The shortage of health care workers in Canada is a growing crisis. The daily tradeoffs of caring for patients while keeping up with administrative demands is leading to burnout – and prompting some professionals to trade private clinics and hospitals for team-based practices.
“Working in a team makes me feel valued. I feel like I have a team that supports me just as much as I support the physician… There's no worrying about rushing to finish your shift and having to choose between not giving care rounds to my patients or not documenting in the EMR.” – Shawna Pasiciel, HealthWORX Medical Clinic
In this episode, host Dr. Caroline Gérin‑Lajoie speaks to Vancouver family doctor Christie Newton and registered nurse Shawna Pasiciel, of Medicine Hat, Alberta, about the wellness benefits of interprofessional collaboration – both for health care professionals and their patients.
If you're looking for resources, tools, and research on the topics covered today, please visit the CMA Physician Wellness Hub at cma.ca.
The shortage of health care workers in Canada is a growing crisis. The daily tradeoffs of caring for patients while keeping up with administrative demands is leading to burnout – and prompting some professionals to trade private clinics and hospitals for team-based practices.
“Working in a team makes me feel valued. I feel like I have a team that supports me just as much as I support the physician… There's no worrying about rushing to finish your shift and having to choose between not giving care rounds to my patients or not documenting in the EMR.” – Shawna Pasiciel, HealthWORX Medical Clinic
In this episode, host Dr. Caroline Gérin‑Lajoie speaks to Vancouver family doctor Christie Newton and registered nurse Shawna Pasiciel, of Medicine Hat, Alberta, about the wellness benefits of interprofessional collaboration – both for health care professionals and their patients.
If you're looking for resources, tools, and research on the topics covered today, please visit the CMA Physician Wellness Hub at cma.ca.
Dr. Caroline Gerin-Lajoie:
Welcome to Sound Mind, a podcast about physician wellness and medical culture. I'm your host, Dr. Caroline Gerin-Lajoie. On a recent episode of Sound Mind called The Great Resignation Comes to Medicine, we explored how more doctors are leaving the profession due to exhaustion, burnout, and dissatisfaction. The problem is particularly acute for family doctors and private practice.
Dr. Caroline Gerin-Lajoie:
In addition to providing comprehensive patient care, they deal with a significant administrative workload relative to other specialties. The CMAs 2021 National Physician Health Survey found that 45% of family physicians reported 10 to 19 hours of administrative time per week, compared to 33% of medical specialists.
Dr. Caroline Gerin-Lajoie:
The shortage of family doctors in Canada is a growing crisis as more patients find themselves without access to primary care. One solution that holds promise for both patients and physicians is to expand interprofessional care teams where doctors work together with nurses, nurse practitioners, social workers, physiotherapists, pharmacists, and other healthcare professionals.
Dr. Caroline Gerin-Lajoie:
Shawna Pasiciel is a registered nurse working at the HealthWORX Medical Clinic in Medicine Hat, Alberta. Dr. Christie Newton is a family physician in Vancouver and associate head of education and engagement at the University of British Columbia's Department of Family Medicine. Thank you both for joining us.
Shawna Pasiciel:
Yeah. Thanks for having us, Caroline. Thank you.
Dr. Caroline Gerin-Lajoie:
Shawna, can you describe who works at your clinic?
Shawna Pasiciel:
We are actually quite a large clinic. We have seven or eight physicians working with us and each of them has their own primary care nurse in the office. We also have a behavioral health consultant in our office who does counseling and therapy to help with the mental health side of things. And I work under a larger umbrella called the Primary Care Network here. It serves Southern Alberta. There's about a hundred physicians and I would say over 70 other health professionals, including the ones that I just mentioned as well as dieticians. We previously had a pharmacist and they all worked to help in a physician led office to support the chronic health diseases of patients in our communities.
Dr. Caroline Gerin-Lajoie:
So as a registered nurse, how do you fit into the team aspect of the clinic?
Shawna Pasiciel:
I focus on chronic disease management in the clinic. So usually it starts out with kind of three monthly follow ups for chronic diseases like diabetes or hypertension following up on hospital discharges or new patient appointments. We have longer times in our appointments. So sometimes the short is 20 minutes if it's a very stable follow up appointment. But I can book as much as an hour really for someone who's coming out of hospital with a new diagnosis and we have lots of time for education and managing their medications in our EMRs and setting them up with standing orders in the community, if they need to.
Shawna Pasiciel:
And then I also do a lots of the admin for the physician that you talked about going through results every day and sorting through the paperwork that comes in because there's a lot of it. So triaging what I can help with and what needs to go to the physician for review and completion as well.
