in the system. So often, even in medical school, you still hear that narrative “Oh you’re just going to be a family doctor – surely you can do better than that.” That kind of narrative really has an impact on people. And, I think, it is actually tied to the issue of pay because when a profession is paid more relative to others or paid less relative to others, it conveys how much respect that profession has. So, I think we have to fundamentally think about how well-respected the job of the generalist is in medicine. What’s happened over the last decade or more is that there’s been an increasing respect for specialization when, in fact, I would argue that generalist medicine is increasingly difficult to practice because of increasing complexity of patients, the increasing evidence base, and whatnot. So, I think that as a profession, we need to do a rethink and start to value Family Medicine.
MV: Tara, you’re a wonderful advocate for Family Medicine. It’s been an absolute pleasure talking to you. Thank you for sharing your insights.