Small Changes Big Impact

How small structural changes can impact your patient population with Dr. Camille Lemieux

April 22, 2020 University of Toronto - Department of Family & Community Medicine Season 1 Episode 24
Small Changes Big Impact
How small structural changes can impact your patient population with Dr. Camille Lemieux
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Small Changes Big Impact
How small structural changes can impact your patient population with Dr. Camille Lemieux
Apr 22, 2020 Season 1 Episode 24
University of Toronto - Department of Family & Community Medicine

In studio today, we have Dr. Camille Lemieux, Chief of Family Medicine at UHN. Today's episode focuses on her leadership roles during COVID-19 and how small structural changes can impact your patient population. 

Show Notes Transcript

In studio today, we have Dr. Camille Lemieux, Chief of Family Medicine at UHN. Today's episode focuses on her leadership roles during COVID-19 and how small structural changes can impact your patient population. 

Dr. Rezmovitz:

Small Changes, Big Impact: a DFCM podcast. I'm your host, Dr. Jeremy Rezmovitz. In studio today, we have Dr. Camille Lemieux, Chief of Family Medicine at UHN. Today's episode focuses on how small structural changes can impact your patient population. Hope you enjoy the show.

Dr. Lemieux:

Hi.

Dr. Rezmovitz:

How are you?

Dr. Lemieux:

I'm good. I'm good. How are you?

Dr. Rezmovitz:

I'm great, thanks. Peachy.

Dr. Lemieux:

That's good to hear.

Dr. Rezmovitz:

What else could I possibly say about a COVID-19 in the current environment, I guess. Let's talk about you. How are you?

Dr. Lemieux:

Oh, you know, I'm busy - kind of a seven day a week nonstop. I want to think about something other than COVID. Trying hard, but it's not working out so well. Every time you try and change the subject, it lasts about 15 seconds. [inaudible] I mean, we're doing fine at UHN. You know, our department's doing well. Morale is pretty good. We're just working hard.

Dr. Rezmovitz:

Yeah. Like everybody else.

Dr. Lemieux:

Yeah.

Dr. Rezmovitz:

That's good. So tell me about all the different roles that you have right now.

Dr. Lemieux:

What do I have right now? Well actually, not that many really. I mean, aside from being chief of the department, I am also the medical lead for our COVID assessment center, which is located here at the Toronto Western. That's pretty much it at this point in time.

Dr. Rezmovitz:

Just two things. I'm sure there's - what about personally? How are things going on at home?

Dr. Lemieux:

Oh well, I'm solo. My kids are actually at their grandmother's because I can't possibly be parents and teacher and cook and short order chef and all that other stuff that kids need at this point - being home all the time. So now they're off somewhere else being fed, which is hard because I haven't seen them for a month. But yeah, you know, it is what it is.

Dr. Rezmovitz:

It is what it is.

Dr. Lemieux:

Yeah.

Dr. Rezmovitz:

So let's add a little bit here. Let's figure out how our listeners can be most intrigued with the chief of UHN of the Toronto Western Hospital - changes that you guys have made to make things better for your patients and of course your staff.

Dr. Lemieux:

