Small Changes Big Impact
Small Changes Big Impact
Encountering a new medical system in New Zealand with Dr. Adam Pyle
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Joining us by teleconference today is Adam Pyle, a family physician at St. Michael's Hospital in Toronto, lecturer in the Department of Family and Community Medicine at the University of Toronto, adjunct assistant professor at Queens University and the Canadian medical lead for the Toronto Wolfpack rugby team. In today's episode, we explore the challenges in encountering a new medical system.
Small Changes, Big Impact: a DFCM podcast. I'm your host, Dr. Jeremy Rezmovitz. Joining us by teleconference today is Adam Pyle , a family physician at St. Michael's Hospital in Toronto, lecturer in the Department of Family and Community Medicine at the University of Toronto, adjunct assistant professor at Queens University and the Canadian medical lead for the Toronto Wolfpack rugby team. In today's episode, we explore the challenges in encountering a new medical system. Thanks for joining us, Adam.
Dr. PyleThank you for having me.
Dr. RezmovitzIt's my pleasure. So tell me a little bit about yourself and what you're doing right now.
Dr. PyleSo I'm primarily a community family medicine physician. I work in an inner city community and I also do some acute care, some sports medicine, some emerge. My training is such that I've trained in a few different locations. I spent some time in Chicago and some time in the Caribbean , but I came back to Toronto where I'm from and completed my specialty training here. As circumstances allowed, I am currently talking to you from New Zealand - that's where I've decided with my family to undertake a locum opportunity for this year. So we've taken some, some time away from our busy Toronto lives in order to practice medicine out here in rural New Zealand.
Dr. RezmovitzThat's awesome. So you took your whole family to New Zealand?
Dr. PyleYeah, so happily and thankfully my very supportive partner and wife is a nurse practitioner, so she was also able to practice in a medical context here and our Kiwi brothers and sisters across the ocean make it very easy for Canadian h ealthcare professionals to undertake these locum opportunities and participate in their h ealthcare system. The schooling here is very similar, so my three children are involved in school here and they will tell you that their favorite part so far is the afterschool surfing program on Fridays. So kind of a different lifestyle than in Canada right now - as I understand, you guys have not the weather conditions for surfing.
Dr. RezmovitzWe're surfing. I've been going car surfing.
Dr. PyleOh, pardon me.
Dr. RezmovitzOh yeah. It's awesome. If you don't change your snow tire - to snow tires and go car surfing, it's fantastic.
Dr. PyleYeah. So it's just been great and it's been a great opportunity that we've been happy to pursue. And over here the people and the lifestyle and the culture - very supportive, very similar to Canada in a lot of ways.
Dr. RezmovitzTell me a story about a time where you felt the need that you had to make a change.
Dr. PyleSo I think leading into this leave opportunity to come to New Zealand is probably a good example of a change time for myself and my family. I think a physician wellness has become a sort of a hot topic and often a cliche and a buzz word in a lot of academic and media circles. But it was becoming apparent to myself and my partner that we were living very busy lives in Toronto and perhaps not taking as much time as we wanted to spend with our children and to unplug from the day to day, and to pursue opportunities that were more family oriented and outdoors and reconnect a little bit with why we decided to practice medicine and the way in which we want to practice moving forwards. So I think, you know, it's very supported to do academic medicine in some of the big centres like Toronto, but as you know, the asks keep piling up and it's difficult to say no. And when you're in your early career, I think the tendency is to say yes to all the things. And I think it was time for us. We were realizing increasingly to take a step away from that and reevaluate what we wanted the next 5 or 10 years to look like now that we're out of our training and out of our first part of our careers.
Dr. RezmovitzYou may have similar genetic background to me as I also have the gene for "can't say no" .
Dr. PyleYeah.
Dr. RezmovitzIt's very difficult to say no, especially when you're trying to build your career. So what did you do?