Dr. Caroline Gerin-Lajoie:
Christie, you started your career as part of an interprofessional care team. How similar was it to what Shawna just described?
Dr. Christie Newton:
It was very similar, and I'm so jealous listening to that. So in 2006, '07, we had an interprofessional team working in the clinic with a physiotherapy, occupational therapy, pharmacy, midwifery, and nurse practitioner alongside our family doctors. We also had students. So we had learners in all of those professions linked to those providers, which was what we think essential. And now I am biased as an educator, but I think part of team based care is ensuring that we train within those models so that we can sustain those models.
Dr. Christie Newton:
Sadly, because of system issues and academic issues, policies, gradually we lost each one of those professions. So now I teach in a family practice residency training clinic because we are also rolling out primary care networks in British Columbia a little differently than in Alberta. They've struggled a little bit, but we have an interprofessional team now that we can refer to. So our interprofessional team is not collocated and I can refer to a mental health counselor, pharmacy. I believe physiotherapy.
Dr. Christie Newton:
Our clinic has a contract space available for family practice nursing. However, we haven't been able to find or hire one just based on burnout, I believe. So, as I say, my current practice has dwindled.
Dr. Caroline Gerin-Lajoie:
So as a physician, what was the advantage of working in that kind of an environment?
Dr. Christie Newton:
Oh, it was just more efficient. We felt that we had actually provided the care that's needed for the patient. The system has become far too complex. Patient care has become far too complex for one provider to manage all of the issues. And today at the end of every visit, you feel like, "Ugh, I could have done more." You're anxious about whether what you were able to do is going to be enough to get them through to the next visit.
Dr. Christie Newton:
And when I was working in that team environment, I was able to do, assess a musculoskeletal issue in a patient. And instead of just handing them a handout or referring them to a website to do exercises, I could actually engage my physiotherapy colleague and their student and book an appointment. So I knew, I was more comfortable with the fact that they were being seen and that other piece was going to be addressed by somebody who's that's their specialty. And it's not just a patient handout or a website.
Dr. Christie Newton:
The same as when I was working with nursing ,I was able to do a well baby visit and then the education in the immunizations were completed by my nursing colleague. And again, there was more time spent with the patient and I was able to go on to my next patient and that patient did receive a broader care than I can provide right now.
Dr. Caroline Gerin-Lajoie:
Shawna, where did you work prior to HealthWORX?
Shawna Pasiciel:
So I spent almost a decade in med surg nursing here in Medicine Hat Hospital. I spent a little bit of time in correctional nursing actually when my babies were young and I was trying to get away from shift work. So I worked a little bit at corrections and I was a nurse educator there as well. And then went back full time shift work. And I just knew that I couldn't keep up with quality of life at home with two little boys and working nights and evenings, and on call. So that was when I chose to move to primary care.
Dr. Caroline Gerin-Lajoie:
And can you tell us a bit more about the impact that workplace had on your health and wellness?
Shawna Pasiciel:
Yeah, I was really nervous. Actually, when I applied for the job, I was just in the middle of taking my ACLS course so that I could go and work down and emerge here. So it was quite a jump. But I was nervous. I thought I'd be bored really, but it is the most fulfilled I've felt in my career so far. And I graduated from nursing in 2008, I think. I feel that part of my burnout from acute nursing was leaving that shift feeling like I left something undone.
Shawna Pasiciel:
I think there was an article recently, the Canadian Federation of Nurses Unions put on an article last week talking about burnout. And I think, Maura MacPhee from UBC actually did a survey on this and just that we feel a rush to care for too many patients at once and feeling like we're not doing what we started nursing to do. And I feel like the move to primary care nursing has regained some of those goals that I started out nursing for in the first place.
Dr. Caroline Gerin-Lajoie:
It also makes me think of the concept of moral distress a little bit where you feel distressed when you're unable to provide the care that you feel that patient deserves. So all important, whether it's burnout or moral distress.
Shawna Pasiciel:
Yeah. I know a lot of the provinces, there's lots of incentives going on in like New Brunswick and Manitoba to help keep nurses. But most aren't going to turn down money, but that's not what's going to keep nurses in their workplace, I don't feel like.
Dr. Caroline Gerin-Lajoie:
Christie, you are no longer working in an interprofessional setting. Can you tell us a bit about what happened?
