The Agenda with Steve Paikin (Audio) - How Can Rural Ontario Access Better Health Care?

Episode Date: January 22, 2025

Emergency department closures, long wait times, falling rates of primary care. Now, imagine if the closest hospital is more than a 2-hour drive away. Access to basic and complex health services has been a continual challenge for rural Ontarians. At the Rural Ontario Municipalities Association conference to discuss why that is and what can be done about it are: Dr. Dominik Nowak, President of the Ontario Medical Association; Doris Grinspun, CEO of the Registered Nurses' Association of Ontario; and, Neil MacLean, Executive Director of the Brightshores Research Institute. They join Steve Paikin to discuss the challenges and solutions.See omnystudio.com/listener for privacy information.

I'm Matt Nethersole. And I'm Tiff Lam. From TVO Podcasts, this is Queries. This season, we're asking, when it comes to defending your beliefs, how far is too far? We follow one story from the boardroom to the courtroom. And seek to understand what happens when beliefs collide. Where does freedom of religion end and freedom from discrimination begin? That's this season on Queries in Good Faith,

a TVO original podcast. Follow and listen wherever you get your podcasts. Emergency department closures, long wait times, and lack of access to a family doctor. For those of you living in bigger cities, imagine if the closest hospital were more than a two hour drive away. Access to basic and complex health services

has been a constant issue for Ontarians living in rural and remote areas. Here to discuss what can be done about it, we welcome Dr. Dominic Novak, President of the Ontario Medical Association, Doris Grinspoon, CEO of the Registered Nurses Association of Ontario, and Neil McLean, Executive Director of the Bright Shores Research Institute

based in Owen Sound. Please welcome our guest to the Roma stage tonight for this discussion. Thank you. Every time we talk about healthcare on the agenda, I always have to do a, in the interest of full disclosure, my wife is a health policy consultant, so we put that on the record for everybody to know. Okay, Dr. Novick, to you first. Healthcare falls under provincial responsibility, obviously, so I'm sure the folks in this room

want to know how municipalities are tied up in all of the issues that we hear about nowadays. What's your view? Yeah, and when I'm meeting with patients with families all across the province, including in rural communities and in northern communities, they don't care whose jurisdiction health care is. They just want the care. And I met with a family a few months ago who was taking their grandpa to the emergency room in a rural community.

They saw a sign on the wall that said, emergency room closed. And the closest alternative option, two hours away. And we know that in rural communities, they're not getting there in the winter or if there's a traffic closure. So they want health care to work. And they're looking at the provincial government to do that.

That's their responsibility. But municipalities also have a role. And we could talk about that. Well, follow up if you would. What do you see that role being? Yeah, when I'm meeting with municipalities, the strongest things that municipalities, your communities can do, is make your community welcoming for new doctors and then also looking at the success stories

that's the grow your own approach. I think of Northern Ontario School of Medicine University and their success story of training doctors in rural communities and in the north and they end up staying there, they end up developing families there, they end up developing community there. That's really the role of mayors and municipalities, not this hunger games that we have right now across Ontario where communities are fighting against one another for doctors. Doris, what would you say in terms of what municipalities can do to play their role in the healthcare drama unfolding these days?

I will build on Dominique's comment. The people of Ontario, whether it is in rural and northern communities or in big centres, they don't care who is in charge, they also don't care who provides the access. So at RNEO we look from a person perspective and it's not only doctors, it's doctors, it's nurses, it's physios, it's other health professionals

that are needed and it's also specialties that are needed in all the domains. Municipalities role, the key in my view, in our view is to welcome the people and to welcome the people with all the aspects that others spoke before in terms of accessible, affordable housing for everybody, education, career development, building their careers on site, and an aspect that very few speak about, which is equity, diversity and inclusivity. I know of many nurses that came from other countries to small communities. they were in love with the smaller communities when their children came and they felt bullied in school and not welcome, they left. They went to bigger centers. So welcome everybody because whether it's

a nurse that was educated here or a doctor or educated abroad and comes to your communities, welcome them, make them part of your community, embrace them and build careers for them there. We now have tons of possibilities from PSW through RPN, from RPN to RN, from RN to nurse practitioner. Let me do a follow-up with you on that because I don't know if you noticed yesterday President Trump made DEI illegal of course in the United States do you think that opens up some opportunities for us here it opens opportunities but watch what will happen here with federal elections let's not think that what happened with Trump cannot happen here I think the previous speakers spoke about the politics of division. We need to end and municipalities again have a huge role on

that. End the politics of division, build the politics of one Canada for everybody, one Ontario for everybody, regardless of the political party here in Ontario. You saw the role of Premier Ford on that issue. And we need to build on that because the politics of division will let this country down spiral. We should not do what Mr. Trump decided to do. We should be different and we should welcome people. And yes, that will create opportunities. And many nurses are speaking about coming here,

and doctors too. Okay. You want to play? Sorry. Applause, applause. Neil, what would you add to what we've heard so far in terms of the role municipalities can play in the healthcare saga? Certainly supportive of the perspective of Dominic and Doris.

