Small Changes Big Impact
Small Changes Big Impact
Advocating for a better health system with Dr. Danielle Martin
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In studio today, we have Danielle Martin, family doctor and chief medical executive at Women's College Hospital. She's also an associate professor in the Department of Family and Community Medicine at the University of Toronto. Today's episode focuses on advocating for a better health system.
Small Changes, Big Impact: a DFCM podcast. I'm your host, Dr. Jeremy Rezmovitz. In studio today, we have Danielle Martin , family doctor and chief medical executive at Women's College Hospital. She's also an associate professor in the Department of Family and Community Medicine at the University of Toronto. Today's episode focuses on advocacy. I hope you enjoy the show . Welcome.
Dr. MartinThank you. Thanks for having me.
Dr. RezmovitzThank you for coming on. So you know, you've been doing some stuff in the department over the last three, four years, five years, six years, seven years, eight years?
Dr. Martin2006 - I joined.
Dr. Rezmovitz2006.
Dr. MartinIt's been a while.
Dr. RezmovitzI think I attended one of your very early health policy lectures when you were still doing academic half days. Do you still do -
Dr. MartinI still do.
Dr. RezmovitzDo you still do the health policy lecture on public versus private administered health care?
Dr. MartinI do. I still do a really great health policy curriculum for our residents at Women's College, and I do a shorter version of it for all the residents at U of T, because I do think it's important to have at least a language for talking about health care systems as we enter into practice. And that's not something that we, I think have fully covered in our medical education yet.
Dr. RezmovitzI agree with you. Your ears must burn when I give my talk on systems - I don't give a talk, it's to patients or you're at a party and someone's like, 'oh, you're a public employee.' I'm like, 'ugh.' I went to a talk once - let me talk to you about publicly funded and privately administered, you know? Yeah . So - yeah, I got it a while ago. And so, these things are near and dear to my heart. Being an advocate for our patients is important. We are very lucky to be in a single payer insurance province I guess? Where it's simple.
Dr. MartinIt is simple. I mean, I think people don't realize sometimes how complex a system can become quite quickly when you have multiple payers in the mix. And I was reading a paper that came out in which the Cleveland Clinic - which is of course a big hospital system in the US - reported that they have 210 million prices for their services because - and of course many of which are different prices for the same service depending on who's paying. So there would be one price for a Medicare patient, one price for a Medicaid patient, different prices for different insurance programs, prices for out of pocket, etc. 210 million . Try administering a health care system where you have 210 million patients. Imagine the size of the billing office.
Speaker 2I just think it's amazing that they have - you know, for simplicity. I've already done the math. They offer 7 million services, at three different tiers, and there you go. There's your 21 million - Oh , you said 210 million. Oh, so 70 million services that they offer .
Dr. MartinI doubt it's the only three tiers. I think it's - any way, just to say you're right, that administratively, it's pretty simple when you've got one payer and that means you can put your money into patient care.
Dr. RezmovitzYou can, we are so lucky in Ontario to have the system set up like this. I think too often we hear from our colleagues about how terrible the system is. Now, it's true. There are some deficits if you will. Some things that haven't been updated in certain year in, you know, in some areas and other areas. Because it's a system and nothing's perfect. But I think we're very lucky to have what we have. Now , I have read your book - Better Now. It always struck me - I've been - you know, I read this book and I've been in QI now for three, four or five years now. I'm doing a lot of QI stuff. Actually, no. Oh my God. When you start doing the math, it's now eight years. Oh my God.
Dr. MartinTime creeps up on you.
Dr. RezmovitzOh my God. That creep factor. So I wanted to start a project here called "better-ship". Do you know about "better-ship"?
Dr. MartinNo.
Dr. RezmovitzOh, do you know about friendship? It's about being friends with someone. "Better-ship"?
Dr. MartinI've heard of friendship.
Dr. RezmovitzSo "better-ship" is about being better, right? When? Well now, so you already coined the phrase, so good on you though. Better Now. But in your book you talk about the F word and we've had a lot of people on the podcast who have talked about small changes, big impact. So there was a life changing event that happened, where they felt that they failed. And for all the listeners out there, the F word is failure, right? And so you talk about failure in the book and it's important in the transition of providers, but also in learning how to be better. And so , I've always said fail is the first attempt in learning. And so, do you want to talk about any failures that you've had professionally - we'll keep the personal failures off the podcast.
