Canadian Physician Growth Lagging Behind Demand, Other Western Nations

Note:  The following was initially published in the University of Toronto Medical Journal in Mid-March and is being reproduced here.  My thanks to the OMA staff for helping with the research.  As we enter the “surge” phase of the COVID-19 Pandemic, I pray that that our already short staffed physicians will come through this ok.

I have been a family physician for over a quarter century, and chose to practice in the small community of Stayner, Ontario. Working in a rural community has given me a closer connection to my patients, and a stronger understanding of the challenges in Ontario’s current health care model and how it could be improved. In the end, everything doctors do is in aid of better patient care and better patient outcomes.

What I’ve seen and experienced shows me that we need to change the landscape of medical care. It’s one of the reasons I became involved in medical politics. It’s something I continue to focus on as President of the Ontario Medical Association.

First and Foremost, We Need More Physicians in Canada

Our population is aging. Our patients are becoming more complex. The rate of growth of Canadian physicians to population needs to keep pace. How many more doctors do we need? Well, it really depends.

There is no straight-line comparison between these factors and the number of physicians required. I would suggest it also depends on the distribution and prevalence of specialties and sub-specialties, the age of physicians, their models of practice, and other resources (particularly allied health care professionals to assist physician led teams) available within the health care system. There are many nuances.

Although there is no magic target number to reach for, we need to look at making a significant investment into training and hiring physicians in Canada in order to fully meet the health care demands of our patients.

To those who say we cannot afford it, I pose an only somewhat rhetorical question: How much money does it cost right now to care for a high needs diabetic with COPD and heart disease who goes to the Emergency Room regularly because he or she doesn’t have a doctor?

Growth in physician ratios not keeping pace with need

When the Canadian Institute for Health Information (CIHI) reported that in 2018, Ontario had 2.34 physicians per 1,000 people – up from 2.26 in 2017 – this was heralded by some as a dramatic increase.1 Although I was very pleased to see growth in physician numbers – because I believe this is necessary to improve patient care – I would have been more bullish had I not noted four things that make this statistic somewhat less rosy.

  1. Ontario Ranks Seventh of Ten Provinces in Physician-Population Rates

Even with a 3.5% percent growth in physicians to population over 2017, Ontario still ranks seventh out of ten provinces. Ontario was ahead of only PEI (1.97), Saskatchewan (2.05) and Manitoba (2.25). Ontario is also below Canada’s rate overall of 2.41 physicians per 1,000 population.1

  1. Recent Growth is Making Up for Past Stagnation

The growth in Ontario’s physician-to-patient ratio is a relatively recent phenomenon.

A review of CIHI data for the period 2001 to 2018 shows that the number of Ontario physicians has grown an average annually of 1.6% more than the growth in the province’s population.

However, the rate of growth during the period 2001-2008 was essentially flat, with the ratio stuck at about 1.8 physicians per 1,000 people for eight years. Therefore, some of the recent increase in annual growth is actually catching up to meet demand from the past.

Additionally, whether or not the rate of growth of physicians meets or exceeds the population growth is not the whole story. It’s simply not enough to say that the population has grown by, say, one percent so we need one percent more doctors, as there are many other determinants of the need for physician services, such as aging and increasing clinical complexity and multimorbidity.

  1. Ontario Sees an Annual 3.6% Growth in Physician Services

Ontario experiences a 3.6% annual average growth in services provided to Ontario patients, representing the cumulative impact of population growth, aging, patient complexity, advances and availability of technology, and other factors.2

Recent analysis carried out by the Ontario Medical Association’s Economic, Policy and Research department demonstrates that prevalence of multiple chronic conditions in Ontario has grown from 2008 to 2017.

This has caused an increase in something called patient resource intensity. As of 2017, the number of patients with at least one out of a baseline list of 84 chronic conditions was estimated to be 9.8 million, an increase of 11.0% from 2008. Multimorbidity also rose. The number of patients with two or more chronic conditions increased by 12.2%, while those with three or more increased by 13.5%.

This means that Ontario patients are becoming more complex, and thus require more time, resources and physician manpower to look after. Given that the majority of health spending can be attributed to multimorbidity, these findings have major implications for population health management and health care spending.

Although this analysis is based on Ontario patients, it is hard to imagine that the same demand does not exist, in whole or in part, in other jurisdictions across the country.