When I think about the work that the municipalities are already doing today to support community paramedics and the role of community paramedics play going and checking on people and keeping people out of emergency departments especially those that are unattached and living in rural communities. I also think about the sort of the idea to launch a research institute in Grey Bruce was really the brainchild of the hospital's board. And it was really driven around a couple pieces. One is the opportunity to look at new models of care to improve patient experience and provider experience working across six small, medium, largest hospitals

deployed within a very large rural setting. Chats with people know this probably better than me. A population of 175,000 people that swells over two million short stay visits because of cottagers and people going skiing and trekking. It's about how do we link the resources that exist that are provincially and federally funded today into communities that are municipally owned and provided. It scares me that there's more than one funder today. And if you're asking me, who's the most responsible for funding ABCD, the multiple choice answer

would be E, all of the above. And because there's more than one funder, the challenge we have is that cascades down to health care being provided in silos. It's disconnected from each other. Providers aren't talking to one another around, how can we work effectively across our areas of specialty? And you see that, whereas a patient,

whereas a family member looking after their patients, trying to navigate health care systems that are fragmented. Because at the end of the day, health care providers in rural communities, I'm super supportive of. I think they're there. In my mind, they're the MacGyvers of health care in terms of solving complex health care system issues with bailing twine and duct tape or whatever those tools are around them.

Like the ability for municipalities to leverage what's what's happening in those like the investments across provincial and federal boundaries I think is what excites me about this and we see it locally. What's population of Owen Sound? Population of Owen Sound is about 60,000. Any idea how many docs you've got for 60,000 people? I think totally there's, we know statistically that it's about 12% of physicians work in rural communities.

So it's not enough. And even if you move outside of Owen Sound to the five smaller sites, it's one physician working in Lion's Head, right? And it's a one stop shop in Lion's Head. Tobermory is an epicenter for cottagers and people going up during their kayaking, canoeing. So how do we better support them in terms

of committee investments for paramedics, committee nurses, and even expanded roles of pharmacists? How do we bring together the broader diversity of talents and skills that exist within rural Ontario? The job of the head of the Ontario Medical Association, whoever it is, is to get out there and hear the stories from around the province and kind of report back as to what you're hearing.

So I know people in this room would well be aware of the situation on the ground, but tell us when you when there are inadequate numbers of family doctors in rural and northern communities around Ontario, what impact does that have? What are you hearing? Yeah, no, I'd say family doctors and other specialists and by the way, nurses and other health professionals as well. We're seeing shortages all across the board. Here's what it looks like. I met with a doctor a few months ago

who was doing obstetrical care for their community and they were telling me about this huge swath of land 500 kilometers wide where right now it's a desert for obstetrical care where if you're a person who wants to deliver, who wants to start a family in that community, in the communities that are in this 500 kilometers wealth of land, you have to, one, move, or two, risk your life. And what we're seeing, what they were seeing, are people that are delivering on the side of the road because they can't get the care that they deserve and what we're

advocating for is a plan from the province that has some sort of sensible distribution of doctors nurses other health professionals builds out teams across communities so that that example doesn't happen anywhere in Ontario because that's really unacceptable I see you brandishing some kind of report there Doris, what's that? So we have reports after reports. This is over 10 years ago coming together moving forward building the next chapter of Ontario's rural remote nursing workforce. So some of it has materialized, just to give credit where credit is due, government does listen whether it is this or past government or

future. Some of it they listen both provincially and federally you just saw the interpretation of Minister Hollander on the issue of nurse practitioners that they can absolutely and they must be part of the health plan not the OHIP by the way and we don't think it should be OHIP but parallel. The reality is why isn't it moving? Why isn't it moving that in rural and northern and other communities there is not a link for example between hospital care and housing. That needs to happen.

In many communities, the problem is housing. So we heard solutions about housing. It's all an integrated whole for people, for Ontarians in those communities, for municipalities. It's not about nursing doctors or only healthcare. It's the whole enchiladas, we say, in my background, right? So it's everything together. And that also is for the health professionals. They're desperate to provide good care.