Dr. MartinIt would take too long.
Dr. RezmovitzIt's okay . We have all day. It's a podcast. Thank God we're not live. Um, but do you have any failures professionally that you think have catapulted, spring-boarded , that you've leveraged - that learning opportunity into something that had an impact for you, your patients, the clinic?
Dr. MartinYes. I mean, I wear different hats in different parts of my life and my career. And part of my role is as a hospital administrator. And the thing about hospital administration - I know that many physicians sort of think of it as paper pushing and whatnot, but hospital administration is actually about people. And it's about trying to figure out how to best support people in delivering services to patients in the most cost effective and efficient kind of way. And I learned through many early failures as I was figuring out the ropes in running, for example, labs or medical imaging or other aspects of the hospital operation that you couldn't communicate early enough or often enough with the doctors. And of course, in the Canadian healthcare system, we have this bizarre situation in which our physicians are a part of the hospital community, but they're not employed by the hospital. And so, it's not so easy to tell a doctor what to do, but you can shift around your nursing model or your secretarial model much more easily. And I think in my early part of my career, I fell down several times in not kind of engaging the physician group early enough in the changes that we were making. And of course, any administrative change you make in a hospital has an impact on a physician's day. And so I think the good news about that is that I remembered at some point that I'm a family doctor and that communicating with people is a talent and a skill that most of us in primary care have. And that I had fallen in some ways into the same trap or failure that so many physician leaders do early in our trajectories, which is that we put on our administrator hat and we forget how to be a doctor. And of course , the most important thing you can do with your patient - much more important than the spectacular nature of your physical exam or the awesomeness of your prescribing habits. The most important thing you can do is to listen and to communicate effectively with your patient about what to expect, about what's gonna happen next in their journey through the health care system. And once I remembered that skillset, it all kind of fell into place - which is not to say that I haven't made a million mistakes since, but it is something that I think many of those of us who transition from clinical practice into leadership - it's a lesson that we need to learn and relearn and carry with us is those very basic family medicine skills come in super handy if you remember to employ them when you're trying to lead change in complex organizations.
Dr. RezmovitzI can imagine. I mean it comes down to - have you burned any bridges to get up to where you are? Because sometimes when you do, when you come back, you still got across that bridge. And so , remembering that the relationship is key to the practice of family medicine can really help physician leaders in their practice, whether it's in the clinic or administratively.
Dr. MartinAbsolutely.
Dr. RezmovitzSo you're the chief medical executive at Women's College and you probably push a lot of paper.
Dr. MartinI answer a lot of email.
Dr. RezmovitzYeah. You answer a lot of email. And so what's something that as a hospital that you guys are doing to - more of on a global scale - so we've talked about the QI like micro systems , meso systems and macro systems. What's something that the hospital is doing and pushing for? Because you talk about different aspects in your book , and you've been advocating for health policy and understanding, like increasing awareness of system policy for a long time. So what are the things that Women's College is working on right now?
Dr. MartinWell, the thing I am most excited about - a thing I jump out of bed for every morning is that we are building Canada's first virtual hospital. And this is really an effort to - you know, technology of course is exploding all over in every industry, all over our society, but in many instances in the health sphere, it is exploding in ways that undermine equity and undermine sustainability of the health care system. And so our team has set a challenge for ourselves to say, imagine if we were to build a hospital where if we ask you as a patient to come for an appointment, it's because that's the best way to deal with your problem. Otherwise, we're going to have a whole suite of other ways that we can connect with our patients. Whether that's eConsults to primary care, telephone backup to primary care, online education models , online groups , self-management, curated apps, video visits, asynchronous messaging with your provider. And the list goes on. And if the best thing for you - either because it's what you want or because it's the best way to manage your situation is an in person visit, and what you need is to drive to my organization and park in the basement for $24 and wait for 45 minutes in the waiting room to get seven minutes of FaceTime with a specialist, then great. But if we stick with the traditional forms of delivering healthcare services, the truth is that we are basically offering that experience that I just described to pretty much everybody because it's the only product we have on offer. And so instead thinking about different ways of connecting with patients, communicating with them, and reinforcing the primary care relationship, viewing our specialists as a service to primary care and not solely to individual patients. It completely transforms the model of the organization. And so we're on a journey at Women's to totally change the model of health care delivery in a hospital environment. But of course, everything we do is with an eye to equity. And so we're interested in how do we use technology to reach out to vulnerable populations? How do we use technology to reach out to people who can't make it during the day for a traditional appointment? How do we use technology to help people monitor their own chronic disease over time? How do we use technology to allow the patient to instigate interactions instead of us calling them in at a given interval? Because again, that's the way we've always done it. So really trying to explore the boundaries of traditional health care models. And there's a lot of tech involved, but actually it's really about a redesign of health services delivery.
