Chasing the rainbow of interdisciplinarity in Quebec primary care

Last Friday, several hundred health professionals met to discuss a common vision for primary health care in Quebec. The participants were mostly physicians, but several nurses, at least one health economist and medical students took part in the discussions as well. The event was hosted by the department of Family Medicine at McGill University.

Although civil and pleasant, the symposium tried to discuss a MEDICAL vision of primary care, but they had invited too many community activists, nurses and prominent health experts to remain within that reduced framework… GPs were praised over and over again as being the ‘heart’ of primary care and being the central players, but Michel Clair and Claude Castonguay made it quite clear that GPs being at the heart of primary care was actually a problem. Even if no one articulated the debate it was interesting to see it unfold nonetheless.

On the one side, several speakers discussed how other health care professionals should be used more to take a load off the shoulders of overworked physicians. This seemingly good idea unfortunately perpetuates the idea that nurses’ jobs are whatever the physician needs.

A nurse practitioner spoke and tried to explain her expertise and scope of practice. In a rather convoluted way, she explained how nursing expertise is complementary to medicine, not subordinate. She was sharing the podium with a medical student and a family physician who had literally just said that nurses can take ‘her more simple cases’, to make her life easier. The nursing role was reduced to ‘sidekick’… and that’s being very polite.

From the very first session, there was a giant elephant in the room that was never addressed. Léonard Aucoin, one of the speakers, said in his remarks that in these times of authoritative, top-down changes in health care, innovations become synonymous with delinquency. SABSA anybody? The recent events surrounding this nurse led clinic immediately came to mind as he uttered these words. Apparently, I was the only one to think of this.

The second session included a bit of an anomaly. After a speaker had thoroughly discredited the Kaiser Permanente method within a publicly funded system in the first session, here comes a reputable scientist who’d worked with them and was eager to praise it. I really wonder whether he attended the first session, because it was all rainbows and butterflies with him in KP land.

The third session included a nurse practitioner speaking alongside the family physician that I mentioned earlier. It was painful to see the NP try to defend her practice in a room full of colleagues who are blissfully unaware of her role and contribution to care. She worked hardto make sure no one (no physician I mean) would be offended by her remarks, so she just mentioned that it was ‘difficult’ at the beginning and that MDs sometimes had had a ‘hard time’ accepting her into the team. But now she’s working with 10 (yes, 10) fantastic physician partners, so all is well, except for the cutbacks.

Again, SABSA was not mentioned, except as a question from the floor during the discussion. The med student and GP preferred not to address this, so the NP answered that although she believed in its efficiency, perhaps being financed by a union decreased its credibility. Let’s not forget the FMOQ is a union as well… talking about the FMOQ:

The fourth session mentioned that it is unacceptable for a union (FMOQ) to have so much power over the model of delivery of primary care. Michel Clair explained that the regulation of primary care in Quebec essentially comes from negotiations between the Ministry of Health and the FMOQ. This, for obvious reasons, makes it difficult to keep the patient at the center of primary care when that center is already occupied by GPs, as negotiated by the FMOQ.

This fourth panel, although it made the most sense, seemed the least understood by the audience. Roxane Borgès Da Silva, a professor of nursing and researcher at UdeM explained how primary care is a collective responsibility, that inter-professionalism and inter-institutional collaboration are the way forward. Unfortunately, no one ever defined ‘interdisciplinarity’, except the family physician mentioned earlier whose ‘easy’ cases can be done by NPs… That was all we got on that magical concept of ‘interdisciplinarity’. It was almost like two conferences were happening at the same time, one based on the bio-medical model, the other on primary health care. We all use the same words, but they have different meanings.

Finally, Claude Castonguay, despite an awkward moment when he had to sit through the audience singing ‘happy birthday’, said it like it is, like he’s been doing over the last few months. He explained how he had already promoted optimizing the nursing role some 50 years ago. Ten doctors for two nurses is not a ratio that makes sense. Nurses will never work a full scope of practice in this context. As long as the FMOQ and the FMSQ are the only ones on the playing field, it will be difficult to make any meaningful change in the healthcare system. The Castonguay-Neveu report is still relevant because it’s never been implemented.

Despite certain shortcomings, the symposium reflected the changing landscape of primary care. No one mentioned SABSA, but a nurse practitioner was one of the featured speakers, which in itself speaks volumes. A few years ago, maybe even last year, a conference such as this would’ve been a homogeneous, consistent wave from beginning to end. It would’ve been a ride through primary care land with physician goggles firmly attached to our heads. This time, the lens is cracked and a different picture is seeping in. It’s unclear and fuzzy, but undeniably in our field of vision.