They love living in your communities, and by the way, they respect hugely, and so do we. We work with mayors all across the country hugely. But you heard politicians today speak about the opiate crisis. Well this province just closed 10 safe consumption sites. That's not evidence-based. Well they say they're opening up these heart hubs that are designed to deal with that. Part of the pie we all absolutely requested that they open the wrap-around services, but not instead of having a place where instead of the needles being on the street, right,

they will be not a place where people will die in the streets alone, by the way, with poison drugs, not with overdose, poison drugs, because we don't want to allow to continue nurses, by the way, they are the ones that serve these people to test the drugs. It all goes together. And unless we look at the lives of people together and health professionals as part of the equation, instead of the center, and that's why it's so important, the role of municipalities, then we are not going to solve this puzzle. Not in terms of retention of staff and recruitment, and not in terms of services for people.

It's everything, social determinants, and health care workforce, and system transitions. Neil, I want to get Neil in on this angle. And that is, okay. I never want to interrupt applause for Doris when that happens, okay. Neil, there to interrupt applause for Doris when that happens. OK. Neil, there'll be lots of people watching this on television, most of them living in cities, fewer of them

living in remote and northern parts of the province. And I want you to tell them, particularly the people who live south of the French River in places like Toronto and Ottawa and Hamilton, bigger centers, what the biggest differences are like in your life when there's a shortage of doctors and nurses and specialists where you live. Maybe I can start out Steve by just saying what an honor it is to be presenting to the Roma Conference, who knows the difference between urban and rural better? And it actually gives me a break from describing what's the difference

between urban and rural, why should I care? And even as I was in the waiting room talking to people, it's like well I live downtown Toronto, it's no better for me to get primary care than it is for rural. I said, but the difference for rural and what I've seen and what I, is that it's beyond medicine. It's about the geography. And it's about the fact that it's overcoming the barriers that exist around communications, collaboration. It's about how do we enable people

to work together across these rural geographies. It's overcoming shortages of people and supplies. It's the, I would say, insatiable demand for services for people that are wanting to age and live in rural communities, which I'm a strong supporter of. Nobody wants to end up in a long-term care home by design. We know care provided in the community is more effective. The outcomes are better.

It's cheaper. It's also where people want to get care. The number one issue in my mind for rural is distance shouldn't be a predictor of health outcome. It is. And we know today, and the work that even heart and stroke nationally have done around stroke care, is time is brain. So the further you're traveling for hyperacute issues,

whether it's for stroke or cardiac, the more likely likelihood for a positive outcome declines. And so how do we mobilize resources to bring them closer to where people are? And how do we look at different types of resources to support them? Not to say that physicians and nurses aren't doing great jobs, but in rural Ontario,

we don't have enough of them as we're recruiting physicians and training them up. And likewise with nurses and RNs in particular, what is the role for non-regulated health care workers? Founding members are providing care well today. How do we embrace people that could take some of the load off of nurses to support people in the communities in doing those checks? Help with medications, helping them just get ready

or get to doctor's appointments. Transportation is a fundamental barrier for people living in communities. And I think we've lost a lot of the social fabric of communities and neighbors who will look after each other because we're all getting older. Our children have moved away to go to school and pursue careers in other cities. When I think about the difference of downtown Toronto or even Ottawa, like, outside of downtown Ottawa, Ottawa's rural. Like, the travel distance from Ottawa to Nepean

and the points beyond, it's no different, in my mind, than the ecosystem that exists today within Gray and Bruce. Maybe it has a different sort of smattering of French language. But Gray Bruce has a very interesting population of indigenous people. And I think I alluded to the two million short stay visitors. The pandemic drove a fundamental shift of people that wanted a more,

I think, balanced work and life. And so they've chosen to move out of the large urban settings like Toronto, and they're living in Meaford and Markdale and Thornbury. And so these are people used to receiving care in a different way. Like, I'm used to receiving care walking across the street to in urgent care. I can get that 24-7. So the expectation of what health care is in rural communities, it's not just the care

that our parents and grandparents are used to. There's a driving force now around care that people that are moving into the rural regions from urban settings are now expecting. Well, let me follow up with Dominic on that. And to this extent, everybody, I think, in this room knows that health care is the largest line

item in the provincial budget. Maybe 15, 20 years ago, it was approaching 46%, 47%, 48% of provincial budget. Maybe 15, 20 years ago it was approaching 46, 47, 48 percent of the budget. They've now bent the health care cost curve somewhat, but it's still over 40 percent of the Ontario budget. And we see the provincial government making announcements all the time, mostly in bigger cities in fairness, of new towers for hospitals they want to build and so on and so forth. What are we up to now? Is it 80 billion a year in health spending I think? I think it's about 80 billion a year that the provincial government spends. Do you see that money getting into rural and northern Ontario? Yeah and

look the investments that we're talking about including primary care, a family doctor for everybody, but also teams for everybody, including doctors, nurses, other health professionals, they save money in the long run. So we can't afford not to make those investments. And I think of the benefits of having a connection to primary care, a connection to family practice, yet abusing emergency departments less often, yet I'm in hospitals less often and for shorter, getting cancer