Dr. RezmovitzThat's interesting because I read it totally differently. I'm going to - for the sake of argument and the sake of a banter here , challenge you on some things here. So the first thing I hear when you tell me that is you're putting patients first, which is amazing. I love hearing that you're putting patients first. It's not about the specialists, not about the family doctor. You're putting patients first.
Dr. MartinThat's the idea.
Dr. RezmovitzYou're going to where the patients are. Not to - making sure. Right. And so I've been talking about adaptive leadership for awhile and so you can't - when you go out and lead and you have no followers, you're a lone nut. You're out there by yourself going for a walk. You need to go to where the followers are in order to make sure that you can be a leader. And so that's what it sounds like you guys are doing as a hospital. But as an organization, the reason I don't think it's novel is because primary care has been going to patients for a long time. You know, the spectrum of house call to come into my clinic - is that spectrum of what it sounds like you're doing. So it's access - it's whether it's through the phone or whether it's through email or whether it's through FaceTime - or I can't remember what that's actually called now.
Dr. MartinVideo visits.
Dr. RezmovitzVideo visits. Fantastic. Sorry. I've been programmed by Apple to just use FaceTime . Video conferencing. Yeah. And so the question is, what's the best way to meet the need of the patient at that given day? Because it can change.
Dr. MartinCorrect.
Dr. RezmovitzAnd so the biggest pushback though is I find from the providers in looking for remuneration consistently so that their time is valued also. And it may not be remuneration in financial model, but remuneration in feeling valued because if you feel valued and part of an organization where you know, there's social capital and there is cultural capital and financial capital, if you feel like you're getting something out of this, then I think people will still do this. But unfortunately, I've spoken to a lot of people in the system who are health care providers who say, 'no, I'm done. I'm burnt out with all this.'
Dr. MartinYeah. And I think that one of the things that we know from the literature about burnout is that the cure for burnout is not, as I say, pizza parties and yoga classes.
Dr. RezmovitzYes it is.
Dr. MartinNot that there's anything wrong with pizza or yoga, or pizza and yoga together even, but that actually the cure for burnout is to help people reconnect with the joy in their work. Right?
Dr. RezmovitzRight. It's a connection.
Dr. MartinAnd so , that sense of intrinsic motivation, that thing that got you excited about a career in medicine in the first place. Not you know, sitting in churning it out at the EMR at seven o'clock at night. And so , part of what we're learning on this journey of building a virtual hospital is - and this is where I'm not sure that I agree with you that primary care has actually been that effective in Canada at -
Dr. RezmovitzOh I didn't say effective, but we've been doing it.