Yeah. So let me think. Where do I start? So there's been so many changes in the past month. They're trying to think through them all. Well let's start with staff because certainly the decisions that I make, I make together with our FIT executive lead because obviously we're one group and one sort of cohesive family here. I think the first thing that we started doing - and I'm very glad in hindsight that we did it because sometimes it can be a little bit of a risk to do this - but we made the choice to be as open and transparent as possible right from the get go. Not only with respect to what's happening within our group and our team, but frankly with what's happening across the hospital. Because we're pretty tightly integrated within UHN. So we started off just being very open about what was happening. We set up daily - really town halls. Every day at one o'clock we pull the group together. For those of us that are still on site, they could join in person, and for those that aren't, we joined by GoToMeeting virtually. Part of that's information sharing and we share things as we learn them, but it's also an opportunity for people to collectively express their positive, negative concerns, et cetera - anything that wants to be sort of brought out to the group. And I think it's interesting that that openness that we've kind of modeled has been infectious and people are very open about sharing everything about everything. Some people share things about their personal lives, people share things about their fears, they share things about how we've decided to restructure the clinic - things that are more process oriented - but I'd say we're closer now than we ever have been. And that's not just our physician group, that's across all our other health professionals, our admin, our reception - really, we feel very cohesive. And there's always terrible things happening and then there's that little silver lining if you want to find it. And that's one of our real silver linings is that I think our initial willingness to just be really open about how we were feeling about things - I think one of the first things I sent out to our group was I'm feeling really uneasy and uncertain and I want you to understand how I'm feeling. And people - when they saw that I was willing to disclose how I was feeling about things - felt very - it was permission for them to talk about what they were feeling. And I think in the moment, therapy like that is really helpful. So I think a really good thing about how we sort of dealt with our team and we continue to, I think, function very well to this day. Obviously, people are worried, people have financial stressors and personal stressors and work stressors, but I think everybody feels supported and for the most part, okay. Not great, but okay.

Dr. Rezmovitz:

I think it's really important to make sure people are supported. This is one of those - going back to Psychology 101 - Maslow's hierarchy of needs, and in the middle of a crisis, you make sure the physiological needs are met, and then just above physiological needs is safety. And so if you guys have the supplies, and you're there binding together, then you're supporting each other, right? Physically, mentally - and then you're gonna get up there soon - I would worry if I were you, because you guys might start having self-actualization sessions go beyond this crisis.

Dr. Lemieux:

Yes. That's very true. Watch for unintended consequences. You sort of touch on some other things - so that was sort of how we were dealing with the team and it's how we've restructured our clinic that I think - again has been an enlightening and interesting journey for us. So we very early sort of identified some of the things that were likely coming down the pipe in terms of the pandemic. And I have to credit my colleagues for at times pushing me a little bit and saying, "you know what? Little bit worried about this. Should we think about this? Should we think about these various different things?" And I think collectively, I've structured the - and my physician group with really a leadership team. I think a chief is one part of the leadership team, but there are many roles for others and collective wisdom is always better than one person's wisdom. And so, I really appreciate it for that leadership team bringing forward things. I would bring forward things, they would bring forward things, and I think that our collective thoughts about this really allowed us to be very sort of prescient and very proactive about what we did. So even before things became critical, we started thinking about how we would restructure our physician teams, how we would restructure our other health professional teams to deliver care to our patients. And we began thinking about what if patient, people, physicians, colleagues, couldn't come into work and how we would structure virtual care versus in person care. And we developed a series of sort of principles around which we would work. One of them was we had to ensure access and that patient access was always going to be important. That things that were deferrable should be deferred, but only if safety could be ensured. That ongoing medical care for most patients would continue and we needed to fulfill that. And that the multidisciplinary model that we work under would not stop - that we would continue to offer multidisciplinary care. And so through that, we progressively, initially had some elements of virtual care - initially by telephone - set up for all clinicians and all other health providers. Now that is progressively over time - over a short period of time - become a model where now we're delivering 95% virtual care. But because we set it up early whereby people became I guess aware and socialized to the idea of delivering care by telephone - and we use the Novari platform as well, so by Novari - it wasn't a big shock for people. We started off slow with some virtual appointments and a lot of people still coming in. And then, over the ensuing weeks pretty quickly transitioned without a lot of hiccups to a model where now we're delivering essentially all virtual care. The other thing we did is we sat down very sort of closely and carefully with our nursing colleagues and set up sort of a regime where they would feel comfortable in the care that they were delivering. Now, I give them a huge amount of credit because they stepped up and said, "we want to do a lot of stuff. We want to help here." And so what we did is we set up - put a number of nursing led clinics. So as we as physicians began to deliver more and more virtual care and we're in the clinic less, the nurses said, "well, we're here, we're not working virtually." So we have a nurse-led procedures clinic. So people that do need ongoing immunizations or suture removals or things that really can't wait, they were there to do that on their own, running it themselves. And we also set up a nurse-led pediatrics clinic where babies that needed weight checks, where immunizations could be done, where breastfeeding support could be done - things where parents really wanted to come in and have an in person visit, the nurses were leading that for us as well. So it became very cooperative and collaborative in that way, which was nice. The nurses felt very empowered to do things that completely within their scope of practice and that they do very well and left the physicians feeling like we weren't abandoning our patients by pulling back to do largely virtual care because we certainly - we went to a model where we tried to have as few physicians here as possible. We don't want our physicians getting sick. So we were trying to keep as many physicians home as possible now doing virtual care in order to keep them safe and well. We did the same thing for our residents. We pulled them back sort of in the same model with virtual care and it's worked extremely well. We were concerned at first that our residents would feel that their learning experience perhaps might be compromised by decreased patient contact or decreased ongoing involvement with patient care. We've modeled to them, with them, the same thing that they're doing with us. So we have almost in parallel, we have minimal onsite residents presence who see patients who need urgent care and largely virtual visits. With that, we really thought, are we going to have much uptake from our patients, but we're full pretty much every day - and "full" in the sense if you look at our schedules, there are consistently large number of patients who are being seen virtually and a smaller number that are being seen in person. And thus far, it's working very well, and I've really not seen any clinician or patient really feeling that they're not getting the care and experience that they need.

