Take the survey: What are your priorities for primary care?

Op-ed in Healthy Debate by Dr. Tara Kiran

Do you have a family doctor or nurse practitioner that you can talk to when you need care or advice about your health?

Even before the pandemic, 15 per cent of people living in Canada said the answer was no. And unfortunately, all indications are that things have gotten worse.

New research from our team published this week shows that the proportion of family doctors who stopped work nearly doubled in the first six months of the pandemic compared to the previous decade. Other research we’ve done found that in 2021, almost 20 per cent of family doctors in the Toronto-area are thinking of closing their practice within the next five years.

Now, two and a half years into the pandemic, there are many anecdotal reports of doctors leaving practice. The reasons are varied and relate to burnout, administrative overload and general “moral distress” at not being supported to deliver the kind of care they want to.

At the same time, fewer medical students are choosing family medicine and even those that do are less likely to work in a practice where they commit to providing comprehensive care for a panel of patients that they see for the long term.

These problems don’t affect everyone in the same way. We found that the proportion of family doctors who stopped work was much higher in some communities, including rural communities in Northern Ontario and near Georgian Bay. Our research has shown that new immigrants and people living in low-income neighbourhoods are less likely to be meaningfully connected to a family doctor. So are people with Opioid Use Disorder and those recently incarcerated – two groups of people who have higher health needs.

Pandemic spurred exodus of Ontario family doctors, study indicates

From the Canadian Press, featured on CBC News Toronto and The Globe & Mail

Ontario family doctors left the profession at the start of the pandemic at double the rate of the years before COVID-19 hit, new research indicates.

About three per cent of family doctors across the province — 385 doctors — stopped practising between March and September 2020, according to a study led by Unity Health Toronto that was published Monday in Annals of Family Medicine.

That accounted for an estimated 170,000 patients losing access to primary care, and was higher than the 1.6 per cent of family doctors who stopped working during a comparable period each year between 2010 and 2019.

“The pandemic has made a bad situation even worse in primary care,” said lead author Dr. Tara Kiran, a family doctor and researcher at St. Michael’s Hospital, which is part of the Unity Health Toronto network.

“We really need to address this issue by supporting more people to go into family medicine and primary care.”

The work builds on figures released last week that showed as of March 2020, nearly 1.8 million Ontarians did not have a family doctor and another 1.7 million Ontarians have a family doctor older than 65 years old.

“This is a big problem for patients in Ontario,” Kiran said.

More than 170K Ontario patients lost family doctors in first 6 months of pandemic, study finds

From the CTV Toronto article

More than 170,000 patients in Ontario lost their family doctors in the first six months of the COVID-19 pandemic, a new study has found.

The study, led by Unity Health Toronto and non-profit research institute ICES, found the number of family physicians who stopped working doubled between March and September 2020 compared to the same time period the previous year.

This equals nearly three per cent of Ontario’s practicing family physicians, officials said.

On average, between April and September from 2010 through to 2019, researchers say about 1.6 per cent of family physicians stopped work.

“Nearly 1.8 million Ontarians don’t have a regular family physician,” Dr. Tara Kiran, lead author of the study and a family physician at St. Michael’s Hospital of Unity Health Toronto, said in a statement.

“Our findings suggest things are only going to get worse, which is really concerning because family medicine is the front door to our health system.”

The study found that about 385 of 12,000 physicians stopped their practice, and that those who did were more likely to be aged 75 or older and care for under 500 patients.

As safe-supply study appears to show benefits for drug users, critics raise warning flag

From The Globe and Mail article

A new study of the earliest formal program to offer prescription opioids to drug users suggests their health improved under the medication, one of the study’s authors says. But some experts warn it’s too early to draw conclusions about the efficacy of safe supply programs.

Researcher Tara Gomes of Toronto’s Unity Health network said the study she helped conduct showed that emergency department visits, hospitalizations and some health care costs declined among those who took the prescription opioids. She said it was the first study she knew of to study the long-term effects of offering a safe supply of opioids to drug users, a system that is being rolled out in several places across the country in an attempt to reduce the toll of the opioids crisis, which claimed 29,000 lives from 2016 through 2021.

Though safe supply might not be the solution for everyone, “this really shows that this program can be beneficial for people at a high risk of overdose,” said Ms. Gomes, speaking in advance of the study’s Monday release.

Cross-country project gives patients a say in solving primary-care crisis

From Healthy Debate

As a family doctor, Tara Kiran has seen first-hand the reverberating effects of the primary-care physician shortage on Canada’s health-care system. And it is in her role as a scientist with MAP Centre for Urban Health Solutions that she plans to uncover what patients have to say about these gaps.

Kiran and a team of collaborators are launching OurCare, a three-phase research project that aims to provide much-needed answers to Canada’s primary care woes. “We’ve been having conversations within the profession and with governments about (improving primary care) for a while,” says Kiran. “But we generally don’t bring the public into those discussions in the way that we should. This project is about extending the conversation to include the public’s view about what that future should look like.”

The idea for the project was conceived in June 2021 as a collaboration between Kiran and Peter MacLeod, who runs MASS LBP, an organization that works to involve people in policymaking. Plans were finalized with buy-in from provincial and national health-care partners, stakeholders and the public through the Canadian Medical Association’s group, Patient Voice.