Advances in technology to both diagnose and treat have also increased the ability of physicians to provide care to their patients, which puts further demand on physician resources.

All of this illustrates that patient demand for services is growing significantly, and we need more doctors each year to meet it. The ones we have will have to work ever harder. According to the Canadian Medical Association, doctors already work an average of 52 hours a week, and in many cases work more hours being “on-call” on top of that. It is not sustainable or even tenable to ask doctors to work more.

  1. Canadian Physician Rates Are Low Compared with Other Western Countries

In contrast with other comparable countries, Canada’s physician-to-population ratio is low. While there are many factors determining the optimal number of physicians, it is hard to argue that Canada has too many physicians relative to its peers.

1 for article2 for article

What does this all mean? The reality is that Canada often gets lambasted for poor health care metrics in the press (e.g. wait times). However, it is clearly impossible to meet some of the noble goals when there simply aren’t enough physicians to do the work. We can invest in programs like public health, telemedicine, pharmacare and so on. These are all good and noble causes that have been clearly shown to benefit populations of patients. But until we recognize that our main problem is a shortage of physicians and that the growth needs to accelerate even more, our overall health metrics will not achieve those of the countries we aspire to.

COVID-19: The New Normal

This article first appeared in healthing.ca, and is reproduced here for those of you who don’t go to that website.

I was on call this past weekend for my Hospital (Collingwood General and Marine).  It’s considered a “Level I” hospital which (in my opinion) expertly provides care for common health conditions to the 75,000 residents in its catchment area.

Driving to Collingwood on Saturday (I live just outside of town) was, well, jarring.  You see, it was the second Saturday of March Break.  We are near Blue Mountain, Ontario’s largest ski hill.  This is supposed to be our busy season.  My patients rely on tourism to make the local economy go. But Blue Mountain is closed because ofCOVID-19. Other businesses were closed as well. And the town was eerily empty.

Empty Town

As I drive by the hospital, I see “the tent.”  That’s the place where all people who enter the hospital must go first to be screened for potential COVID-19.  The disease is now in what’s known as the “community spread” phase.  People who haven’t travelled may have got it and are giving it to others.  Essentially, anyone who has signs and symptoms of a cold or the flu, is presumed to have COVID-19.

Covid Tent

As I walk into the tent to get screened, I marvel at the courage and integrity of not just the doctors and nurses who work there, but at the volunteers staffing the station.  These volunteers must all wear Personal Protective Equipment, and they are constantly wiping down the surfaces.  They still volunteer, even though they are potentially exposing themselves to a serious illness – even after it was announced that our hospital had a patient with COVID-19.  I am truly inspired by their profound commitment to the community that they serve.

As I contemplate all of this, I realize I’ve gone the wrong way. I’m currently averaging over 125 new emails a day, the majority of which deal with COVID-19 and I’ve somehow missed the one that informs me that staff need to go through a separate, dedicated entrance.  The email said I have to show my badge.  (It’s a small hospital, we all know each other, and I don’t think I’ve shown my badge to anyone in 25 years).

A quick walk around the back to the screening site.  It’s necessary.  It’s important.  I agree with it being done.  But it’s still weird to be screened at a place you’ve worked at for so long.

Screening Door

I walk by housekeeping and wave hello to some of the unsung heroes – the cleaners -who were having a meeting.  Once a patient with any transmissible disease (whether COVID-19, or MRSA, or C.difficile or other) is discharged from hospital,  it falls to the cleaners to follow rigorous and thorough cleaning protocols, to ensure that the next person in that room doesn’t get the disease.  Truly unsung heroes they are, who never get the credit they deserve.  While, – all I can offer them is a public thank you, I hope they know it’s heartfelt.

My call group has 12 inpatients this weekend.  It’s less than usual.  The nurses, as always, know the patients really well and fill me in on concerns they have.  It’s the usual mix of medical and surgical conditions.  My initial thought is to grumble once again about the fact that talking to patients takes less time than documenting on our click happy Electronic Medical Records system.  But I realized that the fact that this one thing hasn’t changed actually provided me with a sense of normalcy, for which I’m grateful.

I can sense that the staff are concerned about the circumstances. Yet despite this all of the nurses, ward clerks, cleaners, doctors and many others, are doing their jobs at peak efficiency.  Kindness and consideration for patients is evident in all of them.

