Care Without Borders: Strategies for Delivering Quality Healthcare to Kids in Rural and Remote Communities

Children's Healthcare Canada, its members, and strategic partners have highlighted the need to and catalyzed collective action to right-size health systems for children. Recommendations in the Beyond Bandaids report include a call for the expansion of localized capacity and innovative models for children's healthcare in rural, remote, and Northern communities. Recognizing that it is not feasible to have comprehensive sub-specialized children's healthcare in every community, this podcast will discuss creative strategies/models to deliver better care for kids living far away from urban centres (including, virtual care, rapid transport, and service partnerships).

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Connected by purpose. Driven by passion. This is Children's Healthcare Canada’s SPARK: Conversations podcast series.  

Dr. Katharine Smart: Good morning, everyone. We're excited to share our podcast with you this morning. So, we're going to just jump right into it.  

Welcome to SPARK Conversations, Children’s Healthcare Canada's monthly podcast series. SPARK Conversations is one component of Children's Healthcare Canada SPARK Knowledge Mobilization program. During the 2024-2025 fiscal year, SPARK Conversations is dedicated to the topic of right-sizing children's healthcare systems. Thanks to our SPARK Conversations podcast sponsor, the IWK Health Centre for their ongoing support. I'm Dr. Katharine Smart, and today I'm delighted to be speaking with Crystal Edwards and Holden Sheffield.  

So, we have two really fantastic guests today who are experts on providing care to children and youth in rural and remote settings. Crystal is a well respected leader who is passionate about improving access and equity to quality care for children, youth and families in Northwestern Ontario. She has long been an advocate for change, having made many advancements in maternal child and pediatric care at Thunder Bay Regional Health Sciences Center, including obtaining funding for several program expansions. She successfully expanded the services of the child and adolescent medical mental health unit, as well as established a regional pediatric support program for the North.  Crystal was a strong advocate for the Northern Maternal Child Network, and has worked alongside other leaders in its successful formation.  

But that's not where it ends. Crystal is a Lakehead University graduate, having received two Bachelor of Science degrees, one in Biology and the other in Nursing. She also has a Masters of Nursing Degree from the University of Toronto. Crystal is a member of the Canadian College of Healthcare Leaders, as well as the Registered Nurses Association of Ontario. She started her career in healthcare as a registered nurse, working in critical care while also working in organ and tissue donation as the coordinator for the Trillium Gift of Life, and she provided clinical oversight to nursing students at Lakehead University. Crystal moved into her first formal leadership role as the clinical nurse specialist for the surgical program upon the completion of her Master's Degree, and became the Clinical Manager of the surgical inpatient unit and endoscopy suite. She is currently working as the Director of the Women and Children's Program at the Thunder Bay Regional Health Sciences Center, with the newly added oversight of the adult and forensic mental health program. Crystal actively participates in the number of provincial council for maternal and child health and critical services Ontario committees, as well as numerous community and regional committees and tables. So, thank you, crystal for finding time for us today in your what sounds like very busy schedule.  

We also have Dr. Holden Sheffield. He is a General Pediatrician with a special interest in rural and remote care. Following his Pediatric training at the University of Toronto in 2016 he moved to Iqaluit Nunavut, where the initial plan, as it always is, was to stay for one year. 

I think many of us have started with that plan. He's been there ever since, working full time at the Qikiqtani General Hospital. he became the Chief of Pediatrics in 2018 and in 2022 was appointed as the Inaugural Territorial Chief of Pediatrics for Nunavut. Some of his interests include program design, development and pediatric transport, medicine. So welcome Holden, another northern pediatrician. Really excited to have this chance to talk with you today.  

As many of our listeners know, Children's Healthcare Canada is on a mission to right-size children's healthcare systems. From coast to coast to coast and across the continuum of care, children, youth and their families are experiencing long and costly delays for essential and time sensitive healthcare services. We are exploring what this means in real world contexts, along with the collective action required to change the way systems work and interact and intersect.  

Right-sized healthcare systems for children should be accessible, equitable, connected healthcare systems designed for the needs of children, youth and their families. For this episode, we're going to be focusing on right-sizing healthcare services and systems for children, youth and families in rural, remote and northern communities.  

So, thank you for joining me today. We have two wonderful guests with lots to add. So welcome to the podcast.  

