Western military doctrine endeavours to enable leaders at the lowest level to adapt to tactical situations to gain and maintain the initiative. Generals may lead wars, but battles are won in the trenches. Now, more than ever, this same doctrine must be applied to our medical professionals on the front lines, allowing them to implement courageous, coordinated, actionable local solutions.
Task-shifting and scope expansions have helped meet some of our health-care needs for many years but have yet to help team dynamics. The simple act of measuring blood pressure was a physician-only skill at one time, and we can’t imagine what global health would be if it still were. Every profession has a role, and these roles often intersect with or even replace others in some circumstances. We can choose to hang on to the past or adapt how we interact with our circumstances to access The Power of Teamwork, as Brian Goldman writes in his book.
Twitter medical personality @DGlaucomfelcken’s parody of rural doctors fits the type of person needed to survive not just in rural areas but, increasingly, everywhere in medicine. Rural and remote patients fly to give birth, drive hours to get basic care and, unfortunately, die more often because of where they live. Rural health teams are unique in that they adapt to their environment to provide the best possible outcomes with limited resources. Imagine if they were given more leeway to shape their teams. First Nations have for years listened to and respected the lands they live on; it is time for us to listen to and respect our health ecosystem. Elusive policies to improve system efficiency would balance with more local team effectiveness.
In Port Hardy, B.C., chronic emergency department closures and an exodus of family physicians have left the population with less desirable primary- and emergency-care coverage. Here is Alex Nataros from Port Hardy: “‘Another emerg closure in Port Hardy’ this past fall. These words echoed across B.C. on the morning CBC Radio all too often. I am committed wherever possible to keep our emerg open. Sometimes that means me providing 48-72 hour stretches of coverage. I have excellent nurses who triage and do their best to let me sleep at night, but I am all too aware that I need more support long-term.
“A Physician Assistant (PA) in Port Hardy would do just that. As an extension of my practice, they would see patients overnight when on call, see patients in clinic, Long Term Car, or Emerg. Currently, we have 3.5 doctors in Port Hardy, serving a population that realistically needs 7 doctors. We are set to lose two of these doctors over the coming year. The need for a PA could not be more urgent.
“The solution of PAs is evident, I have willing candidates, and I have offered to fund it. The only barrier is our current Ministry of Health.”
Situations like this are happening across the country. In Port Hardy, they have Nurse Practitioners and Associate Physicians as part of the team, along with a strong nursing and support staff. What’s missing other than the shortage of physicians? Not an easy question to answer but if we were to guess, it would have to do with local health leaders being unable to shape and adapt their team’s strengths to the situation on the ground. In other words, the generals are micromanaging instead of enabling.
The generals are micromanaging instead of enabling.
The Canadian Armed Forces Health Services has had success in multi-national and multidisciplinary health settings around the globe. These teams consist of a variety of skills and scopes of practice that are sometimes pushed above their limits with some expert local or remote oversight. Customizable scope of practice is an asset in this context and should be encouraged by regulatory authorities.
We asked the Surgeon General of the Canadian Armed Forces, Major-General Marc Bilodeau, for some input. Here is what he said: “To optimally support rural and remote communities, we need to first look at the needs of such community based on their age, gender and other social determinants of health. Only then are we able to identify the required skills and competencies required from the health-care team supporting such needs. This then needs to be augmented by reach-back support either by phone or by videoconference as needed and virtual care needs to be optimized to improve access to more specialized services. We also need to clearly define the threshold for medical evacuation based on the means available and distances and other factors such as weather events.
“Effective health care is based on a team-based approach to care delivery in which the most appropriate health-care provider is used to provide the care required to the patient population. Such team is also based on open communication between team members but also with the patients in a patient-partnered care approach. Such communication needs to be enabled by IT solutions and a shared EHR [electronic health record]. Finally, the team needs to be fully connected with the surrounding community in a patient-medical neighbourhood approach in order to optimize the community services’ support in improving health.”
With more than 1 million B.C. residents without access to primary care, enhancing physician services with both nurse practitioners and physician assistants would ease the burden across all health environments. No one profession should be responsible for tackling this challenge alone, and while the government has seemingly attempted to pit health-care professionals against each other, evidence has shown that multidisciplinary care teams improve health-care access, limit health-care provider burnout and decrease the use of emergency departments.
Funding increases implemented in February 2023 for primary-care physicians should attract more family doctors to the province and help retain them. However, this is not enough; finding more than 667 physicians to meet the backlog of patients who require primary care would take decades. There are immediate, long-lasting and affordable solutions available by enabling physician assistants to join the team, as well as supporting further integration of nurse practitioners. Locally adaptable teams with complementing and sometimes overlapping skill sets will gel under good local expert leadership.
Katharine Smart, Past President, Canadian Medical Association, says policymakers and health-care leaders must “must empower people to be bold and relentless in the pursuit of new and better ways of doing. We must harness the full power of emerging technologies. We need to learn from others’ experiences and stop thinking in terms of tiers and silos; rather we must break them to increase access.”
Smart adds that licensed health professionals should be allowed to work anywhere in the country to relieve the burden on underserved areas.
“What we’ve been doing in recent decades hasn’t worked; as practitioners and patients we know this all too well,” says Smart. “In front of us is the opportunity to do better by shifting our focus to people – the people who work in the systems and the people we are meant to serve. The moment is in front of us, and it is ours to seize.
“We will not solve the challenges in front of us by using the same thinking that created them.”