Dr. Christie Newton:
Yeah. So it was many things. For one, profession. So academic policy didn't allow for that profession to have their faculty member work remotely and have the student work in the clinic. And the faculty member was working quite a distance away. I laugh now because we're supervising miles away and half a province away sometimes now with the pandemic and virtual care.
Dr. Christie Newton:
But back in 2006, 2007, that didn't happen. It wasn't something that we had looked into. So for that reason, so academic policy and supervision policy, that particular profession decided to work at a community health center and not do the driving distance back and forth. Our nurse practitioner, the academic policy and the compensation wasn't there. And to maintain one's competence in clinical care, you need a certain amount of clinical practice. And our nurse practitioner was actually volunteering her clinical practice time at our clinic to engage in team based care and really support that model because there was a belief that that model was the best to meet patient needs.
Dr. Christie Newton:
Eventually, she had to say, "I am not being valued by my faculty." Because the compensation model wouldn't allow faculty payment for clinical time. So she decided to value her time and go into clinical practice where she was paid. So we lost our nurse practitioner in our clinic. So for a variety of reasons, we gradually lost each profession. And our last one, again, a compensation reason, we had a clinical pharmacist who was cross appointed between the department and pharmaceutical sciences at UBC.
Dr. Christie Newton:
And after, I think nearly 40 years, she decided to retire. So we lost our clinical pharmacist and the department, and the faculty of pharmaceutical sciences decided not to replace that role and we lost our pharmacist. So gradually one by one, for a variety of reasons, many academic, many compensation issues, we gradually lost all of our different care providers.
Dr. Caroline Gerin-Lajoie:
And in terms of your wellness, Christie, how different is your experience now than when you were working together with other healthcare professionals?
Dr. Christie Newton:
Yeah. As Shawna has mentioned, it's that... And you mentioned, the moral distress. It's seeing a patient and wanting to spend time with them and wanting to provide the expertise that a team has, but not being able to. As I say, I leave each patient recognizing that there is still a to-do list with that patient, that I'm going to have to book another appointment for follow-up, or there's a to-do list that I need to refer to that non-collocated team and hope that actually gets followed up and the patient gets the care with that team, and that I get the information back regarding what happened and how that went.
Dr. Christie Newton:
It's just an anxiety that you have. Also, the one thing that hasn't come up yet, which is really a challenge is with respect to communication and administrative load. And so while I have a team now with the primary care network structure that's being rolled out in British Columbia, I have to make a referral. So I have to complete a referral. It has to go to an external source that then triages the referral and then lets me know whether that patient is appropriate and whether when they'll be seen, and then they make a consult, the patient is seen, and then that information comes back.
Dr. Christie Newton:
So there's layers there that for me are unpaid and time. So filling out forms, receiving and reviewing consultations take time away from actually seeing patients. And so that's also a challenge. We want to book as many patients as we can because we know they need the care. There are so many out there that don't have family doctors, and we're trying our best to attach them and see them.
Dr. Christie Newton:
But at the end of the day, I still have one or two hours of administrative work to do. So to avoid burnout, we have to decrease the number of patients we see, but the compensation system isn't built that way. In the fee for service system, you need to see as many patients as possible to pay your overhead, to make sure you can pay your staff, to pay for your electronic medical records, your technology, all of the things in your practice.
Dr. Christie Newton:
So it ends up that you do that extra two hours of administrative work after a full day of patients which eats into your family time, which you feel guilty about. So there are many things that have changed since having a team because when you have a team that administrative work even is distributed amongst the team members a little better. I feel anxious at the end of the day. I feel tired at the end of the day. I know I still have work to do at the end of the day, and I also know that I'm worried about many of my patients at the end of the day.
Dr. Caroline Gerin-Lajoie:
Shawna, you mentioned to us that you were initially a little bit anxious about joining a family health team, but can you tell us about your experience now compared to those initial concerns?
Shawna Pasiciel:
I feel I was more academic that I was worried about leaving acute care, but the amount of learning that the learning curve when it comes from acute care to actually managing 1,200 patients in all of their chronic diseases, and there's so much more than just medication and administration and counseling. We have workshops every other month here through Primary Care Network to teach on any number of subjects. We just had one. It was Barb Bancroft who's from the United States about infectious diseases. And every other month we have some sort of workshop for learning. And then we also have Medscape and up to date to help us educate ourselves a little bit more when we're coming to the physician with each patient so that we can make some educated recommendations about managing that patient's care.