screening and other preventive care done on time, and you end up costing the healthcare system less money so we make it more sustainable for years and generations to come. That's what we're talking about here. We're talking about making investments now that are going to save money in the long term and make our system more sustainable and that's why we can't afford not to make these changes and foundational investments in primary care, community care, in home care, these sorts of things that we're advocating for. Doris, we're certainly spending a lot of money. Is it getting out to the rural and northern areas? So just to make a

correction first, if you decrease the denominator because you spend less in social services, environmental health, etc., then of course the equation will give you increase, increase, increase percentage GDP. So that's an issue. We believe very strongly that unless the health system anchors in primary care, in primary care, with all the respect to hospitals, they are important and they have a role and I will speak in a minute

about how you link in rural communities primary care with hospital care. Unless we do that, we will spend money more and more and more in illness, less and less and less in prevention, and it will cost more. And that's where it also comes the ring of what the United Nations calls the development goals, of social determinants of health.

That's the link between also healthcare and housing. Now, in communities, in smaller communities, first of all, we need to look at innovation. We keep doing actually the same. Innovation will mean instead of closing emergency departments, and we have spoken, I have spoken with the premier about this immensely, don't close emergency departments. Link them with primary care. Completely.

Link them. Not merge them. Link them, not merge them, link them. In communities where you have upflows of people during summertime, again, link it because otherwise people stop to go to those communities. So don't cut the corners in terms of what rural communities need. Give them the means for them to create innovation. Team-based models, I mean you heard before, even Mike Schreiner that I have huge respect because he often speaks more clearly about nursing, but it's doctors, doctors, doctors.

Rural communities, when you guys do job fairs, it's about doctors. Build teams and thank goodness Jane Philpott is coming exactly to that, right? Teams were patients or people, because it's people like you and me that one day have the title patient. Build actually the entry point, and now with Minister Hollander is clear,

it's either to a doctor or to a nurse practitioner. By the way, Steven, you were the first many, many, many years ago, decades, that put a poll actually in the agenda saying if you can get a nurse practitioner tomorrow and a doctor in whatever it was, what would you do? 80%, I remember, I remember said, I don't care who I get. I just want to be seen and seen fast. Build access points across the system. Link and yes, there is innovation a bit

with Ontario health teams. Let's not discount that. It's building teams together. So let's be critical on what we need to be critical about any party for that matter. And let's give kudos what we need to be critical about any party for that matter. And let's give kudos where we are making from. Neil, can I get you to follow up on something Doris just referenced, which was the Jane Philpott appointment?

This is of course the former federal minister of health who was tasked by Doug Ford to spend the next five years looking to come up with ideas, processes, a new system in fact, to make sure that everybody gets attached to a team, a doctor, but a team as well. A doctor or a nurse practitioner, she was very clear on that. Right. What hope do you have that something's

going to come from that? There's, I think, strong hope. Shane Philpott has a track record of creating new models to train physicians. The work that she did at Queens with Lake Ridge, I think, is phenomenal. Putting medical schools into communities and inciting people to become local primary care physicians.

How do those models scale and spread? And how do we move Lake Ridge to Tobermory or Barrie or other points of rural Ontario? There's no reason why we couldn't I you asked you asked the question about you know the movement of finding into rural maybe just to my but I see Steve is the need but it's not it's no longer about the incentives for nurses and physicians it's about investing in tools to reduce the burnout.

How do we bring it? What does that mean, though? Investing in what tools? Whether they're scribes, ways to automate, ways to actually enable teams to securely communicate and share my health record as an emergency doc to the person's primary care physician, to the pharmacist like She like Doris was teasing behind the scenes like do you have a what's up?

I was like, no, I've got a card and she's like, well, you're one step away from the fax machine while I'm in health care So when I when I think of hospital still use fax machines, that's why I said it I was like I said it without laughing but And pagers, I would also say it pains me to see the fact that the province revoked fee codes for virtual care in Ontario, especially for primary care. We had, like, as you declared your role of your wife, prior to being on this role, I was one of the co-founders of the Ontario Telemedicine Network, saw the impact of technology to level the playing field from a geography perspective and providing equitable access to care,

regardless of whether you're indigenous or you're someone in the far north. Access to mental health and addiction services without the stigma of going in to an emergency department and saying this is the issue that I have. Can I get the head of the OMA on that? Have you lobbied the province to have that reinstated? We've been clear that everyone deserves care and care is care whether it's a virtual or

in person and especially for rural and northern communities having some sort of virtual care can be a matter of life and death, can be a matter of not having to drive the five or six hours to get to your family doctor. Are you going to be successful on getting that back in? Look I'd say I'm hopeful that the government sees the light and getting our health care system back on track and that includes especially rural and northern communities and I want to build on the team's point as well. One of the strongest recruitment drivers I've seen across the province in rural communities for doctors