Dr. MartinThere's - sometimes . Sometimes in some people. There's still a lot of people who - a lot of patients who you know, are going to see their family doctor for that prescription renewal every three months for their stable XYZ fill in the name of chronic disease for no reason. Or having to pay for a prescription renewal by fax because there aren't systems set up to support. So, of course there's a history, a proud and a strong history and tradition of primary care out in the community doing home visits and following people on their journey. But we haven't really, I don't think, set up systems to support the systemic implementation of those kinds of solutions. We've been relying on individual provider goodwill to do that stuff. And as you say, a lot of providers are burnt out. They feel like they're on a treadmill, they're not doing it. They're turning on the answering machine at five o'clock and patients are landing in the emerge. And so I think we can do better. I think part of the journey of the virtual hospital for us is to understand that the goal of course is the quadruple aim. It's population health, it's patient experience, it's provider experience at a sustainable cost . And so the design journey for these new ways of delivering care is super fun. And our physicians are excited about it. You know, our surgeons know that most of the time when a person comes in for their six week post op visit, that it's not a very good use of anybody's time. You know, by the time you show up at six weeks you're healed or you've already been through your complication and had your infection and whatnot and it's been managed. So why wouldn't we get rid of that visit and replace it with a questionnaire that somebody can send in through the electronic record or a video visit and 24/7 access through a mobile app for the first 72 hours when you're home, which is actually when you've got questions for your surgical team. So our providers are engaged and excited about doing things differently. And of course, part of that journey has been figuring out how we can make sure they get paid. And we have had to figure that out. But most of the time, the conversation is we get through the money part just so we can take that off the table and then we start to have fun about how would you redesign this thing from scratch if all of these different technological options were available and we could blue sky it . And it's a very exciting project.
Dr. RezmovitzOf course it is. Actually one of the reasons we started this project was to address the quadruple aim and build community and connectedness of people in our department who practice family medicine, those people who are affected by family medicine. There's a lot of people. And so when we talk about the quadruple aim there's costs - costs is a huge factor. And so are there any blue sky projects that you think would improve the cost of the delivery of health care in Canada?
Dr. MartinWell, the biggest thing - and I think we all in this era of hallway health care have become highly attuned to this. You know, the most expensive place for a person to be in the health care system is the hospital. And so, you know, heaven forbid if I leave here today and get hit by a truck, a hospital is where I belong. And I want a really high functioning hospital system and I want a really great ICU and I want all of those things. But if I'm having my sixth COPD exacerbation of the year , the hospital may not be the best place for me. And in fact, what we've done in Canada in general is we have built systems in which effectively all roads lead to the emergency department and all roads lead to the inpatient bed. And in the time of an aging population and a fiscal crunch this is the worst possible - we built the worst possible system and we've built it. Every system gets - produces the outcomes that it was designed to produce. And so our system has produced hallway health care. And in fact, many of the people who are lying on gurneys in our hospital hallways are experiencing predictable exacerbations of their chronic disease. We might not have been able to predict that they would have an exacerbation on January the 29th, but you could predict that a person with moderate to severe COPD will have an exacerbation during flu season pretty reliably. And so why aren't we investing money in home-based services and in intermediate level of care environments where someone with a COPD exacerbation who needs a little bit more monitoring and a little bit more oxygen and some antibiotics and some basic care could get that without having to go through the emergency department as if we've never heard of them before, and backup to the inpatient internal medicine ward. And so, this isn't intended to be a criticism of the providers or the people who are running our organizations. Everybody's working super hard and everyone has the health of the population at heart. But we haven't been creative enough with the solutions that we're putting in place. And most of the alternatives to hospital care will be less expensive than hospitals. Virtually everything is less expensive than a hospital bed.
Dr. RezmovitzYeah. We have a lot of people in the hospital. I mean they cover a lot. Our health care program, I think OHIP is a lot like a hospital gown. Have you seen a hospital gown? You know, it covers a lot, but not everything.
Dr. MartinNot everything.
Dr. RezmovitzNot everything. Right. And so , I guess we have to become creative, right?. Unfortunately, things like physiotherapy aren't covered . Things like massage therapy, things that actually work for people to get better so that they don't have to go to hospital are not covered. Dentistry not covered. Right? These are choices that our government's made and that we support. So that when you go to hospital you are completely covered. Do you have any other ideas about things that could be covered that we could shift away that - because we talked about the quadruple aim and we talk about ways to improve the system by improving costs in the system. Do you have any other ideas about things that we could improve upon?