Shawna Pasiciel:
I feel that my skills are used to the max actually right now compared to acute care because I feel like sometimes I am just sitting in counseling a patient to vote some depression that they're going through, but then other times I'm trying to adjust their heart failure medications with the physician or managing paracentesis for a cirrhosis patient or different things like that. And they're all physician led, but me and my physician work extremely closely. And so a lot of times he encourages me to come to him with a solution or come to him with what I'm going to do with that patient, and then we kind of talk through it.
Shawna Pasiciel:
Sometimes he changes it, sometimes he doesn't, but it was a big learning curve for me and I love it. I love the learning. I love using all the updated guidelines. I love an algorithm. I'm not sure if all nurses and doctors love an algorithm, but I love them. I feel like it makes everything a little bit more black and white. I love that we work so closely in our clinic as well.
Shawna Pasiciel:
If my physician has only so many minutes with that patient and he can just walk next door to me if that patient needs more care or if that patient needs a referral or they have a new wound or they are a new diabetic and he doesn't want to leave them with a new prescription for insulin, so you can just walk them down the hallway and then I can take on that.
Shawna Pasiciel:
I might not be always able to spend 60 minutes with that patient that day, but we can put a face to the name and engage that patient with a couple minutes of just booking an appointment for the next day and just letting them know that we've got them.
Shawna Pasiciel:
I love the follow up too. I love that you don't have to leave your shift at the end of the day and not know what's going to happen with that patient. We've got lots of reminders and follow up tasks. I rarely leave a patient without booking a follow-up. And if they decline booking a follow up, then I always just set myself a follow-up reminder as a chart check phone call in three months just to check in on them.
Shawna Pasiciel:
During COVID, I did that a lot more just with some of our more vulnerable patients. I would just book a chart check phone call in a month just to check in on them. And oftentimes they really didn't need anything, but they felt safer knowing that someone was checking in on them. I do have a direct line in the office too. So if a patient has a crisis or needs to get ahold of us at any time, they can just call me directly and I can help with refills or ordering blood work if they're symptomatic different things like that.
Shawna Pasiciel:
So we do have some protocols that are signed between me in the physician of what blood work I can order, different things like INRs or diabetics or whatnot. So I don't have to ask the physician for everything. That's just kind of his standard policy. And I don't always grab the physician between every appointment, if there's lots of phone call appointments that I'm doing, but we'll do team conferences midday and then at the end of the day saying, "Oh, I go through each patient and then I can call that patient back if there's a change in orders or anything like that."
Shawna Pasiciel:
So it saves travel for the patient especially. I find a lot of the most difficult managed chronic diseases are patients that are still working and don't want to take the time off to come into the office to deal with these things. So if they know that they can go for their blood work or they can monitor their blood pressure at home and then call me during their lunch break and we can go over everything, I'm finding that there's a lot better care.
Shawna Pasiciel:
And we didn't really learn that until COVID forced us to deal with these virtual appointments, but I'm finding lots of our younger patients more engaged with their diseases.
Dr. Caroline Gerin-Lajoie:
It's nice to hear you Shawna talk about your work and it sounds so meaningful and so rewarding to you.
Shawna Pasiciel:
It is.
Dr. Caroline Gerin-Lajoie:
It's inspiring.
Shawna Pasiciel:
Sometimes a patient can call in with a crisis and I can see that my doctor has refills for one of my diabetics at 10:00. So I can steal that patient and put the acute patient in at 10:00 so that everybody gets seen in a timely manner. A lot of our goals between the two of us is like avoiding walk-in, avoiding admits, avoiding emergency visits. So we do as much as we can just to have them seen in the office or over the phone so that we can avoid that.
Dr. Christie Newton:
That's one thing that I've really noticed and missed with team-based care is that proactive piece. So when you talk about a chart check at the beginning of the pandemic, we tried that, and we're fortunate in that in my clinic we have resident learners and medical student learners. So we could delegate to some extent that role to some of our residents. But then we actually got really busy with respect to following health issues with our patients. And so that proactive piece was the first piece that was dropped.
Dr. Christie Newton:
So we had our lists of chronic disease patients and we had our lists of frail elderly patients. We started to proactively check every three months, but that was one of the first things to fall by the wayside. And even with automatic recalls, we just didn't have this space in our daily appointments to proactively bring people in for that follow up.
Dr. Christie Newton:
I actually think it impacted many of our frail elderly and some of our patients that had multiple issues and that they did feel less safe for months in their home, isolated, not knowing if anybody was aware of how they were doing. But at the same time, they probably saw on the news that healthcare workers were overworked, they were exhausted. They didn't want to bother us. And so many things went beyond what they should have many issues and patients suffered.