is that doctors want to work in teams. Doctors want to work in teams. On one hand, I've been very clear that everyone deserves a family doctor, a primary care professional. On the other hand, the only way to get there, and the only way to recruit people into rural and northern communities,

is to actually build those supports. And by supports, we mean teams. We mean teamwork, doctors, nurses, pharmacists, all sorts of health professionals working together and added up. Yeah, let's take a round of applause for that. Let me add, anybody from Huntsville here or Muscogee in the area? Okay, so you no doubt know that you have a program there to pay doctors $80,000

and a lump sum fee if they will come to the community and stay for five years. Does that work? This is, what we're seeing is a Hunger Games right now across Ontario, where communities are pitched against one another to compete for doctors, and I don't think that's that's acceptable in terms of leadership from the province. And what we, yeah. So let's advocate to end the Hunger Games. Let's move beyond the Hunger Games and healthcare and let's get a plan for rural Ontario and a plan that builds out teams, gets doctors to where they need to be and ends the situation where you know I've families like you know the family that was bringing their grandfather with

signs of a stroke to the emergency room and saw that sign on the family that was bringing their grandfather with signs of a stroke to the emergency room and saw that sign on the door that said, emergency department closed within years to one hours away. What do you think about this idea to spend tens of thousands of dollars to attract doctors? I'm not the physician that would be incentivized by it, but I've seen the reverse of this, which is the emergency departments and departments in rural hospitals being supported by locum physicians coming in from urban centers. And it's disruptive to patients' care.

As much as it keeps the lights on and the doors open, the physician doesn't know the person's history. They don't know that they're being seen by a specialist in the region. And by default, they're being redistributed or potentially transferred for additional follow-up care to urban settings for procedures or surgeries that could be done locally. And so the local knowledge is fundamental to this. When I think about, we talk to a lot of physicians and nurses across the region

around what are the pain points you're facing, and from a research innovation perspective, how can we help you overcome it? And we heard consistently around the fatigue and the burnout, but we also heard about the frustration, the frustration that nurses and physicians have in rural and to because they have ideas to overcome these challenges, but they don't have the benefit of time.

And there's not funding available for them to work as a small team to bring a Skunk Works group together to solve a problem that they see at the front line. Let me follow up with Doris on that. We saw during COVID that the province did introduce a few new ideas in order to attempt to get people to go to nursing school, to retain nurses, to bonus nurses,

in the case of those who were working crazy hours during COVID. How much of that kind of approach do we need now to get more people to become nurses in the future? So let me start by saying that we have more applicants also during COVID. It never stopped. More applicants than what we can take. So that's a sobering.

So it's still an attractive profession for many people. More and more and more and COVID made it more, not less. So the issue is to increase seats. And yes, we discussed and government did listen. We increased by a thousand in RPNs by two thousand on their ends. Register practical nurses. Register practical nurses by a thousand, registered nurses by two thousand nurse practitioners by hundred and fifty. We are putting our provincial platform, the federal is

already out, next week. You will see that we are asking significantly more. Why? Because what rural communities and all communities need is more access. And if you want more access, nursing is a key. Nursing is a key as is other professions. I'm glad that we are moving from doctors, as you said, to an attachment to a primary

care professional. I would say, though, that in primary care, it needs to be either a doctor or a nurse practitioner. Because of the knowledge and expertise behind, it cannot be just whoever, right? Some communities do not have physicians. At least bring a nurse practitioner. They actually perform all the work, as as you well know and with outstanding results. Ideally, you can have teams, but not all communities have teams. So we need reality.

We have done also innovative initiatives like one-to-one tuition reimbursement. What is that? One-to-one tuition reimbursement, which is significantly better than the famous bonuses. We don't support the bonuses. R&O doesn and the province the ends has not moved with that. One-to-one tuition reimbursement and that's critical for municipalities because it's like a hidden secret. Explain how this works. One-to-one tuition reimbursement. If you are an RPN, RPN studied two years and you are studying in a college downtown Toronto and you move to a rural community

one year you get back one year tuition two years two years tuition at end one year two years three years four years so that actually is it working it is working and the other one that we have is grow your own N.P. Grow your own nurse practitioner in your communities and the province provides funding. The other one that we have is nurse practitioners in long-term care as attending N.P.s. The province provides the funding. I think many of these initiatives, it's the fault of all of us together, quite frankly, are not well known to municipalities. So there is already a lot of innovation.

We need to build more innovation, but we need to build more seats for physicians, for nurses. So you create that career progression and you keep people in your communities. Do job fairs that are for all healthcare professionals with equal balance of what we need and you will have a success and welcome them to your communities with open arms and be fair to them.