Dr. MartinIt's not my idea, but all the way back to 1962, we've been talking about bringing prescription medications into our universal health plans across this country. And certainly we know coming back to the hospital overcrowding conversation that cost-related non-adherence so the phenomenon of people not taking their medicines as prescribed because they can't afford to fill their prescriptions or taking their puffers every other day or splitting their pills or running out and not filling that script at the end of the month , is a very significant driver of chronic disease exacerbation. So people end up in the hospital because they can't afford to take their meds. And of course while they're in hospital, their medication is covered. We discharge them with a prescription in hand and they walk out onto the sidewalk completely on their own. So it is a system that is penny wise and pound foolish because we have huge numbers of people who can't afford to take medications that are literally life saving for them. You know, their insulin for their diabetes, their inhalers for their asthma or their child's asthma or their COPD. And that phenomenon is common in Canada. We know that one in five households now report that someone in that household is not taking their medication as prescribed because of concerns about cost in the last year. That is a lot of Canadians and people - health suffers as a result. We put more pressure and stress on the doctor and hospital side of the ledger as a result of that. And so, for health reasons and social justice reasons, I'm a huge supporter of universal PharmaCare, but it turns out actually would also save us a lot of money because we way over pay for our prescription drugs in Canada because of that multi-payer phenomenon. And we could do much better on our pricing if we bought drugs in bulk and negotiated our prices the way that other countries do.
Dr. RezmovitzSo what do you think the biggest barrier is to - I mean, it's been 58 years you've been saying of , you know, we've been talking about this.
Dr. MartinI mean the barriers at this stage are not - they're not related to the evidence as to whether or not this is a good idea. They're political. So we heard even for example, we've got a situation in Canada now where the federal liberal party, the federal NDP party and the federal Greens all included universal PharmaCare in their election platforms. We have the Hoskins panel that was commissioned by the last government as well as the standing committee on health, also commissioned by the last government to ask how should we design and implement universal PharmaCare? Both came back with strong endorsements for universal public, single payer PharmaCare . Like the evidence is not really in question anymore by anybody who's seriously looked at it. So the problem is, can our politicians navigate the federal, provincial, territorial disputes around this? Are the Premier's and the territorial leaders going to come to the table with the federal government? Is the federal government prepared to pay because of course PharmaCare will be much cheaper than our current multi-payer system, but it will require a shift of some of what we pay for in the private sector right now onto the public sector. And so is the federal government prepared to guarantee to the provinces that it will cover the cost of that so that provincial governments don't worry that they're going to end up saddled with and they're all already - we're paying close half of our provincial budgets on healthcare. Premier's are wanting some kind of assurance from the federal government that they won't be saddled with the costs of PharmaCare as well, et cetera, et cetera. In other words, these are, these are political conversations and they have to do with their intergovernmental affairs questions, not health policy questions. And somebody has got to want it. Somebody's got to champion it in cabinet.
Dr. RezmovitzSomeone's gotta be willing to take a risk and say, I may not get reelected in my next campaign, but what I might do is save people, actually create more healthy people. So actually we reduced spending in hospital on those, right? There's a balance obviously.
Dr. MartinRight. I mean that was Monique Bégin in 1984, and Trudeau the senior saying we're going to bring in the Canada Health Act. You know, it was unanimously passed in parliament eventually, but it was a huge political negotiation and a political risk. And were it not for my Madame Bégin, the Minister of Health at the time, taking that on and saying, I am - this is the right thing for Canada and I will champion this, we might not have the public health care system that we have today.
Dr. RezmovitzAnd so , people hear like stories. You like stories? So do you have any stories of patients that you have made a change or made a change in you that has caused you to start advocating like this? Because you're not the norm by the way. We don't have enough people advocating yet to tip the scales to say this is what we need. It's actually a fight sometimes with a lot of my colleagues to try and advocate for things.