Dr. Rezmovitz:

So thank you for sharing that and being open and transparent. I have some questions and some comments. One - I'm really glad to see that you guys are following quality improvement principles of patient accessibility and patient safety. Two - will we ever go back to in person visits?

Dr. Lemieux:

So like with our colleagues we don't see as much, we were missing our patients and I think they're missing us. So I would say as a broad statement, yes we will. But the big button that is, we now know that we can effectively deliver care virtually where that's the most appropriate platform and we do have patients where it's going to be more appropriate for us to deliver care virtually - whether it's through video or phone. So we will definitely change the way we practice. We will still largely be in person visits, but I think all of us will integrate virtual visits to a much greater extension to the way we practice and feel good about it.

Dr. Rezmovitz:

I really hope the OMA advocates on our behalf to the Ministry of Health who maintains some codes for virtual care and make it accessible for the providers and the patients because it is - obviously the viruses exposed some challenges our system, but at the same time the viruses exposed some innovation and that has allowed us to excel and support our patients during this time. So speaking about virtual care, can you just speak about the Novari platform and how you guys got [inaudible]?

Dr. Lemieux:

We're approached by UHN - by a hospital to become one of the pilot sites for Novari. Now this was - oh goodness, probably about three, four months ago, so it was certainly predating COVID by quite a bit. So we agreed almost on a research platform to become one of the trial sites for Novari. Now serendipitous timing because Novari has actually turned out to be a really wonderful tool for us during this crisis. So what it allows us to do effectively is create that direct channel of communication with our patients that's secure, that's encrypted, that allows for transfer into our EMR, which is PSS. I think many patients now, yes, they will set up virtual visits, but there's also of course a lot of anxiety and worry with our patients and they're used to being able to reach out to us fairly easily and make appointments fairly easily and even reach us by phone easily. Now I can speak for myself with a myriad of emails and other meetings and things that are going on, I don't necessarily feel I can reliably get back to my patients in a secure manner or in a timely matter. What Novari's allowed me to do is to have that direct access. Patients reach out to me through Novari. I know they're sitting there waiting to hear from me. I can then go in for a defined period of time and say "I'm going to do nothing but Novari for an hour." And it allows me to address everything from a patient who says, "I just need a prescription refilled up to [inaudible]", to a patient who says "you know, I'm actually having abdominal pain and I'm terrified to go into the emerge. Can you help me walk through this?" And I can help triage a patient over Novari and give them direction as to whether they need to be seen in person by ourselves, by colleague and through the ED. So there's a real spectrum that it allows us to be able to do. And I really like the security of it because if somebody shares that kind of information, let's say over email - certainly not a secure platform at all - through Novari, I know it's encrypted and I know it's going to go straight into the patient's chart. So from an accountability perspective, it's lovely. And then, the cherry on top is of course we can bill for those visits. Now that's certainly not the main motivator for using Novari, but it's just sort of a nice thing at the end to sort of put a bow on it that we can actually bill at the end. So in addition to other innovative ways of providing virtual care, I think Novari has shown itself to be a very useful platform.