Next stop, a shift at the after-hours clinic.  The clinic has changed drastically in the past week.

Front Door Walk inEntry to Walk In

A volunteer meets patients at the front of the building and explains that they have to call a number and wait in the car.  When it’s their turn, I call them, and see if I can handle the problem over the phone.  If they have symptoms of a cold or the flu, they are not allowed in the building as we don’t have a protected room or personal protective equipment.  Patients with mild symptoms are given advice to get better at home.  Those with more serious symptoms are sent to the COVID-19 tent at the hospital.  The family doctors in our area have a good working relationship with the hospital, and we are able to work together and co-ordinate care in times like this.  I wish every part of Ontario had this.

I’m able to treat about 70% of the patients this weekend by telephone.  It’s not ideal, but it improves Social Distancing, which is now an urgent requirement to help flatten the curve and slow the spread of COVID-19.

The next day, is essentially lather (for twenty seconds people!), rinse and repeat.

So, what thoughts do I have about the new normal?

It strikes me that this is going to be life for the next several weeks at a minimum.

I’m worried about many people on marginal incomes, who will be feeling economic pain in the coming weeks.

I’m worried that Social Distancing, which is really physical distancing, will lead to social isolation for many members of the community, and we will see an increase in mental illness over the next few months.

I’m on edge, hoping that we don’t see the same disaster as Italy is going through, and I know my colleagues are as well.

Yet with all that, I also see a lot of hope.  From across our community, volunteers are staffing the registration desks at the hospital and the after-hours clinic to help out.  The nurses and doctors continue to maintain an incredible degree of professionalism and kindness towards the patients, even though their lives could be at risk.  Physicians are donating unused swabs to the hospital so they can screen more people. I’ve had numerous offers from physicians to volunteer in the assessment centres.

I don’t know how long this situation will last.  I don’t know what history will say about us.  But what I will always remember is that despite the fear, anxiety, and stress, it was the kindness, generosity and courage of the people that shone through.

Conscience Rights Matter

As my loyal readers (both of them) know, I happen to be a Trekkie.  Permit me to digress a bit, and reflect on one of Captain Jean Luc Picard’s best speeches (Nerd Alert: from the Next Generation episode “The Drumhead”):

“With the first link, the chain is formed.  The first speech censured, the first thought forbidden, the first freedom denied, chains us all irrevocably.” 

 Picard goes on to point out that these words served as wisdom and warning that the first time anyone’s freedoms are trodden upon, we are all damaged.

 I think of his speech a lot with debate on Conscience Rights for health care workers being played out in the public.  In particular, I think of the decision by the divisional court of Ontario, and then the Ontario Court of Appeal to deny physicians conscience rights.  The courts claimed they struck a “reasonable balance”.  But they also went on to expressly state in their ruling that the “referral requirement does infringe on doctors’ religious freedoms.”  Make no mistake about this, rights and freedoms of certain individuals are being violated by this ruling.

 In the 1980s, the hot button issue driving the desire for Conscience Rights was Abortion. In 2020, the main issue is Medical Assistance in Dying (MAID).  Many physicians’ groups have expressed concern about being forced to make a referral for this service, in violation of their morals and ethics.  This concern has been expressed not just by physicians of faith, but by secular groups like the Canadian Society of Palliative Care Physicians.

 Let me be clear about this: Neither myself, nor the Ontario Medical Association will support any physician who actively impedes or prevents a patient from accessing any legal medical service (including MAID).  Period.  Full Stop.  This includes statements like “If you want MAID, I will no longer be your doctor.”  That’s just not on.

 However, for physicians who feel that actively referring a patient for such a service violates their principles, surely there can be a work around.  Turns out, that’s exactly the case in Ontario.  If a patient wants MAID, they simply have to contact the MAID co-ordination service and the service will ensure the patient gets the appropriate assessments.  Surely handing a patient the contact information (which is not a referral) and leaving it up to the patient to contact the service (which is the patient’s right) is sufficient.  Physicians’ conscience rights are protected, and no patient is denied access to a service they want.

 Some argue that there will be cases where this is insufficient for various reasons.  I disagree.  In order to access MAID, you have to be mentally competent.  If you’re not competent enough to dial a phone number and ask for this service, you’re not going to qualify anyway.  Forcing a physician to do a referral (which involves putting your signature indicating you support the request on a form, setting up the appointment, informing the patient of said appointment and more) in violation of their conscience, isn’t going to alter in any way whether the patient is an appropriate candidate for MAID.

