ORIGINAL ARTICLE

Bridging the gap between family doctors and regionalhealth authoritiesLydia Hatcher, MD, CCFP, FCFP, CHE; Oscar Howell, MD, MSc(A), OH, FCBOM

Abstract—The communication between family doctors and regional health authorities has become more complex and frag-mented over the last 2 decades. By using a novel approach, we developed a medical advisory committee structure for communityphysicians enshrined in the regional health authority bylaws. This has improved bilateral communication, policy making that affectspatients in the community, linkages between programs and family doctors, and input into the institutional care of our patients.We believe this model could be implemented or adapted by regional health authorities elsewhere in Canada having as its ultimategoal better patient care.

When the authors graduated from medical school(1975 and 1982), the urban family doctor was anintegral part of hospital care. Family doctors ad-

mitted and cared for their own patients, they assisted attheir patients surgeries, and they delivered all their ownpatients’ babies. In the late 1980s and early 1990s, familydoctors’ involvement in hospital care had largely ceased toexist. The Barer Stoddart report1 caused major cutbacks inhealthcare. Family doctor-run wards were discontinued,and hospitalists, specialty nurses, or other health profes-sionals took the family doctors’ place as surgical assistants,general practitioner anaesthetists, and the like. Althoughsome family physicians still work part-time in emergencyrooms and do deliveries, the total cradle to grave care hasbeen fractured and remains this way today. The opportu-nity for all physicians to meet, converse, and have “corridorconsultations” that once regularly occurred both on thefloors and in the doctors’ lounge is gone.Specialist care has also seen a major shift in focus. The

knowledge, by specialists, of what a family doctor does haslargely been lost. We believe this is caused by the loss ofthe rotating internship and time spent doing general prac-tice for a few years before completing specialty training. Asmedicine has evolved, more physicians are choosing sub-specialization, leading to fewer generalists. This has addedanother layer of complexity in the provision of continuouscomprehensive care for our patients because our patientsmay have to be sub-referred from one specialist to another

From Memorial University of Newfoundland, Mount Pearl, Newfoundland,Canada (Dr Hatcher); and VP Medical Services and Diagnostic Imaging,Eastern Health, Health Sciences Centre, St John’s, Newfoundland, Canada.

Corresponding author: Lydia Hatcher, MD, CCFP, FCFP, CHE, MemorialUniversity of Newfoundland, 48 Commonwealth Avenue, Mount Pearl, NLA1N 5B6

(e-mail: lhatcher@mun.ca).Healthcare Management Forum 2011 24:188–1910840-4704/$ - see front matter© 2011 Canadian College of Health Leaders. Published by Elsevier Inc. Allrights reserved.

doi:10.1016/j.hcmf.2011.08.004

for definitive management. Over the last decade, the gapin communication between specialists and family doctors2

and the gap of information between Regional Health Au-thorities (RHAs) and family doctors have widened. This hasleft community physicians frustrated and angry with aperceived lack of concern by the RHAs for their patients’care and treatment.For many years, efforts to engage community-based phy-

sicians with RHAs have failed. There are myriad reasons forthis including the lack of interest on the part of communityphysicians, the lack of resources both personnel and financialfor both physicians and RHAs, a stronger focus on institu-tional care by RHAs, the lack of relevant organizational struc-ture for both parties, the need to communicate not beingperceived as necessary by RHAs, frequent RHA restructuringpreventing stable committee structure and function, and thelack of funding models for such initiatives.

RATIONALE

In the last few years, family doctors, especially those in moreurban areas, have become more vocal about the deteriora-tion of patient care. The lack of involvement by family doctorsin RHA policy making and the negative effect it is having ontimely patient care have been recognized both provinciallyand nationally.3 Rising concerns about wait times for patientsto have specialized testing done and access to specialist carehave been major concern for family doctors. Some of theseissues have been discussed at length nationally. A number ofarticles have been written to address ways of improvingcommunication and wait times.4–6 With no real access for thefamily physician to bring these concerns forward, provincialmedical associations are being asked to help find ways toassist.