Dr. Christie Newton:
So to have that team and that ability, to have that proactive piece or even that psychosocial piece of connecting with somebody who's isolated really benefit the team piece of that and the ability to have somebody on the team doing that would be great. And I miss that. I can remember when we were able to effectively do that.
Dr. Caroline Gerin-Lajoie:
And of course when you decrease prevention, it has longer term consequences both for the patient's health, but also of course, for the healthcare system. Canada is facing a shortage of healthcare professionals, both in nursing and in family medicine. Shawna, what role can team-based care play in reversing that?
Shawna Pasiciel:
I think it's part of... I feel like working in the team makes me feel valued. I feel like I have a team that supports me just as much as I support the physician. If he checks in on me and sees how I'm doing, and I know that if I'm struggling with a patient or they come in for a stable follow up, then I can just walk down the hall and grab him. There's no worrying about calling the doctor on call. There's no worrying about rushing to finish your shift and not ending the shift with either choosing between not giving care rounds to my patients or not documenting in the EMR.
Shawna Pasiciel:
I feel like EMR documentation was a huge, huge toll on my time as an acute care nurse that I just felt wasn't spent efficiently. It was funny because I did acute care for a long time and then I went off on mat leave for a couple years and I came back and there was these giant computers and hours of time spent documenting in these computers, documenting care that you wish you could have actually been given properly. But instead you're pushing these trolleys in. We were encouraged to push these computers into the patient's room and document and that didn't feel right to me because you're not actually spending the time with the patient. You're looking at the computer.
Shawna Pasiciel:
So I feel like as a primary care nurse and I leave knowing that everyone was taken care of properly. So I feel like lots of the studies now are talking about burnout based on patient care and not so much hours worked. You're still there for eight hours. But if it's eight hours that you feel like you're doing a really good job and you're leaving feeling appreciated and accomplished, that's much more important than the bonuses that they're trying to throw to nurses.
Dr. Caroline Gerin-Lajoie:
Christie, you've been trying to rebuild your interprofessional team. Can you tell us how that's going?
Dr. Christie Newton:
It's going. As I say, we have a contract available for a community, family practice nurse. However, we haven't been able to find one interested in practicing in our team. And as you noted, there's a shortage, and I put that in air quotes, of family doctors and nurses. And it's hard to rebuild when professionals aren't interested in going into community practice because the supports and infrastructure aren't there.
Dr. Christie Newton:
I think there would be greater interest and we would have that contract filled if the system was better structured. So we talked about the administrative burden for professionals and the compensation issues, the overhead issues. Actually, we have increased the number of residency training spots for family practice significantly over the past few years. However, just over 40% don't go into community-based family practice. They go into things like emergency medicine, maternity care, hospital medicine, where there is the infrastructure to support them so that when they go into these practices, they actually are able to the care that they were trained to do and not worry about inventory for your office, hiring staff, paying staff, making sure that you book enough patients to cover those costs.
Dr. Christie Newton:
Also, the administrative burden. So much of that is done in these areas where our new grads are going towards. So if we could improve this system, and I do believe that it's getting there in British Columbia. It's just getting there very slowly and I think it needs to speed up and the support for team-based care in the community needs to be a priority.
Dr. Christie Newton:
So I'm happy that I at least have a non collocated team of healthcare providers that over time I will likely develop improved communication efficiencies. But right now, it's still a bit of a challenge here in British Columbia. And so I really think that it will help attract more medical students and graduates into residency training. And again, we need to do that for residents as well. We need to provide those learning environments that are positive and to do that, we need to feel supported. So we need a system change, but we also need a team change. I think I'd like to move to Medicine Hat right now to join, what sounds like a highly functioning team.
Dr. Caroline Gerin-Lajoie:
Thank you both for speaking with us.
Shawna Pasiciel:
Thank you.
Dr. Caroline Gerin-Lajoie:
Shawna Pasiciel is a registered nurse working in the HealthWORX Medical Clinic, Medicine Hat, Alberta. And Dr. Christie Newton is a family physician in Vancouver and associate head of education and engagement at the University of British Columbia's Department of Family Medicine.
Dr. Caroline Gerin-Lajoie:
Sound Mind is produced by Podcraft Productions. If you're looking for resources, tools, and research on the topics covered today, please visit the CMA Physician Wellness Hub at cma.ca.
Dr. Caroline Gerin-Lajoie:
We'd love to hear what you think of Sound Mind. Please consider giving us a rating or review through your favorite listening platform. And please share this program. It's really the best way to get the word out. I'm Dr. Caroline Gerin-Lajoie. Thank you for listening.