Dr. Rezmovitz:

Amazing. Any chance you know how other people, community doctors can get involved with Novari?

Dr. Lemieux:

I don't actually. I mean, I do know the people to ask that question out, but I don't off the top of my head. Yeah, yeah.

Dr. Rezmovitz:

Okay. It's something to follow up on.

Dr. Lemieux:

Yeah, absolutely.

Dr. Rezmovitz:

As far as in person visits go and your nurse-led clinics, is there any outreach to the community who may, for like solo practitioners or small clinics that don't have nurses, so that we can minimize exposures and use the resources in the FIT?

Dr. Lemieux:

You know, that's actually an extremely good idea and has not been something we've done to date. So I would actually take that back as the learning for myself that is something we should definitely offer to our community partners.

Dr. Rezmovitz:

So there's this really crazy idea that I was talking to some people about about a month ago. It's called using the Ontario Health Teams to leverage resources. And so it's possible to start getting community doctors and community clinics to sign up through the Ontario Health Teams to really work as a team. I mean, I think that's what the intended structure was there for. And I don't know - are you part of a team yet?

Dr. Lemieux:

We are, yeah. We're in the - we're not an approved team, but we're still in the end of development phase. Yes we are. So I would certainly take that back, I think, as a really good idea because now that we've set up the infrastructure, I think we can certainly share that infrastructure beyond ourselves.

Dr. Rezmovitz:

Yeah. I mean, I think that's what everybody wants in the end is - especially during a pandemic is to share resources.

Dr. Lemieux:

Absolutely.

Dr. Rezmovitz:

What about PPE? What are you guys doing for PPE?

Dr. Lemieux:

So we're very fortunate and I knowledge we're very fortunate because we work within a hospital setting and that hospital - UHN - has, as strong procurement strategies and then definitely has a lot of PPE. So we're the beneficiary of that. I feel very strongly for people who are in the community who don't have that pipeline of PPE available to them. So for that - for us, that has not been a struggle.

Dr. Rezmovitz:

Okay. [inaudible].

Dr. Lemieux:

Now I was gonna say one thing - I'm going to digress a little bit - the one thing we are doing, because we're privileged to be in this position of being within UHN, have PPE available to us, we are, I think one of the few family health clinics that continues to swab our own patients for COVID because we're able to do so safely. Again, that sort of speaks to the collaboration and teamwork within our group - that our nurses and frankly us, because we swab as well as physicians - are willing to offer that to our patients. Because I think many clinicians, I'm sure in the community, felt the struggle and that frustration of having patients they feel probably have COVID but no access or ability to be able to test them themselves. So we're fortunate to have been able to do that for our patient population.

Dr. Rezmovitz:

You know, I just had a patient today - 77 years old, return traveler, still in quarantine, productive cough - is it pneumonia? Is it influenza? Is it COVID-19? I don't know. No fever. You know, how do we manage this case?

Dr. Lemieux:

Yeah.

Dr. Rezmovitz:

It presents some difficulty as somebody in the community. I don't have access to swabs to swab. So it's difficult. It really is.

Dr. Lemieux:

Yeah. So with that, I can sort of speak about my other hat that I'm wearing currently, which is as the medical director of our corporate assessment center. This has been something I've been fairly vocal about of late, is about the - I guess the lack of accessibility of those COVID assessment centers to frontline practitioners. I think many people have stories of patients that they have suggested go to an assessment center to be swabbed, only to have that patient turned away because of restrictive criteria. I'll be very open and saying I think that the position taken by the government or the regional table on this right from the get go I think has been flawed. I understand at points during the process there have been resource limitations, but those have been overcome and I think overcome in relatively short order. And what we've done is we've left a lot of practitioners - like you just articulated - unsure about really how to manage their patients. What are we dealing with here? And also, just I think leaving a lot of patients feeling very abandoned and alone because they really don't know what's happening to them. So I've been a very strong advocate, and our assessment center has been a very strong advocate of really swabbing more liberally than what the current guidelines have suggested now. Very thankful that the province, and the minister has been more forthcoming and suggesting that swabbing should be done more liberally. But I think now we're kind of past that now, right? Where we've had so many cases that we just don't know about and we don't understand. We don't know what the risks are because you know, you have your elderly person and you're not sure if they have a bacterial pneumonia versus COVID. Well, the implications for them could be quite significant in either way, but how are you going to manage them or follow them? It's going to be quite different. Understanding COVID, you're going to keep a very eye on them because at day 10 to 14, they may go South and we see these patients - they tick along for 10 days and then they drop off a cliff, versus your bacterial pneumonia, which of course, you're going to want to sort of manage aggressively with the antibiotics right from the get go. So the way I would look at my patients is going to be very different if COVID in the scheme of things versus not. So I think there's always a lot of learnings post [inaudible] post - after everything happens.

Dr. Rezmovitz:

[inaudible]

Dr. Lemieux:

Exactly. So I think with COVID we have the opportunity to learn in the moment. Like we can be going through rapid PDSA cycles with COVID all the time and learning what we're doing well and not doing well. And some of my frustration is some of those PDSA cycles are not being allowed to happen, right? We as physicians go through them and say, "okay, this is how we can improve things." But at the other end of the pipeline, there's nobody to say, "yeah, I'm going to help you improve things."You know? And so I think it hampers our ability to be good family physicians, comprehensive care, looking at all aspects of our patients.

Dr. Rezmovitz:

It's true. Although I really appreciate your approach. It's like writing a paper. When you write a paper, you a steal shamelessly and cite liberally. And so it looks like you're doing the same thing with swabs, which is steal shamelessly, but swab liberally. I like that.

Dr. Lemieux:

Well, to a point, yes, we are. I mean we're doing what we feel is right - both for our internal FIT patients by having the privilege of swabbing them within our clinic, but also by the COVID assessment center also looking more broadly than perhaps what the initial intent of those assessment centers was.

Dr. Rezmovitz:

No, I - listen, I agree with you until we find a denominator and really understand how do the contact tracing properly, take care of our healthcare workers - there are so many unknowns that you're dealing with and try and understand how to manage people that I think a liberal swabbing policy is best right now.

Dr. Lemieux:

Yeah, I 100% agree. And then there's the whole side of serologic testing that's now coming to the fore. I mean, if we're going to look forward beyond COVID rather than just staring COVID in the face and wondering when it's going to leave, we need that sort of comprehensive plan of proactively swabbing so we know who's infected in the moment with the contact tracing as you suggested. But there's so many people out there that have had COVID that we'll never know about. And unless we do some serologic testing to determine what the level of population immunity - even if it is short term immunity because I think that's not yet known if it's long or short term - is we're not going to get past this, right? We're just going to keep looking at new barrages of infections and not really understand what they mean in the broader picture. And unfortunately, what we're seeing now is that barrage of infections in longterm care homes, right? But what does that tell us about what's happening with community spread? Nothing, other than unfortunately it's been brought into these homes by unsuspecting workers who probably were minimally symptomatic.

Dr. Rezmovitz:

So I was on a call today and - with indigenous leaders, because it's going to spread like wildfire through our indigenous communities due to cultural and systemic challenges that are faced within our indigenous communities due to the fact that there is crowding and housing, due to the fact that they're just cultural values that are placed on getting together with people.There are a lot of challenges and hopefully, through the pandemic we can raise awareness about some of the issues because there are still communities in Northern Ontario that don't have access to clean water. You know, when you say wash your hands with soap and water and you don't have clean water, it's a moot point. And it was interesting - we were talking about spread. And so let's say you can't distance yourself six feet or two meters. The other thing to think about is how much of the transmission is through what people are calling now microdroplets, aerosols, through our feet and what we're - it can go up to 13 feet by being on our shoes. And so we have to think about although people have been saying it's primarily through contact and droplet, we really have to think about all the other ways in which this can be transmitted in contexts that aren't similar to what we say are our standard living in the house or going to work kind of context. So there are some challenges that we're going to face, I think, as a community. We need to start thinking provincially - like beyond local and think provincially and thinking nationally about how we can save the communities that are most at risk right now.