Oops. Let me pay. You still almost have a tilt, Doris. Doris was getting so enthusiastic there we almost lost her. Okay, hang on. Hang in there, Doris. Okay, I've known a lot of former presidents of the Ontario Medical Association.

How old are you? Steve, I'm 33 years old. He's 33. You are the youngest OMA president I've ever seen. Thank you. And I'd say it's a sign of people willing to step up and take a leadership role. And it's a sign of, frankly frankly things being really difficult in health care

which is why I know a lot of people here in this room and Watching are running for things are raising their hands to contribute are raising their hands to make a difference But here's the question I wanted to ask We're delighted that you're 33 and a doctor, but there are a lot of doctors my age Which is almost twice as much as you, almost twice as old as you, who are in the next few years all going to retire, and we are going to be up you know whose creek

without a paddle. I think it was the name of a TV show. Anyway, how are we going to attract the next generation of doctors to get in there and make the commitment that's necessary? So that we are not high and dry. Yeah, and by the way that number is around 40% 40% of doctors are either thinking of retiring or scaling back in the next few years That's that's a crisis. It's already accurate crisis. It's that it's a catastrophe for this province and

what I think of when I meet medical students and residents as a teacher of medical students and residents is what are their pain points? What are they seeing in practice? Number one, they're seeing that family medicine has no longer financially viable career choice for them. How can that be? Doctors are still well remunerated.

Are they not? Look, if you look at the financing behind family practice, behind running an office, behind hiring nursing team members, other team members, behind the technology, behind everything like that, it adds up. And meanwhile family doctors are trained in a way where they're in demand in other parts of the health sector, in hospitals, in long-term care. They're the Swiss army knives of the health care system so it's become no

longer a viable career choice when medical students can choose another way of practice and then number two the administrative burden the administrative burden is 19 hours per week that's crushing for our family doctors and medical students see that and they say look I don't want to spend my evenings at 10 or 11 p.m. at night and my weekends when I'm supposed to be off you know navigating the sheer bureaucracy and red tape of our health care system they're seeing those two things and they're saying I'll choose something else is there a way out of all that bureaucracy

you know what there is and you know alluded to it, things like AI scribe, technology. Early studies on this that we've done have shown that AI scribe, so a computer listening in with privacy in mind to a conversation that you might have with your doctor, and making the note for your doctor that can cut down three or four hours per week of doctor time.

And now let's make those investments, let's build teams, and let's set up those conditions so that doctors, family doctors like myself, like new graduates, feel that joy in medicine, joy in clinical care. Because caring for people is joyful. I'm a family doctor myself, I love every moment of it. Where do you practice?

I'm at Women's College Hospital in Toronto. And we're a team, by the way, and that's part of what makes it joyful that I get to work with, not just doctors, but also nurses, physiotherapists, mental health professionals. There's support, there's technology infrastructure there. Those are the kinds of conditions that pull doctors in,

and they're like gravity to keeping doctors in our communities, including in rural communities. As you watch this issue, these issues, unfold over the years, are we at least getting better at some things? Are we making progress in some areas? I would say we're seeing new models of integrated care that have been developed to support people living in urban communities that are being adapted now for rural. What about rural?

That's what I'm saying, they're being adapted now to bring them into rural. Programmes to support people with complex chronic wounds. There's a technology that enables a nurse at the bedside to take a picture of it. It automatically determines its size, its depth, whether it's infected or not. And so rather than having one nurse practitioner criss-crossing six sites in 8,000 square kilometers, she's now able to sit in one spot and watch a curated list of photographs of someone's wound progressing, and or not, hopefully not,

based on the treatment plans. And that also brings the power of those technologies to the patient. They're seeing the evolution of the treatment path and now they're taking a more active role in self-managing these things. We looked at, you know, the models of care to support people with congestive heart failure. When you look at the stats and you know the Roma group published out the likelihood of someone living in Grey Bruce dying from cardiovascular diseases 28% higher than

28% higher than anywhere else in the province or in Canada So what are the models of care that exist in women's college probably a leader in in acute care and innovative a leader in acute care and innovation specific to heart and a whole array of other things. How do we bring those models? I'm a fan for team-based care. But integrated models of care take it one step higher. Because in an integrated team, Dr. Novak puts his hand up to say, I'm responsible for this person's journey.