GETTING STARTED

In the spring of 2008, the Medical Director of the local RHA,Eastern Health (EH), met with senior staff of the Newfound-

land and Labrador Medical Association (NLMA) to discuss the

BRIDGING THE GAP BETWEEN FAMILY DOCTORS AND REGIONAL HEALTH AUTHORITIES

issue of the lack of engagement of family physicians. A deci-sion was reached to try and establish a community physicianadvisory committee for the greater St John’s area of EH. EH isthe largest integrated health authority in Newfoundland andLabrador, serving a regional population of more than 290,000and offering the full continuum of health and communityservices, including public health, long-term care, communityservices, hospital care, and unique provincial programs andservices. It also encompassed the provincial tertiary careteaching hospital. Many staff physicians are also full-timeacademic physicians with the Memorial University of New-foundland.The greater St John’s area includes a number of smaller

surrounding communities and includes more than half of thetotal population served by EH. It compromises approximatelyhalf of the family doctors in the province and more than halfof the specialists and specialty services and most tertiary careservices.Discussions ensued with a group of interested community-

based physicians selected by the NLMA. A number of ideaswere discussed, and an agreement to formalize a committeewas made. Some of these ideas included the following: (1)regular involvement in local hospital policy making, (2) sittingon relevant standing and ad-hoc committees, (3) having inputinto relevant clinical forms (laboratory and diagnostic imag-ing in particular), (4) getting timely information about theirhospitalized patients (new admissions and timely dischargesummaries in particular), (5) getting information about theirpatients seen in the emergency department, (6) getting cop-ies of tests ordered by other physicians when a patient hasidentified the family doctor as within the circle of care, (7) aneed for better liaison with specialist colleagues, (8) a needfor better information technology access with the local hos-pitals, (9) a need for better information technology tools inthe region, and (10) remunerating community physicians todo committee work during their regular business hours. Un-fortunately, no one had been identified to lead the process ofmoving forward. Neither organization had identified it as apriority. No further meetings occurred, and it appeared theprocess was stalled.During this time, a set of provincial medical staff bylaws

was being developed, and one of the physicians whoattended the 2008 meeting brought forward the conceptof formalizing a Community Medical Advisory Committee(CMAC) enshrined in the bylaws. This physician organizeda number of meetings with senior management of EH tochampion the idea. The concept was approved by theadministration of EH, and the committee was approvedand made part of the new RHA bylaws.

FORMATION OF THE CMAC

A meeting of the physician champion, who had agreed to

be Acting Chair, and the Vice President of Medical Services

Healthcare Management Forum ● Forum Gestion des soins de s

EH took place, and a draft terms of reference was drawnup. It was decided to have 10 regional members represent-ing the city of St John’s and the surrounding communitiesas well as an academic family physician and a communityMedical Officer of Health. An effort was made to have a sexand age balance. There was recognition of the importanceof post-graduate student involvement, and a family prac-tice resident was chosen by their program director to sit onthe committee. The medical officer of health for EH wasinvited to sit on the committee because public health wasbelieved to be an important part of the community phy-sician group. From the EH administration, the Vice Presi-dent of Medical Services and Diagnostics (ex-officio), theDirector of Medical Services (ex-officio), and, when avail-able, the President and Chief Executive Officer (CEO) of EH(ex-officio).The notification about the CMAC was sent out to all

eligible physicians through the NLMA web site andthrough a letter from EH. A request for physicians inter-ested in sitting on the committee was included. There waslittle response. This lack of engagement may have been alack of interest, a lack of knowledge about the intent,physicians being too busy, or simply apathy. In retrospect,it was likely a combination of these factors.The Acting Chair then called community physicians us-

ing the database from the College of Physicians and Sur-geons of Newfoundland and Labrador. This database waschosen because it is updated monthly, includes both cer-tified and non-certified family doctors, and can be easilybroken down into specific regions. Other provincial data-bases for family doctors are not as complete. From this, theCMAC was officially struck. This was a relatively simple taskbecause there were less than 300 family physicians toconsider and the chair knew many of them.It was originally decided to have four face-to-face meet-

ings per year and other meetings by teleconference or atthe call of the Chair as necessary. The 2-hour meetings areheld on a weekday evening at a central site of EH. Thus far,the first hour is dedicated to a specific EH program. Thisincludes a formal presentation and subsequent discussionof how the program affects patients in the community andhow this aspect could be improved. It is anticipated thatone-third of the committee members will be replaced ev-ery 3 years. This will keep the committee fresh and allowcontinuity at the same time.