Dr. PyleSo we work a number of jobs and as I mentioned we are very lucky that they are quite supportive. So we approached our various bosses and asked very nicely on bended knee if we could take some time and if they would protect our jobs until we came back. And you know, they were just great about it. Everyone at the University of Toronto was very supportive of this decision. They were happy to have me communicate in the way I'm communicating with you now at a distance and to do some things that maybe would normally have been done in person via phone or via the internet. And so we got this limited time, sort of 10 months to come here and sort out our lives a little bit.
Dr. RezmovitzSo was there one thing in particular that happened with your kids that you missed out on or something with your wife that you said, "you know what, this has got to stop."
Dr. PyleYeah, so it's a good question. So luckily there wasn't. It was more a combination of things having come to a close. So the first five years of my career were over, I had written my emergency medicine exam last year. I had a return of service with the Ministry of Health and Long-Term Care that had just ended. I had completed a number of sort of early career goals around teaching opportunities and bringing to close some research projects. And it was more a case of, if we don't go now, I'm afraid we never will and we could just continue on this path forever and then look back at the end of it and say, "Oh, you know, we didn't do those things or take that time." So we prepared both, you know , financially and geographically to make a big switch. And it was, you know, six months to a year of planning, but at the end of it we've ended up here and we couldn't be happier with it.
Dr. RezmovitzSo what town are you in in New Zealand?
Dr. PyleSo we're in a small town on the North Island - so in the Northern part of the North Island. I think a lot of people will know Auckland in New Zealand. So we're about an hour and a half North of Auckland in a small beach side farming community called Waipu , which has a population of - I don't want to get this wrong - but approximately 3000 people.
Dr. RezmovitzWow. It's probably a little different than practicing at st Mike's.
Dr. PyleIt is very different. Yeah. But I've enjoyed and embraced those differences because as you well know, the people in family medicine are one of the most attractive features of it. And the people here certainly are quite different to the people in Toronto .
Dr. RezmovitzSo tell me a little bit about the people in Waipu and how they're a little bit different.
Dr. PyleYeah. So I think rural New Zealand has this great propensity towards really enjoying the lifestyle and the land that they come from. So people here seem to get up early. They seem to work hard, and then at the end of the day they seem to stop and there doesn't seem to be quite the same attraction to getting ahead and working more hours and collecting more money or more things or sort of conspicuous consumption of items, partially because of the limited availability of certain things in New Zealand, but I think also because of the culture here. So people are a lot more outdoors-y it seems, and they really enjoy their country and its natural beauty. They enjoy going to the beach and sort of surfing and running and biking and hiking and all of the things that you can do here for free that are just wonderful because of the climate and the location.
Dr. RezmovitzSo tell me some of the challenges or barriers that you were anticipating in making the move.
Dr. PyleSo I was anticipating some challenges with sort of continuing duties at home and being called back via email and via meetings and things, but by and large, these have proven to be okay and not insurmountable. I have a number of research projects still ongoing that I'm sort of teleconferencing in for , and some educational projects that are still happening. The Toronto Wolfpack, as you may know, has recently signed , a major New Zealand rugby player who's going to be our new hallmark player in Toronto. And so that's raised a lot of media attention in both this country and in Toronto coincidentally - that he happens to be a New Zealander. So it's going to be a big season for them. And so I've been meeting with the members of the medical team there as well. So I was apprehensive that this was going be a little bit stressful and difficult to negotiate, but by and large, it's been great.
Dr. RezmovitzThat's amazing. I'm really proud and happy that you're able to do something like that.
Dr. PyleI feel very lucky. Very lucky.
Dr. RezmovitzYeah. So tell me about some of the challenges or the barriers that you've encountered from a medical standpoint practicing in New Zealand versus, you know, St. Mike's.