Dr. Holden Sheffield: Thanks for having me.  

Crystal Edwards: Thank you.  

Dr. Katharine Smart: So, I want to jump right into it. You know, I think what's really challenging right now across the healthcare space is we are hearing about so many problems. You know, there is crisis after crisis after crisis. But part of the reason we wanted to speak with both of you today is you are also examples of leaders who are executing on many successes, even though you're working in really challenging environments. So, I want to give each of you a chance to tell us a little bit about your programs and what some of the successes are that you've been having. So, Holden, I'm gonna, I'm gonna start with you.  

Dr. Holden Sheffield: Sure. So, I like how you frame that. And in many ways, we have been able to set up a successful pediatric program over the years, and we have been able to provide a program that is based around continuity, longitudinal care and ownership over patients, and I think those have been the cornerstones in terms of how we've gone about setting up our program. 

When it comes to success of a program, particularly in rural and remote centers, I find one of the most important things generally is recruitment, retainment of staff and how we ensure that they're able to stick around long enough to, you know, have meaningful impact follow patients through their care, and that's been a big focus for us. So one of the things that we did, when you look at Baffin Island, for example, there's 11 flying communities that we service, and one of the biggest pushes that we wanted to ensure was that every single one of those communities had an assigned pediatrician who had connections to our Iqaluit based program and was able to follow patients day in day out, regardless of if they were actually in that community at any given time or not, in addition to the onsite visits. And what we found was this really helped create a lot of great relationships, again, that longitudinal care could take place, and most importantly, the pediatricians would feel ownership over the patients. And when you're able to follow those complex patients, and you might have staff turnover in other areas, say, you know the nurses in the health centers, for example, they still know that there's that reliable person who has always been there for that patient, who they can reach out to at any time in order to get advice, make set plans. And what we found from that was so many great things that kind of stemmed from that, most notably reduction in travel, because we knew what patients needed, we were able to service them very well based on our local program in terms of maximizing what we're able to do, sending them down to higher level levels of care only when needed, having that level of oversight, and again, that level of responsibility. Say, these are my patients. I want to ensure I can minimize travel, deliver high quality care, and, you know, ensure that this is something that happens every single day. So, I think that's been a big cornerstone to our success that maybe I would highlight there.  

Dr. Katharine Smart: Great thanks for sharing that. And I think it's really interesting how, you know, what you're really talking about is relationships, right? Relationships and trust, relationships with patients, with community building those trusting relationships, and in that context, you're able to execute the type of care you want your patients to receive. So, I love that. And I think it's always interesting how it's those simple concepts, often that drive excellence, not necessarily technology.  

Crystal, tell us a bit about you and what's happening in Thunder Bay. 

Crystal Edwards: Yeah. And I think you know, very similar to what you were just saying, relationships. One of the biggest strengths that I think we have in the north is our partnerships and our relationships with each other. You know, we've always had sort of that, that culture of supporting one another and working with each other. So really, a lot of the work that we've been doing is building on the relationships, building on the partnerships, and looking at, how do we support each other? How do we recognize, you know, where there's gaps, and, you know, who can help and, you know, build each other up. So, a lot of the work that we've been doing over the years is really trying to to expand that. Some really innovative thinking is, is really what's been driving the change that we've been doing. So, one of, you know, really great example of pilot project that we started was the regional pediatric virtual care program. So being able to, you know, utilizing the skills that we have in our level two center, and being able to support our level one regional hospitals as well as the northern communities that we serve, you know, recognizing that when children are sick, you know, people want help, they want to know what to do, they want guidance. And technology has been a really great way to help to, you know, expand that out. And so that's really helping us to build our partnerships as well, building trust, you know, getting to know some of our regional centers and partners and letting them know that, you have a question, you can reach out, and we're here to help and to support so, you know, hoping to leverage that and expand that, but we've also been very fortunate that we've done a lot of advocacy over the years, and we have a pediatric emergency transport team that we're trying to develop that will be up and running in the new year, and that also will help to build those relationships and those partners. It's, you know, the same teams from Thunder Bay that will be going into these regional hospitals, going into these northern communities, and actually meeting the people who are working there, and building that trust and that relationship and, you know, hopefully, you know, help them to feel that there's that opportunity to reach out and to help and to ask questions. So, those are two really big pilot projects that we that we're working on. 