ROLE OF THE COMMITTEE

Establishment of the CMAC was proposed to provide anopportunity for primary care physicians within the com-munity to have a voice and a formal means of providinginput within EH. This would give them an opportunity tohave input into the development of policies and makerecommendations to the CEO and the Board of Trustees on

issues affecting direct patient care.

ante – Winter/Hiver 2011 189

Hatcher and Howell

It was also believed that the CMAC should have inputinto the assessment and formulation of policy optionsrelating to medical care services in the community. Thiswould encompass quality, safety, coordination of care,timeliness, and adequacy in the management of thehealthcare delivery system. It also advises on matters re-lated to community medical care and related issues asappropriate. It serves as a forum for the identification ofissues facing community-based physicians and to facilitateor recommend solutions. Its overarching aim is to improvepatient care.

FUNDING AND SUPPORT

This is provided by EH through the Vice President of Med-ical Services and Diagnostics’ Office. The Chair is the onlyposition for whom a small monthly honorarium is paid. TheVice Chair and committee members are volunteers. Secre-tarial support is provided by EH. There has been an effortto remunerate family physician committee members whosit on RHA committees that meet during regular clinichours, typically 9 to 5. This recognizes the lost incomeopportunity for these doctors.

ORGANIZATIONAL STRUCTURE

There are five Medical Advisory Committees (MACs) whoare formally recognized within EH’s structure.7 The otherfour of these are hospital-based MACs. They are action-oriented committees that provide regular reports to theCEO and to the Board of Trustees through a formal report-ing structure. All of these committees report via the Chairsto a regional MAC on a quarterly basis.

RESULTS

Despite the terms of reference suggesting four meetingsper year, the committee met monthly except for two of thesummer months. This was out of need because there wasrecognition of the huge learning curve both for the familyphysicians as well as the RHA’s program leaders. There isalso communication through e-mail for the approval ofcertain items and rapid response issues. This was used withexcellent results during the 2009 H1N1 epidemic.As a completely novel committee, we recognized the

need to meet with all programs of EH and hear theirconcerns and more importantly advise them of the family/community doctors’ concerns. This strategy has produceda number of significant results thus far including the fol-lowing:

1. Revamping of laboratory and diagnostic imagingforms to better meet family physician needs.

2. Positive relationships being developed with various

programs/specialists that now recognized the need

190 Healthcare Management For

to liaise with the CMAC before developing policythat affects community practice.

3. Community issues being recognized by specialtygroups and contacting the CMAC for input.

4. The development of central bookings for some spe-cialty groups and diagnostic imaging (although wehave not yet seen an improvement in wait times itis a first step toward this).

5. Family doctors sitting on a number of hospitalstanding committees, thus providing the commu-nity perspective for our patients. As part of this, weattempted to use family doctors not presently onthe CMAC to further broaden the involvement offamily doctors in the healthcare institutions.

6. Having a community voice to strengthen issues ofpatient care when dealing with government. Someissues have already come up from the departmentof health and community services that the CMAChas been asked to take forward.

7. Recognition that family physician’s need to be re-munerated to do committee work if it is duringclinic hours. Funding for attending standing com-mittees has been approved.

8. Awareness that family doctors often do not haveaccess or knowledge of both hospital stays and ERvisits until the patient presents for follow-up. Thishas been brought to the various programs, andmeans to accomplish better and faster delivery ofinformation are being developed.

9. Opportunities for RHA planning across the contin-uum of healthcare delivery. Our committee has pro-vided input for a number of initiatives that impactcommunity health.

10. The development of a physician portal to EH thatprovides physicians who have courtesy to activestaff privileges, access to call schedules, a physiciandirectory, policies, on-line forms, minutes of meet-ings, and other useful information. This portal wasbeta tested by the CMAC before going live.

CHALLENGES

Having a physician to champion this concept was impor-tant. Without a board of governors or the provincial gov-ernment identifying this committee as a priority, neithersenior management of RHAs nor the NLMA had time ormandate to organize it. Once a physician took on the task,the concept began to move forward.The most challenging issue initially was getting family doc-

tors to sit on the committee. The Acting Chair called a num-ber of physicians from across the region, including those whohad attended the meeting in 2008. Almost all the availablefamily physicians who were at that meeting agreed to sit onthe committee. About half of those called who had not been

previously involved agreed to serve. An effort was made to

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BRIDGING THE GAP BETWEEN FAMILY DOCTORS AND REGIONAL HEALTH AUTHORITIES

have physicians from all areas in the region represented aswell as an age and sex balance.As the committee began its work, there were some

common and recurrent problems including the following:

1. The slowness of change has been frustrating. It hasmade family doctors, who typically operate their ownbusiness, aware that although a small enterprise canadapt quickly, it is often not possible in a large or-ganization.