 For me however, there is a bigger picture that many people may be missing.  We live in an era where technological advances are rapidly occurring.  These advances are not just related to computers, and possible interfaces with humans – think ports at the back of your skull to download information directly into your brain – and no, that’s not just science fiction, Elon Musk (yikes!) and Facebook (double yikes!!) are exploring this today.  However, the more stunning advances, and I believe the ones with the greatest potential for ethical dilemmas, are the ones in genetics.

 Look what’s already happening thanks to gene editing by CRISPR.  A scientist in China has edited babies genes. Designer babies (hair, eye colour on order, muscle and IQ per your specifications) are so within the realm of possibility that the ethics are already being debated.  Rapidly progressing work is being done to identify the genes (it’s not just one gene, but likely a cluster of several) that link to autism, Asperger’s and, yes even sexual orientation.

 To those physicians who are opposed to legal protection for Conscience Rights, let me ask you this.  What would you do if a patient asked you for a referral to have only a blue eyed, blonde haired baby? 

 Becomes a moral quagmire doesn’t it?

 Another Star Trek Captain, James T. Kirk, once said (Nerd Alert:  The Original Series Episode: “A Private Little War”):

 “There came a time when our knowledge grew faster than our wisdom, and we almost destroyed ourselves.”

 This is why Conscience Rights protection is so essential in society.  With the explosion of knowledge that is going to continue over the next few decades, it is essential that we handle these advances in fair, ethical, and yes, moral manner.  In order to do that, we must allow health care workers the same freedoms as everyone else in society on matters of conscience. 

 The first link in the chain has been formed.  It’s time to break that link with legislation that protects everyone’s fundamental freedoms.

Medical Students Have the Power to Inspire

The article below initially appeared in Scrub-In, a magazine for medical students published by the Ontario Medical Association.  It’s being reproduced here.  Pictured above are the three medical students I had an impromptu meeting with, from Left to Right, Zak Haj-Ahmad, Harris Sheik and Nader Chaya.

Life is funny sometimes.  I was wondering what to write for Scrub-in.  So, I did what most people my age do when in a funk – I went to eat carbs (in this case Pizza).  As it happened, I had a chance encounter with three medical students from the University of Toronto.

Like most medical students, they wondered what to specialize in, whether there will be work in their chosen field, how government regulations and changing scopes of practice will affect them, and more.  But despite that, what was plainly obvious was the passion, enthusiasm and pure joy they exhibited at simply being in Medical School, and the gratitude at being chosen to join our noble profession.  I was inspired by them, as I remembered the wonder I felt when I first got accepted into medical school.

I also asked them what they thought medical students would like to hear about.  I was relieved that it was similar to what I was thinking.  Medical school has many ups and it has many downs.  It can bring joy tremendous joy and pride.  It can bring you tremendous sorrow, and sometimes pain.  But here is what helped me, and I think will help you.

  • Try to stay on an even keel. I realize that many of you are watching your grades fall seemingly like guano from stalagmites or seeing incredible triumphs  like your first successful procedure. But remember – things are never as bad as they seem.

 

  • Don’t forget self care. Not only does self care mean the usual – eat right, exercise, take time for yourself., It also means don’t neglect your friends and your family.  They can support you through the tough times.  Self care also means taking care of things like planning for the future. It may seem premature to get insurance and start saving for retirement (especially when you have $200,000 in debt) but small investments in those now can pay off significantly in the future, and give you more peace of mind than your realize.  Visit our Advantages Retirement Plan™ website or contact an OMA Insurance Advisor at retire@omainsurance.com to get started.

 

  • Remember that everyone has a role to play here (my thanks to future doctor Zak Haj-Ahmad for helping me crystalize my thoughts on this one). Look, when you graduate, the simple fact that you get to use “Dr.” before your name will afford you a tremendous amount of respect and privilege in the eyes of the general public.  But with that respect comes a responsibility that you have to ensure that you treat your patients (and others) with kindness, humility and basic human dignity. Everyone has a role to play in a health care team (student, teacher, nurse, janitor etc). Make sure you exhibit the kindness and empathy you expect from doctors to others at all times, particularly when things are stressful.  It will reflect well on you, on our profession, and I find it will help you become a better person.