Recruitment is always, I think, a big challenge, and I will say it's interesting, because where we are in Northwestern Ontario, we don't have as recruitment is actually not as big of a challenge, at least in the nursing perspective. Certainly allied health and medical staff, you know, there are some challenges, for sure, but we're fortunate that people seem to like our community, and so they go to school, they come back, and they stay, and because we're the only, you know, level two Acute Care Center, we don't necessarily have people leaving us, so we're really trying to build on keeping and retaining our staff so that we can, you know, staff these programs and help to get them excited about these expansions. I think that that's one of the things that really empower our staff to be part of these innovative changes.  

Dr. Katharine Smart: Thanks for that. And you know, again, I think what's so interesting about what you're saying is, as we all know, the HHR crisis, I think is one of our biggest challenges across the system. You know, Holden, you touched on it on a lot of your work has been, how do I recruit and retain a group of people that are committed to community? You know, Crystal, you've talked about how your community has been really successful in creating a space where people want to work. And then I think what's also interesting, what you were saying about your virtual outreach program is how that's then supporting that next layer of providers in the community. And I often wonder, you know, about that work and that importance of those levels of support to keep people where they are and working. I'm part of a similar program in British Columbia called CHARLIE, which is real time, virtual supports provided by pediatricians into the north and that's often the feedback we get right from family doctors and really rural small emergent emergencies or nurses and nursing stations. To have that access to an expert to support them, it just creates those levels and tiers of care. And often, as people working in regional and rural centers, we're well positioned, actually, to give good advice, because we understand the context of what's happening, and then we create those connections. So, I think it's really interesting how we can, sort of think we've got those expertise at the children's hospital that's really important, but there's also a lot of expertise as you move through those layers of care that can really help support the HHR.  

So, I'm curious. Holden, what do you think you've got a successful program now you've talked about the fact you've been able to get a group of pediatricians. What's been your secret in terms of your HHR approach? 

Dr. Holden Sheffield: Great question. Flexibility is a big one. I think you have to be flexible, and you have to be able to work with individuals, understanding their career goals, where they might be at in their particular lives and careers. Work with that and, you know, take their interest and run with it a little bit. So, one thing we've been able to leverage, for example, is flexibility around do you have to come and be a full-time pediatrician, you know, to work out of Iqaluit, or is there some middle ground where we don't have a continual revolving door of new locums. But rather, can we get some recurring locums. And this is sort of what we've done in that we've taken a few individuals have been very interested in providing care in the North, have a lot of time in their schedule, but for whatever reason, have some other things on the go that would limit their ability, let's say, relocate in Iqaluit, for example, put them on part time recurrent contracts let them develop continuity and relationships with the community. Have them come every so often, say, you know, 100 days a year, for example, and really leverage the ability to have some flexibility around those contracts and recruit. And it's made a massive difference. So we have three pediatricians, for example, on that type of contract, and in their other time, they're often doing work that, you know, really helps echo the work that they're doing in the North you know, for example, we have one physician who does ID part time at CHEO, which is our referral center, and then works for us part time, another who's an intensivist. You know, incredible to have them available, to have their knowledge and expertise and applied in a Northern context.  

So, I think that flexibility has been really key and just understanding that there are a lot of great individuals who have a lot of great skill set who are interested in working in a Northern environment, and sometimes you just have to make it happen a little bit. It might not always be the most, you know, routine, sort of full-time person coming up, you know, to work and relocate, but that's been a big, big driver of our success.  

Dr. Katharine Smart: And I love your approach, right, of looking at, what is it that people want and need, right? I think so often we're trying to put people into a model, rather than asking ourselves, could the model change, and by being a bit flexible, and really, you know, answering that question, what? What do this group of physicians need to make this work? Work for them? You've been able to be flexible and create something that works.  

You know, Crystal, you were talking about the development of your new pediatric and neonatal transport team. I'm also hearing you've done, it sounds to me, like a lot of work creating professional development opportunities for nurses and other people in your setting. How important do you think those professional development opportunities are to HHR to recruitment, to retention, and what is your approach to that?  

Crystal Edwards: Yeah, I think it's super important. You know, during the pandemic, we saw, you know, a lot of educational opportunities. Everything stopped. Everything halted, and one of the messages we heard loud and clear was people wanted education. They wanted to get back to what they did before. So, certainly, these opportunities to upskill our staff, to be able to send them for, you know, certifications, various different courses, it has been, it's been really empowering, I think, for the staff, the uptake has been fantastic. They crave that knowledge, they crave that opportunity to be able to expand their knowledge.  