2. Getting universal agreement on change is difficultwhen trying to accommodate a number of hospitals,each with slightly different policies.

3. The lack of information technology (ie, Internet ac-cess to programs, lack of electronic records support,and so on) makes many good suggestions very dif-ficult to implement.

4. Having family doctors recognize responsibilities thatmay seem trivial in their own offices (ie, using mul-tiple patient identifiers on forms and writing clinicalinformation legibly) but are very important and nec-essary in a larger system.

5. Getting family doctors in the community to understandwhy they need to adapt to changing medical practicesthat they may feel do not directly affect their practices.

6. Making physicians of EH aware of the CMAC and itsrole. To this end, we have developed a physician portalon the EH web site and have implemented a briefquarterly newsletter to apprise physicians of our work.

7. The complexity of interlaced and competing demandsfor resources came up repeatedly. Examples would behiring more staff in contrast to equipment upgrades ormultiple programs each of which have competing bud-get requests. With limited budgets in healthcare, thesecompeting interests are a constant challenge.

EVALUATION

Since the implementation of the new organizationalstructure, the RHA agreed to develop a scorecard thatlooks at many parameters of patient care and safety. Itincludes wait times in the emergency room for diagnos-tics and certain specialist appointments. The length ofstay, infection rates, and other inpatient indicators arealso being measured. The scorecard items are beingmeasured and evaluated quarterly. At present, this in-formation is only being presented to the MACs andBoard of Directors of the RHA. In time, it is hoped thiswill be publicly available.With respect to our own committee, we have a written

evaluation process for each meeting. This looks at suchitems as the quality of information we receive, the timeli-ness of completing an agenda item, and the effectivenessof the chair. Thus far, the committee feels we are making

slow progress in certain areas, but overall the evaluation is

Healthcare Management Forum ● Forum Gestion des soins de s

strongly supportive of the role and function of the com-mittee and the positive impact it is having on our ability tocommunicate more effectively.We also have a formal written (on-line) process for an item

to get on the agenda. We require a short paragraph outliningthe issue, hoped outcome, rationale, and urgency. This en-sures items that are urgent do not get buried and ones thatare not relevant to our committee are identified and advisedof this. This tool has proved to be very useful.

CONCLUSION

The development of a CMAC has not only brought a voicefor family doctors to the RHA table but also has brought agreater awareness of some of the challenges family doctorsface in their offices every day. Likewise, the family doctorssitting on hospital committees have gained insight into theworkings of the RHA, which they in turn are communicat-ing to colleagues.By developing bilateral and timely communication, we

have begun to see small improvements in patient man-agement. The process of change has been slower thananticipated, and this has led to some frustration on thepart of CMAC members. We have developed an ongoingevaluation of our committee work, which is helping us tokeep focused and stay on track with our goal of improvedpatient care. Awareness of our committee by the generalphysician community has been problematic, and we areattempting to reach out in a variety of ways to improvethis. We still have a long way to go, but there is a light atthe end of the tunnel.

REFERENCES

1. Barer ML, Stoddart GL. Toward integrated medical resourcepolicies for Canada: Background document (HPRU 1991;91:06D). Vancouver: Centre for Health Services and Policy Re-search, University of British Columbia; 1991.

2. The College of Family Physicians of Canada, Canadian MedicalAssociation, Royal College of Physicians and Surgeons. Na-tional Physician Survey. Available at: http://www.nationalphysiciansurvey.ca/nps/2007_Survey/2007nps-e.asp. AccessedNovember 14, 2008.

3. . . .And Still Waiting: Exploring Primary Care Wait Times in Can-ada, the Primary Care Wait Time Partnership, The College ofFamily Physicians of Canada and the Canadian Medical Associ-ation; April 2008.

4. The Wait Starts Here. The Primary Care Wait. Time Partnership,The Canadian Medical Association and the College of FamilyPhysicians of Canada; Dec 2009.

5. Professionalism in medicine. Canadian Medical Association;2001.

6. When the clock starts ticking: Wait times in primary care(discussion paper). The College of Family Physicians of Canada.October 2006.

7. Eastern Health Bylaws Respecting Medical Staff. Adopted June

2009. St Johns, Newfoundland, Eastern Health.

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