“Primary care is the foundation of the health-care system, yet we’re in a country where almost 5 million people report not having a family doctor or nurse practitioner,” Kiran says.

The ongoing COVID-19 pandemic has exacerbated existing issues in primary care. Burnout, retirement and change of professions have all contributed to dwindling numbers of family physicians.

Replacements are slow in coming: the number of medical students choosing to go into family medicine is declining. Specifically, fewer medical students are going into “comprehensive office-based care,” in which physicians look after patients of all ages throughout their lifetimes.

“This kind of family medicine has become increasingly challenging for a number of reasons,” Kiran says, explaining that comprehensive office-based care models have doctors dealing with the business aspect of medicine on their own. Instead, many family physicians are opting for hospital-based work or specializing in family medicine within emergency medicine or palliative care.

For Kiran, another driver of the shortage of comprehensive office-based family doctors is the payment model. “I’m very lucky to work in a practice where I get paid not by fee-for-service (FFS) or pay-per-visit, but by a payment called capitation.”

FFS is the predominant model in Canada, in which doctors are paid per patient visit. With capitation, the province pays doctors a fee for each person who enrols in their family practices. “(Capitation) gives me more flexibility to spend more time with patients.”

Kiran adds that she feels more supported in her work because she is in a team-based setting, another model preferred by younger family doctors. “There are ways of making practice more attractive, but our systems haven’t moved to that.”

St. Michael’s research project aims to improve care access for unhoused people

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From The Globe and Mail article featuring Stephen Hwang, Alyssa Ranieri, and Fred Ellerington

People experiencing homelessness often suffer from a range of health problems that put them at heightened risk for severe illness and premature death. But because they lack housing, it can be a major challenge for those individuals to get and keep medical appointments and meet other basic needs to help prevent such poor outcomes.

After seeing so many patients fall into this cycle – being discharged from hospital only to be readmitted a short time later in even worse health – Stephen Hwang decided to do something about it. Dr. Hwang, a general internist at St. Michael’s Hospital in downtown Toronto who studies the connection between homelessness, housing and health, is in the midst of an ambitious research project to determine what happens when unhoused people who end up in hospital are given a helping hand.

That means that when certain individuals experiencing homelessness are admitted to the hospital, they are paired with a counsellor who helps them navigate follow-up appointments and fill prescriptions, makes sure those individuals have a place to stay after they’re discharged, and provides them with food and other basic necessities.

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Le projet de recherche de l’Hôpital St. Michael vise à améliorer l’accès aux soins pour les personnes sans abri

Extrait de l’article du Globe and Mail avec Stephen Hwang, Alyssa Ranieri et Fred Ellerington

Les personnes sans domicile fixe souffrent fréquemment de multiples problèmes de santé qui les exposent à un risque accru de maladie grave et de décès prématuré. Mais parce qu’elles n’ont pas de logement, il peut être très difficile pour ces personnes d’obtenir et de respecter des rendez-vous médicaux et de répondre à d’autres besoins fondamentaux qui contribueront à prévenir ces conséquences négatives.

Après avoir vu tant de patients entrer dans ce cycle – sortir de l’hôpital pour être réadmis peu de temps après dans un état de santé encore plus précaire –, Stephen Hwang a décidé de réagir. Le Dr Hwang, interniste généraliste à l’Hôpital St. Michael au centre-ville de Toronto, étudie le lien entre l’itinérance, le logement et la santé. Il mène actuellement un ambitieux projet de recherche visant à déterminer les conséquences de l’aide apportée aux personnes sans logement qui se retrouvent hospitalisées.

Concrètement, cela signifie que lorsque certaines personnes sans domicile fixe sont admises à l’hôpital, elles sont jumelées à un conseiller qui les aide à s’orienter vers leurs rendez-vous de suivi et à faire remplir leurs ordonnances. Le conseiller s’assure également que ces personnes ont un endroit où loger après leur sortie de l’hôpital en plus de leur fournir de la nourriture et d’autres produits de première nécessité.

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‘Nowhere to go’: Homelessness and mental illness create a ‘revolving door’ of admissions

From the Healthy Debate article

When Jane was asked if she was excited to leave the psychiatric hospital, her first reaction was:  “Where do I go?” Jane, still in her teens, had been sexually abused and was battling addiction and homeless. She wasn’t aware of an alternative discharge option besides sleeping on that same stoop on a busy street.

Homelessness at hospital discharge for those with mental illness/addictions is an issue for more than just Jane. Across Ontario, more than 1 in 50 adult patients from psychiatric hospitalizations are homeless at discharge.

Vicky Stergiopoulos, who recently stepped down as physician-in-chief of the Centre for Addiction and Mental Health (CAMH), recalls that when she worked at St. Michael’s Hospital in downtown Toronto, one in five of her patients was homeless.

“It was very hard to feel good about the care you provide … and (that) the care you provided can have a positive impact. But how can you when you see them being discharged to go back to the pavement on the street, or in a shelter setting with no support?” asks Stergiopoulos. “And the moral distress associated with that, it’s very uncomfortable.”