I want to wish all of my future colleagues the best of luck as you pursue life in our great profession.  Follow me on twitter @drmsgandhi.

If you want to know more about the OMA and how we can help you, please visit our website or contact Jenny Cheadle at Jenny.Cheadle@oma.org

 

Not Too Late to GET YOUR FLU SHOT!

The following blog was published on the OMA website, but is being reproduced here for those of you who don’t access that site.

We are now approaching the height of flu season. While this usually extends well into March, this year, experts are concerned we may have a longer one (like Australia did). If you haven’t already gotten your flu shot, do it now. It’s not too late.

When you get the flu shot, you’re not just protecting yourself. You’re protecting your family, friends, colleagues and strangers around you as well. This is very important, as the flu can make the young, the old and those with health complications very sick.  There have already been some sad stories of young healthy people either dying or suffering permanent injury due to the flu this year.

The flu is not the same as a cold. It is an illness that kills an estimated 3,500 Canadians and hospitalizes 12,000 Canadians every year. There are different strains of the flu. Influenza A, which usually affects older adults, and Influenza B, which typically targets children. Usually, one strain wanes as the other peaks. However, both flu strains are present at the same time this season.iu

Despite the very real risks of getting the flu, only 42 per cent of Canadian adults reported getting a flu shot last year. This is in part due to vaccine hesitancy, based on misinformation. I have written before about vaccine hesitancy, which is a growing phenomenon that the World Health Organization listed as one of the top threats to global health care in 2019. I can confidently speak for all of Ontario’s 31,500 practicing doctors when I say that some of the points I have previously made are worth emphasizing again.

The flu vaccine is safe. The vaccine occasionally has some mild side effects, such as headache, fever or muscle aches, but these are minor and will quickly go away.

Vaccines do not give you the disease they protect against. The flu shot will NOT give you the flu. However, it will reduce the risks of getting the flu or flu-related complications. The flu shot doesn’t give 100 per cent immunity, but it can reduce your symptoms if you become ill.

Finally, the flu shot reduces the chances of spreading illness to others. In a perfect world, everyone would get the flu vaccine. However, there are a few people (a very very small minority of people) who legitimately shouldn’t get the flu shot (for example, infants under six months of age).  But if the rest of us get the shot, we are also protecting those who are not able to get the shot or are particularly vulnerable to the effects of the flu. This is called herd immunity.  Essentially it means the flu can’t get a hold on the population because everyone else is immune.

It is crucial to our health and that of our families and our communities that we resist the vaccine hesitancy trend.

I urge everyone to listen to their doctors, and not some of the so called experts that permeate the internet.  There is no substitute for the medical advice given by your doctor.

The OMA has launched a multi-channel social media and advocacy campaign to target the spread of anti-vaccine myths. It specifically deals with the importance of flu shots.

For more information about the campaign, visit askontariodoctors.ca/flufacts

Governance Transformation Essential for the OMA

 

Note: The following guest blog was was written by Dr. Paul Hacker and Dr. Lisa Salamon (pictured above).  While the opinions are theirs, I happen to share those opinions as well.

We, the co-chairs of the Ontario Medical Association’s Governance Transformation 2020 Task Force (GT20), welcome discussion and debate about the recommendations for change in our report, Better Together. These recommendations were made in response to the broad input from council delegates, members, board directors, senior OMA leadership and external stakeholders.

Recent reports about these recommendations have, unfortunately, included inaccurate statements leading to erroneous conclusions. The report, including a summaryand FAQ document, is available in the links or on the OMA website (here).

We would like to highlight for OMA members, the changes that we hope to see in 2021 if these recommendations are endorsed at the council meeting this week and receive final approval at Spring council in May 2020.

Members will directly ratify all negotiated Physician Services Agreements (PSAs)

Currently, council has the authority to ratify any negotiated PSA. In the future, this responsibility will rest with you, the member. Contrary to other reports, if these changes are passed, the OMA would introduce a new bylaw requiring member ratification that could not be overruled or ignored by the board of directors.

Fully informed members will directly vote for their president-elect and directors. Currently, members elect a small proportion of directors to the board, based on where you practice; other members and council elect the rest. In the future, members will vote for all directors, informed by a standardized profile generated by an independent third party.