Dr. Lemieux:

Yeah, no, I would 100% agree with that. I mean, local strategies worked for things like influenza, but unless you get macro strategies for something that is so highly transmissible, you're not going to be able to get on top of it. And then the other population of course it's similar to indigenous people is the homeless and disenfranchised population. Again, very difficult to socially distance and limited resources. And often, you know, a lot of comorbidities associated there as well. So I think we're about to see a wave in that population as well.

Dr. Rezmovitz:

Yeah. Do you guys have any plans for outreach for [inaudible] populations?

Dr. Lemieux:

Yeah. Yeah. So we do - actually working on that right now. So St. Mike's has certainly been a leader with their other mobile unit to go out into some of the populations in shelters. And we're looking to work with them - not to duplicate what they're doing, but to actually assist and support - whether it's with physician resources or other resources that we're able to offer with shelters in our area. The other thing we're proactively doing is reaching out to longterm care homes in our area. And funnily enough, the support we're giving them now is literally helping them swab. I mean basic on the ground stuff because they have so many staff members that are out ill, and so many patients that are unfortunately ill and dying that they need that roll up your sleeves, hands on support of literally going and assisting them with swabbing the patients. The next place will be to help them with medical support if they need it, but they just need that grassroots basic stuff at the moment. And it's really quite sad to see.

Dr. Rezmovitz:

Yeah, I don't have an answer for that other than we need to find a way to mobilize. Maybe there's a role for residents as well as to increase the amount of - I don't want to say manpower person power. I apologize. These words systemic [inaudible] - so person power to support the ongoing crisis that - I don't think we're out of the woods yet, although we see hospital admissions reducing, I don't think we're out of the woods yet. I think there are going to be populations that haven't presented themselves yet that are going to start spreading. And we really need to figure out ways to support those populations.

Dr. Lemieux:

Oh, 100%. I mean, yes, the hospital admissions are definitely decreasing, which is good. But a lot of the populations that are going to be affected as you alluded to, often aren't people who rush to seek healthcare. Right? They're often people who aren't necessarily trusting of healthcare until they get so sick that it's going to be catastrophic. So the outreach I think is particularly important to those particular communities to try and get ahead of this before these people become so dramatically unwell that it's really quite catastrophic.

Dr. Rezmovitz:

So on that note, any suggestions because I have been working, trying to figure out how to get ahead of the curve, if you will, on marginalized populations. And there aren't any very good answers for any of this.

Dr. Lemieux:

I think the key is to be out and present with them to the extent that you can be. The folks running shelters or in touch with the homeless population or running longterm care homes - if you extend even the smallest offer of help, the door just - the floodgates just opened in terms of what they need. So I think it's that being present and understanding what is needed. You may not be able to fill all their needs, but even a little bit of being able to go in and do something, I think makes a big difference. You know, at this point, I don't see a broad based strategy for addressing these groups. I think that at this point it really behooves us to be a bit more grassroots on this and be proactive and doing what we can. I think the biggest thing is our presence. We're not going to solve everything, but at least being there and being able to offer what we can offer is better than nothing. And I think all of it, it makes a difference.

Dr. Rezmovitz:

Yeah. That's the approach we're taking right now with the grassroots organization I'm a part of called Conquer COVID-19. And the goal is 80/20. You know, we do our best. We take care of as many people as we possibly can because our hope - and tell me if you agree with this - our hope is that the government will help us at some point, and procure a supply of PPE and help us take care of these patients that need - these groups of people that need to be taken care of and help us address the health inequities that are very, very present and be exposed by this virus. I hope somebody from the government hears this podcast and says, "you know what, maybe two people have it right today and that we'll do our best to support these populations that need our help the most right now."