Psychiatrist Sarah Levitt has seen that distress in her inpatient practice. “There’s a lot of pressure on the staff, in terms of bed pressures, and making sure that when folks don’t absolutely have to be in hospital, they are discharged,” she says. “And at the same time, from a compassionate perspective, it feels so awful to be discharging people with nowhere to go.”

Homelessness at discharge in psychiatric settings comes with significant cost to our health-care system and, more importantly, to those with lived experience. Homelessness at psychiatric discharge nearly doubles mental-health related emergency department visits and increases readmission rates by 43 per cent within 30 days of discharge compared to those with housing.

 “If people think that their best housing option is to stay in hospital, then there’s something really wrong with our system.”

“If people think that their best housing option is to stay in hospital, then there’s something really wrong with our system,” Levitt says.

And it doesn’t just end with one readmission. Says Melonie Hopkins, a social worker who manages Alternative Level of Care (ALC) at a mental health hospital: “(For) those individuals who are homeless upon admission, and they return to homelessness, you can get this revolving door.

Sean Kidd, psychologist and senior scientist at CAMH, says health-care workers have little choice but to discharge patients.

“We are really underfunded. We cannot meet the demands and needs of the people we’re trying to serve,” says Kidd. “So, it’s not like any hospital or any provider of any kind is thinking it’s a good idea to discharge somebody into no fixed address or to a shelter. It’s just a matter there’s no choice …”

Jesse Jenkinson, postdoctoral fellow at the MAP Centre for Urban Health Solutions, points to the shortage of shelter beds as a major barrier.

“There literally aren’t any spaces for people to go. A shelter space is already a suboptimal discharge destination for someone leaving the hospital. But it’s the only option that exists for most people,” says Jenkinson. “And now… we don’t have that option either. So, it’s very bad.”  At the time of writing, the shelter bed occupancy in Toronto ranged from 94.5 to 100 per cent.

Currently, there is no provincial strategy for discharging people experiencing homelessness from hospital settings. Though there are best practices outlined by the Ontario Hospital Association to confirm with provincial legislation and funding, Stergiopoulos “doubt(s) there is close attention across the province on what happens at discharge.”

Bracing for fentanyl: NZ experts push for safe drug-using space

From 1News New Zealand

The Foundation says providing a safe, medically-supervised space for people to use drugs will reduce harm and save lives.

Its executive director, Sarah Helm, called on the Government to support a three-year pilot of the service in Auckland’s city centre.

The call for this centre comes as experts fear New Zealand is unprepared for the arrival of fentanyl in the community. In July, 12 people were hospitalised in the Wairarapa for fentanyl overdoses. Those who overdosed believed they were taking cocaine or meth.

During a launch event at Auckland City Mission, Helm said: “At the moment we are turning a blind eye to overdoses and drug harm occurring among our most vulnerable in Auckland, especially those experiencing homelessness.

“That is causing untold harm for them, it is distressing for bystanders and inner-city businesses, and it takes up a lot of police and ambulance resources.

“An overdose prevention centre would offer a more compassionate, health-based approach that is also better for the wider community.”

What is an overdose prevention centre?

If the centre is approved by the Government, it would be the first in Aotearoa.

However, more than 130 sites are operating in at least 14 other countries around the world.

Auckland’s proposed centre would be available to anyone but would focus on people experiencing homelessness and using drugs that can cause people to overdose.

The centre would be staffed by people like registered nurses, peer support workers and security staff.

It would have a medically supervised consumption space and also offer basic medical services, resuscitation, naloxone, and drug checking, as well as showering and laundry facilities, hygiene and sanitary products, and hot drinks.

The NZ Drug Foundation says overseas evidence shows overdose prevention centres do not increase drug use.

For example Uniting Medically Supervised Injecting Centre in Sydney has supervised more than 1.2 million injections without a single fatality since opening in 2001.

New York City’s new overdose prevention centres, which opened in late 2021, prevented at least 59 overdoses in their first three weeks of operation.

Bracing for the arrival of fentanyl

Helm said synthetic cannabinoids, which caused at least 51 deaths between 2016 and 2020, are among the drugs favoured by the drug-using community in Auckland’s city centre, but added that the drug market changes rapidly.

“If fentanyl arrives on our shores, international evidence says this community is likely to be impacted the most heavily. At the moment we have very few overdose prevention measures in place,” she said.

New figures have also found one-third of all drugs tested in New Zealand between January and July were either mixed with other substances or were something completely different.

Helm said New Zealand needs to prepare for a fentanyl outbreak now, saying it will be too late to wait until it happens.

“We can do better, we must do better. New Zealand is so behind on overdose measures. [An overdose prevention centre] is not a new idea, it’s just new to Aotearoa.”

Speaking at today’s launch event, Director of the Centre on Drug Policy Evaluation in Toronto, Dr Dan Werb, said Canada’s fentanyl overdose situation was dire.

“New Zealand is in an exceptionally lucky situation to put overdose prevention measures in place in a proactive and not a reactive way. The proposal to put forward an overdose prevention site is an exceptionally forward-thinking move,” he said.