Dr. PyleSo it's a very different system here in a lot of ways. I think countries with sort of the publicly funded healthcare system tend to have a lot of similarities in their ethics and the way in which they provide care. But there are some pretty significant differences here in New Zealand. Just to highlight a few of them, they do have free PharmaCare here - or essentially free PharmaCare. So medications for public consumption on a preapproved formulary are covered by the government, which is, as you can imagine, pretty huge and a pretty large departure from what we may be used to in North America. They also have a semi-private , public/primary care system where people do pay a nominal fee in a lot of cases to visit a GP or to enter into the system even though hospital care is free. And so they are heavily subsidized. So they do have a sort of a dichotomous, almost a two tier system where you can access a private system that runs in parallel to the public system if you want. And that begins at the primary care doorway. But by and large , I think because they are similar to us in that they have a lot of public health interventions and they have a strong population based health plan for the country, and because it's so small, I think population wise there are, there are a lot of similar challenges to what we face in Toronto and in Canada.
Dr. RezmovitzSo please tell me about a time, a challenge that you faced with a patient that really made you wonder how you're doing things, and you said, "you know what, we need to make a change here."
Dr. PyleSo what I like about this country and what I've found to be a tool that we can use here that I was hoping to bring back with me to Canada is people here seem to take a lot of ownership for their health. And so this can be a plus in a lot of ways. People are more conscious of dietary and lifestyle concerns it seems, and they don't have the same difficulty with accessing medication. But one of the challenges then is that they don't come in. So episodic care for preventive health type issues perhaps doesn't happen in as prolific a way as you might hope it to. And so one of the challenges I have found is getting patients back in for return visits, getting patients in for preventive health visits where they know they have to pay for each primary care visit , and it becomes a little more difficult for you to access them rather than for them to access you.
Dr. RezmovitzAnd so that's happening in New Zealand right now. So have you made any changes to try and bring them in?
Dr. PyleYeah, so one of the things we try and do as we do in Ontario and as I'm sure you yourself do, is we try to max back these visits. And so what is supposed to be a 15 minute or 10 minute encounter with a GP ends up stretching to 20 and 25 minutes because you're just not sure when you're going to see them again. And I'll give the example of skin cancer, which is a big problem in this country because of the ultraviolet differences and geographically. But people here seem to have a lot of skin cancer and so when you see suspicious lesions and you want them to be biopsied or excised , often it is something that you want to do that day or that week or within a limited time span, and you're trying to motivate patients to buy into the fact that you are interested in helping them in the short term and getting these lesions dealt with. And sometimes that means repeated visits and sometimes that means going to the office today and trying to get things done, even if your schedule stretches a little long.
Dr. RezmovitzSo I'm no stranger to stretching my schedule if you will - we have the same issues here obviously. So what do you think is a solution to the time issue especially for Canadians practicing or Ontarians practicing that maybe we can learn from people in New Zealand?
Dr. PyleYeah. So the idea of the health care home has really come under a lot of scrutiny I would say recently, but also been adopted in a lot of places in different ways. So both in Ontario and Canada in general, but also here in New Zealand, they're doing a model of the health care home. And I think one of the issues they're looking at in both of our systems is how to meet patients where they are at, right? So how to bring them the care they need at the time they want it. Whether that's increased urgent care access, whether it's weekend and evening clinics, whether it's times when they can be triaged for an urgent appointment that day, if they need to be seen that day. And then subsequently when they are in the office checking up on some of the other things. So using our electronic medical record, which of course is all different here and I'm sure as you know, we all love to learn a new electronic medical record when we come to a new location. But using that electronic medical record to flag reminders to get people to remember or to access their preventive health at the same time that they might be there for an acute issue. And I think technology plays a big role here, even in rural New Zealand. I think we are trying our best to, as a clinic, as a group, as a university, as a nation to use these opportunities to meet people on their schedule for the medicine that they need without, of course, compromising finances and our own wellness in the interim.
Dr. RezmovitzSo do you have an example of you going out to a patient's home?