Dr. MartinI mean I'm of course - there's not a single thing I do that hasn't been shaped by my clinical practice. As is the case for all physicians. I think for me in a way I've come to advocacy because I don't actually see what other tools I've got to help the people I encounter that our system is failing. So I often tell the story. I tell it in the book of a patient of mine who is a cab driver in downtown Toronto. And this is an educated guy who's a first generation immigrant. He speaks perfect English. He is a lovely person and a big smile. He's got three kids, his wife stays at home and he's driving a cab and often driving very late nights and middle of the night. And as we know it's a sedentary job. He's a South Asian guy, so he's already at risk for diabetes, heart disease, and he's got all the things that you would kind of expect a person of his age and stage and genetic and occupational risk profile to have. He's got type two diabetes, he's got hypertension, he's got dyslipidemia. And he is self-employed. He's a cab driver . He's got no drug coverage. And we have gone through 15 years, 16 years now - I've been his family doctor. There are just these spans of time where I don't see him. He just doesn't come in. He won't come in for six months or nine months. I might even call, leave a message or whatever, and then he'll show up. And I know that when he comes in, it's because he can spare the money to fill the prescription, but when he doesn't come in, it's because he's ashamed to tell me that he's not taking his medication. And he's got other priorities - got to put food on the table and pay his rent. And Uber's really put a dent in his income. And I just think to myself, this is crazy. This guy - you know, I know, the listeners of this podcast know, what's gonna happen to this person. He's going to have a heart attack or he's gonna have a stroke or he's going to go blind or he's going to end up with an amputation. And all of those things will cost a fortune and they will also knock out the sole income earner of that beautiful family. And there is no way that that makes economic sense, let alone human sense. But it doesn't even make any economic sense of why wouldn't we pay for this guy's medication? So I guess I would say - I mean every one of us has a story like that. This is not an unusual situation that this person finds himself in and there are millions of Canadians in exactly that circumstance. And if we're not advocates, then there's really nothing that we're doing to help this person. I mean, I can help him apply for Trillium, but he can't afford the deductible. So it's not really - that's not a solution. The solution is to change the system. And if I am not participating in the great advocacy work that so many people across the country are doing for PharmaCare, then I'm not doing anything for him. And I will feel worse about myself and my profession if I'm not engaged in that way.
Dr. RezmovitzSo for anybody that's been inspired today, how would they get involved?
Dr. MartinWell , there is an organization called Canadian Doctors for Medicare that's been very active on this PharmaCare file. I'm a member. I think we all should be members and there are lots of opportunities to get involved in organizations like CDM. Lots of other organizations that are doing great work. Heart and Stroke Foundation just came out with a big statement on PharmaCare and I mean, this is a mainstream issue. This is not a radical issue. The big health care organizations - the ones that are not far funded by the pharmaceutical industry are active on this file. So whatever your area of interest , I think attaching yourself and giving your time or your money or both to an organization that's active on the issue is the most important way to help.
Dr. RezmovitzThank you so much. Just one last question. We play a game here called if they only knew. If they only knew - so you can speak to your former, your younger self, being a 26 year old, family physician in Toronto - I assume that's how old you are. At least that's how old you look.
Dr. Martin29 again.
Dr. RezmovitzYeah. So if they only knew, if you only knew earlier or if they only knew. You can speak to a patient population, you can speak to the Department of Family and Community Medicine, the globe at large. But if they only knew, so pick a population to speak to and then come up with something profound that you'd like to - something that you learned that you want to help other people.
Dr. MartinWell, I have been engaged in this conversation about wellness and burnout and provider and physician wellbeing in my organization. And it is one of the things that I would say the medical students and trainees who come through my office for mentorship raise very often. Like how do you balance that life - work and family and how do I make sure that I'm not going to burn out? And to me, I've never really felt that this notion of balance was an accurate depiction of how one gets to happiness. I never feel especially balanced. I'm always on one side or the other side of the ledger at any given moment in time. I think balance is - the arc of balance is long, I guess is what I would say. So you take your different sources of joy where you can get them. But I've also never liked the term work life balance because it implies that my work is something that I do because I have to in my life is something that happens elsewhere. And actually, I mean, I have a family I love, I have interests, I have hobbies, I have all kinds of stuff. But I love my work also. My work is a source of joy and a source of meaning. It is the place where I can be in some ways my better self, as my 10 year old would certainly tell you. And there's lots of ways in which I am fulfilled personally by my work every day. And so I guess what I would say to the young people coming up behind us is to not get trapped in this notion that your life is something that happens when you're not at work. Of course, you want more than just work in your life, but your work is also - should be a huge part of your life. And there are a lot of folks out there who do not get the joy, the compensation, the meaning that we get from our daily work. So gratitude for the ability to do a job like this is a good place to start from when we talk about balance.
Dr. RezmovitzAmazing. Oh , I'll say thank you.
Dr. MartinThank you.
Dr. RezmovitzAnd it was excellent having you on the show.
Dr. MartinThanks for having me.
Dr. RezmovitzTake 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.