Not 8,000 people trying to figure out, well, that's yours, and that's yours, and that's yours. There's one person navigating this, and we're seeing this within models that have been deployed for lower limb preservation. People with diabetic feet that are losing, not just feet, but below their D amputations for procedures now that can actually restore not just the blood flow, but enable people to get their lives back. We're talking to the vascular surgery room, how do we bring this model to care that you've deployed within Mississauga's massive OHT and other parts of the 401 corridor into a rural. And it's like it's not the

sophistication of the technology, it's bringing people together and defining what the resources are and how do we close those gaps? And how do we use technology to coordinate this? If we don't want municipalities playing hunger games against one another to try to attract more medical professionals to their world, what would you suggest they do? Doris, you want to start on that? So, first of all, stop looking at pain points

and look at aspiration points. Turn it upside down. Not pain points. Not pain points. By the way, about diabetic foot ulcers, tell them to use the new guideline of RNL with Wound Care Canada, which is on preventing amputations. And you will save a lot of limbs and people's working life

because a limb also brings disruption in your working life. Look at aspirations, look at what people are aspiring to versus what people's pain points are. And you will look at what people want is pleasant lives, community, career development, wherever you live. That's a problem that we have now, that we need to move in medicine to a big center to actually be a specialist.

Look at what will keep people, whether it's a nurse, whether it is a doctor, or whether it is anyone else in your communities, and you will find the answers. They're not complex. They're not complex what people want. They want meaningful careers. They want engagement. They want career progression. Some not. We don't, for example, in nursing,

have ever supported higher compensation for a nurse that works in an ICU versus a family doctor. That's something in my view, and I have spoken many times in past years with the OMA about that. Because when you build those differentials, people will go to the more lucrative possibilities. Build them for everybody the same. A family doctor is as important, a family nurse as important, a nurse practitioner and

plan by care as important as one working in ICU. It's different specialties. And we have created these layers and hierarchies in compensation. We are asking in nursing harmonizing upwards, whatever a nurse practitioner, I know, whatever is this chair. I can look at all of you, but I want to look at them. Whatever is the harmonizing upwards, the compensation of NPs and nurses in community care, RNs, RPMs, all of them. So rather than going to hospital care

because they get paid more, they stay in home care. Home care, we talked about primary care, but home care is a huge challenge. In February, you will see that we were bringing and get that ECO enhancing community, getting Ontario 4.0. 4.0, it means there were three others. We started with Deb Matthews in 2012. We issue ECO 1.0.

Speaks about making community the center of care and some aspects have evolved and have improved and we need to recognize that otherwise it gets very demoralizing for everybody and then let's continue to look at the aspirations and build up rather than bringing everybody down Let me ask Dominic about this. The reality is not an awesome, which is awesome The Northern Ontario School of Medicine is, the Northern Ontario School of Medicine. NOSOM is awesome. Northern Ontario School of Medicine University is awesome. Awesome. It's awesome. Agreed. Yes. Not them, but almost every other med school in the country is in a big city.

And I wonder if that inevitably means that all of the doctors that we are going to produce over the next decade to take care of all those folks who are retiring you just referenced, if inevitably they're all going to stay in cities or the vast, vast majority and rural and northern Ontario is going to get left with the short end of the stick again. Yeah, look, Steve, I'm hopeful around this and we need, at the same time, we need more than hope. And the reason I'm hopeful around this distributing health professionals and doctors across Ontario is because many of your communities actually have so much

joy in work. And that's what draws doctors and health professionals in. If I could leave everyone in this room with one message today, it's joy in work. That's how you recruit and retain doctors, nurses, other health professionals. Joy in work means, do I feel like I could be my very best as a doctor in this community? Do I feel like I'm part of a team, like I'm part of something bigger than myself? Do I feel like I have coverage?

Do I feel like the province has a plan for me in a broader healthcare ecosystem? And by the way, right now the province has a plan for me in a broader health care ecosystem? And by the way, right now, there is no plan for rural and northern Ontario. That's what we're advocating to change. And do I feel like this is a financially viable career choice for me with the costs of running a practice and doing health care in 2025 with an aging population,

more complexity, people living longer and sicker All of that comes into joy and work Plus more plus you know is my family taken care of do are there opportunities for my family members for my kids for child care for these sorts of things and That's what brings doctors in that's why I'm hopeful that you know your communities already have so much joy and how can you focus on building more joy and how can we have a

plan across the province so that no community is left behind from that sort of joy and work that you know doctors practicing the rural communities feel intrinsically as being part of important members of your communities. That's a lovely answer but now I'm going to follow up with a brass knuckles politics question.

Please. The minister of health, who you just said doesn't have a plan for northern and rural Ontario, I mean, she doesn't represent a rural writing, but it's an ex-urban writing, right? It's not an urban writing. She's got elements of rural in her writing. If she doesn't get it, how can you be so hopeful yeah

look and I've been I've been hearing the stories of patients across the province and they've been they've been telling me what's working and what's not working in rural and northern communities and I've been hearing the stories of doctors we've been telling me those same stories and I think of that that swath of 500 kilometers in a rural community where there's no obstetrical care. And again, people who are starting a family in that community have to choose between moving or risking their life.