You know, certainly as we've moved into, you know, more virtual opportunities, that's made things a lot easier, because certainly you know when you're when you're in rural settings, we don't necessarily have access to all of the courses, so knowing that there's easy ways to access things, has made it easier, but we really do try to support within our program that expansion of skills certifications that our staff want. We've done a lot of work in going through and recognizing like, what are, what are some of the mandatory and really strongly recommended courses, you know, for a pediatric nurse, for our neonatal intensive care nurses, for you know, our obstetrical nurses like really trying to build frameworks so that staff sort of know what's available, what we're willing to support, and then really leveraging opportunities for, you know, programs that come out. You know, certainly there's some funding for our NICU nurses through the CCsO. So, trying to leverage, you know, the new nurse mid career, nurse education. So, I think it's really, really important, and it helps to recognize the fact that these are specialty areas. There's a lot to learn. You know, you don't learn everything in school. So, you know, having these opportunities to be able to further expand your knowledge and lots of simulation. That's been huge. We've really expanded in that. So, expanding our simulation as it particularly relates to the pediatric population, and ensuring that we have those equipments, and relying on our foundation to help, to support, to purchase the equipment that we need for training, and really trying to build in this routine simulation training opportunities. So, I think it's, I think staff really appreciate it.  

Dr. Katharine Smart: And again, I think it's really interesting how investing in your people has that outcome of retention, right? Because so often we talk about recruitment, but we're maybe not focused enough on retention. And that, I think, brings me to another thing I think is really important, is this idea of mentorship, right when we're trying to build out these programs in rural settings, regional settings, having mentorship of both pediatricians who have experience in that context, to mentor newer grads and nurses to mentor their colleagues, and, of course, across the healthcare professions, I think that can be a really important aspect too, of retention and quality of care. So, I'm curious, Holden like, in your setting, how does that mentorship work? And is there some challenges with that, like, especially with staff kind of coming and going, how do you create that environment where people feel like they can come and can be supported to provide the type of care that they want to provide?  

Dr. Holden Sheffield: Well, you said a really good word, and I think it's the key word to a lot of what we do, and that's relationship building. So by having again, familiar faces, relationships, whether it be pediatrician, nursing staff, pediatricians, RTS, pediatricians, nursing staffs up island in some of the community health centers, building that relationship and trust is huge. When you know you have somebody who's a familiar face that you can call with a sick patient in the middle of the night, it makes all the difference. And so we see that level of mentorship build up naturally. When we have again, the same familiar faces, we try to staff with the same pediatricians we have, we try to have those recurring locums. Makes a huge, huge difference, because they know they've worked with that individual before. It's somebody they can trust. And there's that instant connection. There's not that level of okay, who's on the other end, who's going to pick up the phone? Should I call? Or should I not? I'm worried. And as soon as you have that level of trust, it makes a huge difference. It works for us in the other way as well, because we, you know, we call for help too, all the time to our tertiary care center, which is CHEO, and the familiarity is everything you know, to know who's on the other end of the phone, to be able to, you know, run any cases by them, judgment free, is a huge, huge relief for us, I find, and that has been a big part of what we do in terms of building up those relationships with our referral sites, making sure we're able to talk about cases and do the right thing for our patients. So, I think that's a big thing around mentorship.  

The other piece, I guess I would mention in this is learners as well, which could be relevant here too. So, in order to, you know, have ongoing recruitment, ongoing mentorship, being able to take on learners in our program, I know you, you guys as well, also are taking on learners, it can be very, very helpful for that. So having residents, pediatric residents, rotate through experience what it's like to work in our setting, but also use it as a bit of a recruitment tool and a mentorship, you know, diving platform, so to speak, can be extremely helpful, too.  