Dr. Lemieux:

Yeah. No, I would 100% agree. I mean, I kind of sort of can't speak to what some of the PPE delays or shortages are related to. Certainly know there are many people out there willing to donate PPE and that there's certainly a very openness to trying to get PPE to people, and what some of the pitfalls or some of the hurdles have been. I know - obviously not certain, but I do hope the government is able to hear the need. I mean, even - if I can be a little bit direct - I mean, even if these are not the populations that are the top priority for some of the decision makers - and I know that's a little bit blunt to say, ultimately when it comes to healthcare services being overwhelmed, it's going to impact all of us. So being empathetic and open and seeing what's happening to these populations is in everybody's best interest. I mean, certainly as physicians, we see them as patients and we want to help them as patients, but even broader decision makers, we cannot afford to have the healthcare system flooded by people who have been - well there's been delays perhaps, or oversights in terms of willingness to get them tested, willingness to provide appropriate housing and distancing, et cetera to make sure this doesn't spread.

Dr. Rezmovitz:

Agreed. Any last words for our listeners today?

Dr. Lemieux:

I think the other role that I had previously - now we're going back 20 years, but you know, my sort of involvement with this stuff goes way back to SARS. I did a lot of work at the provincial level, post-SARS in terms of looking at really what needed to change posts-SARS. And it's kind of interesting having been in that chair where post-SARS we had that ability to look back and say, "what would we do different if this happened again?" And now being in the again and then seeing the again happening. And some of the things that we did do that were good and I think have made a difference, and some of the things that just didn't happen, which is unfortunate to see. So some of the things that really changed and were good - I mean we certainly see much better collaboration and support between our public health partners and our healthcare institutions, and I would even argue with community providers - I think it was more of a public health presence. And we now have more consolidated public health resources at what we call the Public Health Agency or Public Health Ontario. So I think there are those structural things were all good things, but the cracks we're seeing now are the cracks we saw previously back in SARS. And I think we really need to take a hard look at like why 20 years later, are we seeing the same thing over again? So the big thing is the public health lab capacity. We knew during SARS at the public health lab needed to be really put as a high priority in terms of funding, in terms of capacity, in terms of being able to have quick turnaround in either development or implement implementation of testing. And we're seeing now that our poor public health lab is struggling. We've had to look to private lab partners to be able to get the testing capacity out. So again, I think that needs to be looked at very, very carefully. And the other thing is about ensuring we can keep healthcare providers safe without it becoming a big political agenda. You know, this whole PPE supply chain is - people stockpile. They stockpile in the 10 years after SARS, we had great stockpiles, things were looking good, and then things started to expire. And I think people looked at it and said, "well, do we really want to replace all this expired PPE? Do we really need to have all this stuff?" And there wasn't, I think the same attention paid to good stockpile management because people forget. They get a little bit complacent and this has left us where we are now. And so as boring as stockpile management may seem to a lot of people, it's really important. It's important to keep an eye on the fact that today is okay, but tomorrow may actually be a disaster. And the importance of having the ability to have protective equipment and supplies for staff - those are the two things that are really shining out for me now that we learned post-SARS and somehow it just - we're still struggling with it today.

Dr. Rezmovitz:

Yeah I agree with you. I don't know if I could have said it any better. I think that's all the time we have today, unfortunately. I think we could talk forever. I hope you stay safe and stay sane. You know, if you just switch one letter and all that, you get stay [inaudible].

Dr. Lemieux:

Yes, it's very true.

Dr. Rezmovitz:

And I hope you get to see your kids someday soon.

Dr. Lemieux:

Thank you. And I appreciate the time with you and you stay safe as well.

Dr. Rezmovitz:

Thank you. Be well.

Dr. Lemieux:

Bye. Bye.

Dr. Rezmovitz:

This podcast was made possible through the support of the Department of Family and Community Medicine at the University of Toronto. Special thanks to Allison Mullin, Brian Da Silva and the whole podcast committee. Thanks for tuning in. See you next time.