No, but I'm asking about the health minister though. Does she get it? I would say that's a question for everyone here to ask the health minister. And I would say that it's on all of us to show those stories, right? Show those stories to our elected officials. Show those stories to the health minister. There are far too many gaps in the healthcare system right now. And we need a government that steps up and owns those challenges that we have in healthcare, and gets our system back to a place where we can be proud of it again.

Because I think that sense of pride in Canadian health care is that sense of pride in Canadian health care, in particular I'm seeing in Ontario, is slipping away. That's how a 33 year old gets to be the head of the OMA. That was a smooth answer, right? That was very smoothly done. OK. But what about it?

What about it? Do we have a health minister right now who is adequately seized of this issue to give the people in this room some confidence that they're going to have some progress made? I haven't seen it yet. And at the same time, the Hunger Games are probably going to continue.

And I would say what I'm seeing from the role of research and innovation to bring opportunities for clinicians, physicians, nurses, to look at how do we amplify the work they're doing through publications and getting the word out there around the new models of care that they've developed is exciting. It's also become a beacon for people to migrate from urban to rural and consider a rural practice because the structures are there to support research and innovation.

When I think about the broader opportunities, I just get the sense that rural Ontario thinks hospitals are the enemy. And I can say firsthand, I served as the board chair for a medium-sized rural hospital in southwestern Ontario, challenged with exactly the same pieces. I spoke to the CEO of the Bright Shores Health System last week, and she said she's being tasked with helping support the recruitment of physicians to primary care. And she's like, it's not her responsibility either.

But I think about the power in the voice of Roma and like these esteemed leaders here, how do we bring this collective voice forward if we were to include the voices of hospitals in particular? Because at the end of the day, they've become the backstop. Their emergency departments have become urgent care clinics. People are scared around, what do I do for my loved one, especially if they don't have a family doctor? Hospitals aren't designed to be the backstop. They're designed to be specialized for traumas,

deliveries that you described. And the list goes on in terms of the types of urgent and emergent types of surgeries and procedures. The incidence now of an emergency doctor in rural Ontario identifying cancer for the first time is rising. People coming in, we've heard from the chief of staff across the six sites and right shores, people are coming in with such advanced stages of diabetes and cardiac care and respiratory that there's a swift, like there's an opportunity to shift healthcare from hospitals into the community and that's really why the hospitals stood up, this research institute, to think about how do we better

tighten the linkages between acute and community-based providers and how do we potentially scale and spread that? There's a tradition in healthcare that Doris Grinsman always gets the last word. So Doris give the folks in this room in our last minute here something they should be hopeful about. You ask if the minister listens. I think she does partially. I think though Roma knows that closing emergency departments in any of your hospitals it means you were not listened enough. We believe that we shouldn't close emergency departments in those communities. We believe that we need to shift care significantly to the community, home care, primary care,

interprofessional with entry point as physicians, family physicians and nurse practitioners. We believe it will happen and I credit Jane Philpott already on making it happen. It's essential because if if not not only we will bankrupt your communities and the people in your communities we will bankrupt the health care system and as for joy and engagement in work absolutely it's what it is the Queen Tupe Lane and Araneo follows to the tea

what needs to happen on that. The meaningfulness of work is the joyfulness part, meaning careers in your communities. The experience of patients, whether it is in a hospital or whether it is in primary care. The experience of mayors, we heard before, the disaster of people being attacked quite frankly. That needs to change and then we will start to decrease cost in a good way, not by cutting resources but by using them in the right place. And we will improve health outcomes because if you improve what you just spoke before about early detection of cancer or early detection of diabetes. You actually prevent, whether it is in diabetes, more chronic illness, complications from chronic illness.

So you start to build on the health of people, not only, which is important, on the illness. You know, nurses and doctors and other professionals work on all of it. So do mayors, when you work about housing, et cetera. That is prevention. So we need to build up on healthy policies rather than focusing only on illness policies. Great.

Two sentence closing thought. There's so much doom and gloom in healthcare right now, but if you look at it in Canada and Ontario, we world-class doctors world-class nurses world-class hospitals and if you get can get through the wait you'll get world-class care and world-class mayors and world-class mayors and we could get our health care system back to a place where we're proud of it again because we have the people that are going to be the foundations of that well we violated the cardinal rule here, which is that Doris always gets the last word. But OK, we'll give you the last word.

He's a doctor. Don't forget that. She got it. I know this audience wants to join me in thanking these three for a really thoughtful, great discussion here at Roma this morning. Thank you very much, you guys. Thank you, Steve.

That was terrific. Well done. Steve, that was a pleasure.