Dr. Katharine Smart: Yeah, I totally agree. My first recruit to the Yukon, the second pediatrician that joined me there was my first resident on my first month there as a pediatrician. I think I stole her from Holden. So, there's some controversy…  

Dr. Holden Sheffield: You did. *Laughter* 

Dr. Katharine Smart: But that's exactly what happened. And so, I agree, and certainly that's been my experience with having learners come to Whitehorse in the Yukon is for a lot of pediatric residents, they've not, maybe necessarily even considered rural or regional pediatrics. And they come and they see the breadth and the wealth of the work that we do, the incredible teams that we work on, the incredible family physicians and nurses and community nurses that we get to interact with, as well as the people themselves. And they're like, Wow, the number of residents that end up saying to me, like, I really wish I would have known about this before. Sometimes they're already on a subspecialty path. Not that that's bad, but, but it's, you know, they sort of realize this can be a really rich and rewarding career. So I think those learners are key. And I know in Thunder Bay, with NOSM, you guys are training nurses and physicians in your communities. And again, you know, when you think of that broader retention, we want people to be able to be close to home.  

How does the educational piece work for you in Thunder Bay? And what does that, how does that link to pediatrics and child health? 

Crystal Edwards: Yeah, I think, you know, we certainly have a, you know, we have a great team that is, you know, super supportive. And one of the things that we've really been trying to expand is that sort of interdisciplinary education piece. And I think the work that we've been doing in trying to train our pediatric transport team has really built that interprofessional right? We have our physician colleagues who join residents, are joining our nursing are, you know, respiratory therapists and so really creating these opportunities where everybody is working together, going through the simulations, you know, doing similar education and certifications, and it's really sort of building up that team and creating, you know, really positive learning environments. But you know, also, I think it's gone a long way in building the work. You know, the team was always strong. You know, we are a relatively small team, and because of the size everybody, you know, the relationships are there. You know, our teams work really well together, but having these opportunities to do additional training and education together, I think, has really gone a long way in building that, that trust with one another.  

So it's, it's really, it's something that, now that we have done so many with this one particular team, there, there's opportunities now to see, how are we going to roll this out to more of our staff, you know, not just our transport staff, you know, our pediatric train staff. And, yeah, I think, I think it's a really important piece that sometimes gets missed, right? Sometimes we don't put that education, you know, to as strong, you know, it's the first thing that gets cut when you get busy, or when funding gets cut. But I think really getting back to that is really where we need to go.  

And then, you know, with this regional pediatrics piece that we've been doing, we are actually sending our staff out to out to the community, out to the region to do these regional road trip is sort of what it's called, and going and offering the education at our regional hospitals, and then continuing that with virtual sessions, so that you know that opportunity to connect and meet the teams in the region, and then being able to engage them on an ongoing basis after and so it's been really appreciated by the region, because they like to have that expertise come to them. And yeah, it's been huge. And so that's something that will continue to focus on building more. 

Dr. Katharine Smart: That's fantastic. It sounds like you guys have really an amazing program happening there.  

Dr. Holden Sheffield: Katharine, I actually just have a funny story that I have to mention based on what you said, so, and this is, I deeply respect pediatric nephrologists. So whoever in the audience, I think I saw, well, I've seen Patricia Burke a couple times, but if there's any other nephrologist, take no offense to this. But I was matched to pediatric nephrology as a fellowship, and I went to Iqaluit as a resident for a rotation, fell in love with the place and the idea of rural medicine, and I backed out of my pediatric nephrology fellowship. I say this again with the highest level of respect for nephrologists. I still love what they do, but I guess I found a bit of a different passion and different career trajectory. So, you know, I tell residents all the time, go through your training and your life with an open mind, because you never know what might happen. And I can guarantee this was in 2015, I never thought that in 2024 I'd be sitting here talking about, you know, a pediatric program in Iqaluit. So, there you go. 

Dr. Katharine Smart: I love that story. Holden, I want to pull on a bit of a thread of something you said, because I think we also want to touch on, we've been talking a lot about relationships trust, how we reach out and work with the communities we serve. But you know, you also talked about the importance of our relationships with the communities that support us in rural and regional settings. So, of course, those relationships with the children's hospitals, both to access subspecialty care for our patients, sometimes critical care for our patients, are really important. And you touched on CHEO as your referral center, and the support that you've had from there, and again, how that's been important for the pediatricians in Nunavut to feel supported and like they can work well there effectively. Tell us a little bit more about you know, what's important from your perspective as a rural provider, with that relationship with your referral center, and is there anything you guys are doing with CHEO that's innovative at all, that's helping your patients still get access to that level of care when that's what's indicated for the child or youth?  