Members are likely aware of their current role regarding the election of the president-elect: participation in a non-binding member poll while council makes the final selection. In the future, you will vote directly to choose your president-elect.

A collaborative general assembly will replace council

Council, governed by outdated parliamentary rules which promote factional disputes, will be replaced by a general assembly that still represents members through section, district and forum delegates, but seeks to work collaboratively to identify the priorities most important to members.

Members will be given new and enhanced opportunities to contribute to time-limited working groups. This ensures that the work of these groups is relevant to you and other members and uses the expertise found within the membership to help guide the OMA.

The OMA will become more nimble, able to respond to emerging issues effectively:

A streamlined governance structure will result in a more agile organization. Members should notice that communications are clearer, the OMA acts more decisively and that it advances solutions that make sense to members.

Both of us became involved with the OMA in 2016/17 because of frustration with the results we, as members, were seeing. As we got more involved, it became clear that the underperformance of the OMA was not due to a lack of effort. The OMA had stagnated under a governance structure that had grown out of date and was no longer responsive to its members. And in 2019, members told us nothing had changed.

We believe that it’s time for an upgrade. We invite and welcome all members to join us in this change.

Dr. Paul Hacker and Dr. Lisa Salamon are the co-chairs of the GT20 Task Force.

PATIENT SAFETY AND CONTINUITY OF CARE MUST COME FIRST

On October 22, an article by Shawn Jeffords, reprinted in HuffPost online, talked about the government’s call for feedback on letting nurses prescribe certain medications.

This is a critical issue and one in which I and the Ontario Medical Association (OMA) Board are actively involved.  For us, patient safety and continuity of care must come first. The ultimate goal of any scope of practice change should be to improve and enhance high quality patient care, not just to provide convenience.

In the summer and fall of 2018, the OMA shared our concerns directly with the College of Nurses.  We are now completing our submission to the Ontario government.

In short, we welcome and appreciate the value all health care providers bring to patients and the broader healthcare system. I personally have been strongly supportive of nurses in the past as there is simply no way I could look after patients without their help.  Both I and the OMA encourage collaborative, team-based, patient-centred delivery of health care. To that end, the OMA evaluates any changes in scope based on the OMA’s Set of Principles outlined below.

The ability to seamlessly share information is equally critical to the continuity of care for patients. Ideally this information would be shared through electronic health records, so this should be a consideration when looking at any changes to prescribing authority. A complete medical history, including all diagnoses and treatment information, is essential for any practitioner to effectively treat a patient.

OMA Set of Principles

OMA’s highly rigorous process for evaluating scope of practice changes involves using the following key principles. Scope changes should:

  • Be consistent with the knowledge, skill and judgment of the professionals involved
  • Be subject to a rigorous regulatory structure
  • Support a truly collaborative, team-based approach to care as opposed to parallel care
  • Not raise patient safety concerns
  • Be accompanied by system initiatives/supports to ensure that no health care provider is unreasonably burdened with complications arising from expanded scopes of practice from other professions
  • Be subject to stringent conflict of interest provisions
  • Be applied with consideration of current best practices and lessons learned from other jurisdictions
  • Be applied with consideration to cost effectiveness at a health system level
  • Promote inter-professional communication and information sharing
  • Promotes continuity of care
  • Promote positive relationship with patient
  • Should be subject to system evaluation to determine if leading to positive outcome.

To some, the above principles may seem overly onerous.  Others may view this as “turf protection”.  But the reality is that multiple studies have shown that the best care provided to patients is when continuity of care is maintained.  This does not mean that you must get a treatment from your family doctor, it means that your family doctor must be aware of what treatment has been given, so that it can be part of your medical record to inform future decisions made about your care.

Also, to be clear, there are many instances where the changes in scope of practice have been beneficial.  My own ophthalmologist has a collaborative relationship with three optometrists that provides continuity of care, and ensures patients get care in a timely manner.  These type of unique models (not just in ophthalmology) occur throughout Ontario, and must be supported.

The priority of every doctor in Ontario is the health and well-being of their patients. We care for more than 340,000 patients every day.  There is simply no substitute for a doctor.  In order to ensure our patients get the best care, it is important that policy decisions always focus on appropriate high quality health care.  It is this way that we can help to fix the health care system and solve critical issues like hallway medicine.