Dr. PyleYeah. So here in New Zealand , the medical home model that they have has just recently included a physician triage model. So that means that for a certain period of time in the mornings , physicians are now answering phones and they're answering phones for people who want to be seen that day and could maybe be sorted out on the phone. And what it has meant is a 50% approximately decrease in the number of people actually physically coming into the clinic for urgent issues that can maybe be solved next day or over the phone, which frees up almost an entire day's worth of physician time for a moderately sized clinic to deal with other issues in the clinic where people do need to be seen in person. And so often people will think they need to be seen in person and it can be sorted out over the phone or vice versa - they think it can be sorted out over the phone and they actually need to come in. And having that physician triage, the one-to-one contact with a physician over the phone for a few hours in the morning helps to sort out a lot of these issues and point people in the right direction and subsequently frees up a lot of healthcare provider time, nursing time, physician time, time that can be spent on vaccinations, preventive health , well baby checks, things that need to happen in the clinic.
Dr. RezmovitzIt sounds amazing. Is it the physician for - like the most responsible physician for that patient that's answering the phones?
Dr. PyleYeah, so it's a great question. They've toyed with a couple of different ways of doing it and it seems like they are trying to encourage that sort of model, but right now it's on a duty roster situation. So often it is not the MRP, the most responsible physician, but it is the physician who is on that morning. They do have a rostering system here where patients have a primary physician, but they also have a shared care model where multiple physicians within a practice are all sort of vaguely aware of their patient population. And I will tell you in a small town like this, you are seeing these patients on the street that, you know, they're in my touch rugby league after work. I'm going to play beach volleyball tonight with a bunch of them. So you're seeing these patients all the time and I think people are just a little closer knit in terms of community and who knows whom. So I'm not sure necessarily matters in this model here, but in the big cities, I think they're trying definitely to connect the most responsible physician with the patient.
Dr. RezmovitzYeah, I've worked in a small town also and um, you end up having like four locations that you visit for like a year. You know, you're at the clinic, home, the restaurant, and the pharmacy or something like that. You know, or the beach - that's all you're going to. And everybody else is there - I mean, you just meet everybody. And so it's interesting that what sometimes doesn't fly in the big city from an ethic standpoint is a completely normal as the way of life because you're human being existing in a small community. And so that's fascinating. Triaging -physician triage. I wonder if we're going to bring it back to let's say Toronto - St. Mike's. I want to try it in my office.
Dr. PyleYeah. So I definitely think there are a number of ideas that I've been sort of collecting on a pad of paper and typing into my phone here that are things that I want to mention at a grand rounds or at some sort of lecture - ideas that I think that we could benefit from and learn from our Kiwi brothers and sisters about how they are managing some of these aspects of health care . Because I definitely think there's some good learning here that we could bring back to our - even our larger urban environments in terms of how they handle things.
Dr. RezmovitzSo I don't want to spoil your grand rounds, but maybe the top five? Top five things you've learned so far.
Dr. PyleSo definitely the physician triage would be on the list. Another thing that I particularly like that they do here is they have all the nurses handle all the prescription refills. So at my clinic in particular - but I gather at a bunch of other clinics as well - the nurses liaise with the pharmacy for all prescription refill requests and triage them through as well. So do they actually need refills, which medications, how much for how long, whether this was instigated by the patient or by the pharmacy. So those sorts of questions all come through nursing. Another thing that they do here that I really like is they have great, great integration between their district health boards and their primary care offices in terms of referring people in electronically to the system. And that could be to the emergency department, that could be to the specialists - they have a good back and forth electronically and great patient care access that way. Similarly , for number four, I guess I'm up to now, I would say that they have a pretty seamless electronic medical record transfer here where most of the country is on one primary care product. And so consequently, when patients hop between practices, the seamless transition of electronic medical records directly in a paper free manner happens quite quite easily from what I've witnessed. And I'm sure that this is not always the case - that it's not always as seamless as I might hope for some of these things. But I think compared to what we have with a fragmented, siloed sort of system, there are definitely advantages to the way in which they do that here. And then finally I would say their prehospital access and provider network is excellent. It is mostly volunteer, so I have no idea how it functions as well as it does. But they have a St. John's ambulance, primarily volunteer based system. They have mostly volunteer firefighters out here, mostly volunteer paramedics. They have a great helicopter transfer system and I am shocked at how well they're able to triage patients in the field and to access care. And this starts sort of at their surf lifesaving clubs on the coast. It moves towards their land ambulance and then their air transfer, which are all excellent programs that are largely volunteer based with some trained and staff personnel as well. And of course their fire people make up part of that system as well and they're also volunteer based.