Dr. Holden Sheffield: Yeah, that's a great question. And actually, our relationship with our referral site represents a real cornerstone to our program. There are some interesting, you know, technological advancements that we use to help, for example, direct care to ICU via virtual connection. So, you know, being able to dial in through video if we have a sick patient, and allowing an intensivist on the other end to, lay eyes directly on the patient, but to be honest, what actually makes the biggest difference, and again, to go back to it, is relationship building, and how do we leverage those in order to ensure our patients are getting the best care? And what I found is, when you're a familiar person in a setting that is calling regularly and discussing cases, there is a level of trust that is built up over time that cannot be replaced. And so what's happened is, when you know your referral site knows they can trust you with patients, knows who can stay and who needs to go, and can trust your judgment on that, all of a sudden you see a huge decrease in travel down and a huge influx in, you know, a local program's capability. So, building that trust is everything, and again, not really needing much technology, not to mention nephrology, too much in these talks. But you know, in discussion, for example, with the pediatric nephrologist at CHEO, what we've done is we've recognized, hey, most of these patients do not need to come down and see you. We can do local ultrasounds, we can do local blood pressure monitoring, we can do local urine checks we can check creatinines. What we should actually do is, every few months, get together, talk about all the patients, make sure that they are getting high level of care, the same care they would have been getting if they were in Ottawa. But why do we need to send any of these patients down? Perfect. So now, you know, four times a year we meet, we talk about all of our patients and our outpatient send outs have basically dropped by about 85 90% and so that was, you know, that was simply by building relationships and saying, hey, this is something that we should just be doing. Why would we send a patient down to get an ultrasound review? We can chat with you guys, when you know we can tell the patient very well that we're getting the same level of expert advice and opinions, and we'll keep care closer to home, which is, again, kind of our driving theme. And then all of a sudden, when that works, you realize, hey, we could do this with the development team. We can do this with the respirologists. We can do this with maternal fetal medicine and NICU to see what's actually safe to deliver here, and you start realizing you cut back on so much unnecessary travel. And for families, it really makes all the difference.  

And again, there's nothing there's nothing brilliant about this. This is really how it should be done, but it's the relationships, and it's the trust that you've built up over time to allow for that. And then on the flip side, too, you know, repatriating patients. When there's that level of trust to say there's a reliable person in Iqaluit who will make sure that they get their care, we can send them home. All of a sudden, you get patients coming home way earlier than they normally would have, because there's a level of trust to know that they will get that high level of care closer to home.  

Dr. Katharine Smart: Yeah, absolutely. And I've had a very similar experience. And again, you know, another theme, I think, on what you're saying is communication, right? Being able to talk directly to each other, having that clear path, so that the subspecialists know who to reach out to, and can make sure those connections are happening. And we've, in the Yukon, we've started a few different things that are working well. In that regard to, we have the endocrinology team from BC Children's comes twice a year and actually works in our pediatric clinic. So, one of our pediatricians is there. All the kids get seen by their team with one of our pediatricians, and it's been a fantastic collaboration. You know, often we're picking up on things that have maybe been missed, like mental health problems or developmental problems that the endocrinologist isn't as focused on because they're thinking about diabetes. We know all the local access how to get kids those different programs, and then our pediatricians having the opportunity to learn as well, and all those families now are don't have to go down to Vancouver, so it's saving, you know, 25 people that trip, and that local capacity is being supported, and people are getting that team based care, and then they know who to connect with in between, when we have other outreach programs as well that come up, cardiology as well. And like you, you know, we, I think, are developing more relationships with specialists who reach out to us, and we're coordinating, you know, infusions of biologics and special treatments in our community that before those kids would have had to travel.  

So, I think you know those themes of relationship, trust, communication, teams, supporting each other, ongoing professional development, you really realize you can actually provide excellent care for people very close to home by supporting the staff, creating professional development opportunities, having those relationships and being supported by those centers of excellence that we still need, but we don't necessarily need them in person, right? There's ways we can access that care. So I think that's really, really amazing. Crystal?  