Dr. RezmovitzSo which one do you think you're going to implement first when you come back to Toronto?
Dr. PyleWhich of these items?
Dr. RezmovitzYeah.
Dr. PyleYeah. So it's a good question. I want to tackle some of their community practice based interventions I would say first because that seems to be the lowest hanging fruit for what we could do or implement moving forward. I think some of the national level paramedic issues maybe have some medical legal complications associated with them. But in the spirit of all of these ideas are that Kiwi's take care of each other. And I know that's easier to say when the population is so small and the, the country is smaller and people are less spread out. But they do have some rural areas here and they do still have, you know, good health outcomes and good primary care and good integration of the system over some not insignificant geography. So I think there are definitely lessons there that can be applied to Canada where we also have similar population density variances, and some of our medicine is practiced very rurally.
Dr. RezmovitzTell me a time when you were the medical lead for the Wolfpack rugby team where you noticed that, you know what, something needed to change.
Dr. PyleYeah. So the Toronto Wolfpacks road into the super league was a bumpy one. It's a novel team is as people may be aware. So it plays games both here in Toronto and in England and France. So it plays primarily in a league that's based over there. There's a lot of travel time for the players - it's the first transatlantic professional sports team and so it holds this unique position as a team with two coasts or two locations. We started off playing in essentially the British thirds division and h ave moved up to the super league over a period of years. And so when we were in our first season, it was anything goes. It was trying to conform Canadian regulations to what the RFL wanted in terms of its medical standards. And some of the medications we didn't have over here or they weren't available, some of the training was only available in England, some of the supplies and the way in which they practice sports medicine o n the sidelines was actually more advanced than what we were doing here and different, and their prehospital medicine was quite different. So for myself and the other members of the medical team, it was playing a lot of c atch u p and trying to integrate into their system so that games wouldn't be held up or canceled by by our need to do due diligence for the sports med side of things. And so what needed to happen - or w hat we were recognizing increasingly needed to happen - is we needed to standardize all this and have it fit into the Canadian system. So to get people insurance here - both malpractice insurance and h ealthcare coverage for the players to make sure that we had equipment that was equivalent to what they wanted, to do the training that they wanted us to do. And so one of the aspects of that that we've now undertaken is to bring the courses here - to hold them at U of T and at St. Mike's, and partner with the RFL and get some people some training on this side of the ocean. So it was really a learning process and a growth curve as these things are over three years. But now here we are i n the super league and we've signed Sonny Bill Williams a s people may have heard. So it's a great shout out for Toronto and the Toronto sports teams that w e managed to get such a hallmark player and now we're playing in the British super league.
Dr. RezmovitzThat's amazing. Do you have any final words of inspiration for people today?
Dr. PyleYeah, so another great question. I think that if there's anything that my humble origins and teaching and path in medicine can teach people is that you can do whatever you want in it. And it doesn't just have to be in medicine. I would urge everyone to take a look at their careers and take a look at their past if they were struggling with the same sort of questions that I was struggling with. And if you have the opportunity, to take some time and to try another thing - you know, be a rugby doctor, be an emergency doctor, be a family medicine doctor, move to another country , try to do a job that is different than yours, try to have a side hustle or a side gig as it's becoming known - then I would urge you to seize those opportunities because I don't think any of us are getting any younger and often the work that you do can have great implications and repercussions to your home life and your regular life when you come back.
Dr. RezmovitzYeah, I think that's amazing. Just for all those listeners who aren't aware of acronyms, I believe the RFL is the rugby football league.
Dr. PyleThat's right. Yeah.
Dr. RezmovitzJust making sure. Adam, thank you again so much for coming in today. Really appreciate it . Hope you had fun and we'll catch you when you get back.
Dr. PyleThank you. I appreciate it and thanks for having me again.
Dr. RezmovitzNo problem. Take care. 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.