Crystal Edwards: Yeah, thank you. And you know, we are very fortunate. We have a similar London Health Sciences Center is the tertiary center that supports us. And you know, relationships are huge. Trust is huge. We do so much our pediatricians, you know, our teams, know their teams. They know us, they know our patients. And you know, a lot of opportunity to, you know, work together to prevent travel if needed. What can we do in Thunder Bay with the support and the guidance of the team in London? You know, repatriating our patients back quickly. We also have the pediatric cardiologists that come and do visiting clinics in Thunder Bay a couple of times a year. So, it's definitely great opportunities when you have that, you know, sort of the tertiary center supporting the level two centers in the north and then it gives us that ability to then, you know, take that knowledge and support our level one, you know, regional centers and nursing stations. So, it really the partnerships and working and being able to support one another is huge. And we are so appreciative of, you know, what London team does for us. 

Dr. Katharine Smart: I feel like I could talk to the two of you all day, and because we have a shared passion for healthcare, for Northern, remote and rural communities across Canada, we have lots more we could talk about, but our sadly, our time is coming to a conclusion, but before we end, I want to just give each of you a chance to give us a few final thoughts. So, what would each of you give us for a 30 second pitch on what's important right now for right sizing, children's healthcare in the north. So crystal, I'll start with you, and then I'll go to Holden. 

Crystal Edwards: yeah. I think you know, when it comes to the north, and I mean, of course, everybody, it comes down to funding, of course, right? It always comes down to money. But I think you know, just that recognition, that it is far more complex in the north. The funding, the way that you fund programs, or look at programs, should not necessarily be the same. You know, we don't necessarily have the volumes that you know normally. Of course, it's always like, what's the volume? Can your volume support this? And that's not necessarily you know, what's going to work in the North. The reality is, is that we have children and families that we need to support. We may not have the volumes as compared to larger centers, but they still deserve to be able to receive that good quality care. So, you know, we really need investments to be to be able to support and expand our teams. So I would think that that's one of, you know, really important thing.  

And permanent based funding. I said this last year at one of the conference at this conference, when we had one of our panels, it's not helpful, especially in the north, you know, temporary funding. We're trying to recruit and retain our staff, and you can't do that with temporary money. So, we really need to be able to, you know, permanently fund these staff, to build these positions, to be able to expand, to support, you know, our teams, and really recognizing that there are disparities when it comes to travel and accommodations. Our families really have a long way to go, and there's financial burden, there's a lot of stressors there. So, we really just need to be considering, you know, those factors, you know, when we're when we're looking to expand programs and fund in the north, and I think care coordination like that's, that's huge, right? We're serving large groups of people who are very dispersed geographically. We're trying to support them, you know, in the region, as well as collaborating with our tertiary centers. And it's very complex for our families, and so we really need to be investing and looking at how we can help to coordinate their care and be able to support them through their journey. 

Dr. Katharine Smart: Thank you. Holden?  

Dr. Holden Sheffield: Yeah, I could build on that. Those are all excellent points, and I agree when it comes to funding and comes to making an argument for expanding pediatric programs in rural, remote sites, you are competing against adult volume, and we will never win, is the reality of the situation. But what I think has to be made, and the argument that I often come back to is when we look at the core issue, especially in rural, remote care, we're not just dealing with the child, but the family as well, and the impact that it has on a child to send them out for care also has a massive impact on those who go with them, the family they leave behind, and it creates immense challenges. And some of the hardest news, actually to deliver in a lot of situations is we have to send you down. It's a difficult conversation for a lot of families to have, and it creates a lot of challenges.  

So, you know, I guess my pitch would be, we have to always think about the family that's involved as well. It's just not about one person, but it's often about many. Decisions around healthcare, and the ability to provide local care closer to home, impacts the families as well. And I think when we frame it this way, this can hopefully lead to a lot of success around hopefully being able to advocate for more funding, improve programming, and again, driving that message of care closer to home.  

Dr. Katharine Smart: Great. Thank you. I've really found this conversation with both of you really inspiring so many examples of success, creativity, connection, and of course, that shared passion for excellence in rural healthcare delivery. So, thank you, Crystal and Holden, it's been an absolute pleasure to have you today. 

Thanks again to SPARK Conversations podcast sponsor the IWK Health Center for their ongoing support. That's it for today. Thanks for listening to SPARK Conversations. To stay up to date on all spark offerings, including upcoming podcast episodes, visit our website, at ChildrensHealthcareCanada.ca, and subscribe to our spark news bi-weekly e-bulletin, if you haven't already. If you like this podcast, show us some love by leaving us a review and telling your colleagues about us. We'll see you again next month.