Small Changes Big Impact
Small Changes Big Impact
Supporting family physicians with Dr. Arun Radhakrishnan
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Today's episode focuses on the importance of support to improve our health care system. In studio, we have Arun Radhakrishnan, a family physician with a focused practice in chronic pain. He's the clinical lead for the Collaborative Mentoring Network at the OCFP and an adjunct professor at Women's College Hospital associated with the University of Toronto.
Small Changes, Big Impact: a DFCM podcast. I'm your host, Dr. Jeremy Rezmovitz. Today's episode focuses on the importance of support to improve our health care system. In studio, we have Arun Radhakrishnan, a family physician with a focused practice in chronic pain. He's the clinical lead for the Collaborative Mentoring Network at the OCFP and an adjunct professor at Women's College Hospital associated with the University of Toronto. Hope you enjoy the show. Thanks for coming.
Dr. Arun R.Well thanks for having me.
Dr. RezmovitzNo problem. Um, so why did you come on the show? What did you -
Dr. Arun R.Well I think I came on the show cause I think it was just an opportunity to talk with you and talk with sort of a talk with the group, the audience, get a better , uh, give , uh , have a better opportunity to talk about the mentorship programs.
Dr. RezmovitzOkay.
Dr. Arun R.Yeah, I think that was really our reason to come on.
Dr. RezmovitzI hope so. Um, I'm interested to hear about it. What I'm really interested to hear about is what small change you made that had impact.
Dr. Arun R.Okay.
Dr. RezmovitzAnd it can be anything. I mean, Oh , by the way, if you decide to scrap the OCFP , um, you know, mentoring network and you want to talk about, you know, something you did. Yeah. Other than that we can do that. But yeah.
Dr. Arun R.Well I think, you know, I think in the context of that I can talk about a small change that I felt that , uh, did have an impact. The mentorship networks have been operating for since 2001 so they've had a long history of a very organic ground up , uh, process of building. Um, but one of the things they didn't necessarily have was a process of , uh , measurement and evaluation , uh , understanding what kind of impact they were having on their mentees, what kind of impact they're having on the larger or the mentors and the larger community at hand. Um, and so what the small change I felt that I was able to bring by joining the leadership group there was to bring a focus on how do we measure this, how do we, what are the different instruments we can use to learn about the impact. This is having , uh , on our mentors and mentees and sort of make it not just a simple programmatic evaluation, but a bit of an exploration , uh , on how this is affecting the physicians that are , are, are, are participating in the program.
Dr. RezmovitzLike a qualitative approach.
Dr. Arun R.It was a mixed qualitative, quantitative -
Dr. RezmovitzOh, you're speaking my language, mixed methods, great big data with a qualitative, explorative approach for educational purposes. Amazing.
Dr. Arun R.And it was, it was , I have to say is quite revolutionary cause we went into this with a lot of assumptions. You know , that were - this is an effort and an engagement around knowledge translation. How do we help , uh, physicians , uh, learn better, know more about mental health, how can they manage patients more effectively in that area? How can they see more patients? Same thing with chronic pain and substance use disorders. Um , and so we thought it was just an information piece that was being the source of that or the core function of that program. But what we learned really as we went in is that there's a lot more to it. There's a community, there's a support component. Uh , there's an element around creating safe spaces for our physicians. There's an element around creating compassionate spaces for our physicians. And that sort of comes back to some of that work that I've been doing with the AMS fellowship around compassion and how these compassionate spaces have in turn improved the resiliency of our physicians, but in turn improve their capacity to be able to provide care that's compassionate to their patients.
Dr. RezmovitzYeah. Tell me about that. So how would you define compassion?
Dr. Arun R.Yeah, there's a lot of, there's a lot of different , uh , definitions that are out there around what is compassion. Um , but I think many people will say there's an innate sense around an individual. There's a want and a need to try to help and improve the life or the outcome or some particular outcome for a given other individual. Um, now of course there's a lot of debate on those pieces and all of those sub piece, a sub constructs that may come on there. Uh, but I think that's the core of it, right? You have an innate interest in wanting to try and help another individual in whatever that'll come in as you're looking at, or what if it is an element around suffering? How do I help alleviate that suffering?
Dr. RezmovitzAmazing. So I have this theory , um , and I speak to patients all day about this and we talk about surviving versus thriving, right. And I find it really difficult how we expect people who are surviving to take care of other people. And there are so many doctors out there who are just surviving and they don't talk about it because of the stigma and the socialization and the culture that we've created in that it's not right to talk about how you are just surviving. You're suffering. And so how do you get around that? And, and so my two questions are, one, how do you get around that stigma? And two how do you get them from surviving to thriving? Because in order to demonstrate compassion for others, I firmly believe you need to first also have compassion for yourself.
Dr. Arun R.Absolutely. Yeah. Uh, you're, you're, you're asking such a great question, right? And this is part of that bet fourth arm, the quadruple aim that we've been, that we're all starting to talk more and more about. Right? How do we support that, a healthy human resource to be more , uh, resilient? Uh , so what you're talking about as a culture change, it's a venture and in changing cultures and it's not something that's gonna change overnight, it's gonna take a lot of work. I think if any of the attempts to change culture, we've seen what a challenge that can be. So I can talk more specifically to the work that we've done. And I think if you ask from that place, I think there's a couple of things that are really critical. Uh, the first is community. You need to be a part of a community. You need to feel engaged in a community, right? So isolation, it's hard to overcome. It's hard to go from surviving to thriving in isolation. And when you're part of a community, I think that helps to foster that. Right? So that's number one. And number two, I think it just can't be any community. It has to be a community that is really looking to create a safe space and to model the kind of behavior that we want to see there. And so I think that's some of the pieces that we've worked on, which is really how do we create that community, that models safe spaces, safe conversations, bring what you need, put it on the table, identify your stresses and your worries. And , uh, we, I think we see that in the conversations that many of our mentees bring to us. It isn't just about, Oh, what do I do with this medication? Or what do I do here? But oftentimes it's that 'I feel like I'm at the end of my rope. I don't know what to do. I don't know where to go, what other resource I have.' And that ability to express that emotion and share it with one mentor or your group, I think it proves to be quite invaluable. And we've seen that in the qualitative work that we've been undertaking.
Dr. RezmovitzSo how do you get people to commit? Um, cause I think it would be quite scary to tell somebody who you've never met before 'Oh, by the way, this is your mentor and now I want you to tell them all your deepest dark secrets.' And, and, and, and reveal, you know, be vulnerable. Right? And so I'm curious how you create the actual application for anybody who's listening, who , um, who wants to be able to create this community, the sense of community who wants to be able to create the safe space and we'll touch on safe space and yeah , we'll talk after. But I'm just curious, how do you get, cause there's an inertia that you need to overcome, right? So how do you do that?
Dr. Arun R.You know, and that inertia I think in part is that I think that our colleagues are just so overwhelmed. There's so much going on, right? How do you process all of that and where do you go? So I think the way we've approached this is trying to ah , come to where clinicians are, reach out to them in the areas that they are already saying we have struggles. Right? So maybe that's in clinical areas. So you know , what we've seen in some of the work that we've done in some of the surveys is identifying what are the clinical challenges that many people are facing. And a lot of that focus is around mental health, substance use disorders, chronic pain and palliative and end of life care discussions. These are some of the real clinical challenges that clinicians are facing or families docs are facing. And so we reach out to them in those venues. So you've got a clinical challenge. This is causing you difficulties. How do we reach out? How can we connect on that and build that relationship from there? But then some - for others, it's not about the clinical challenge, it's about practice challenges, right? How do I start a practice or how do I get a locum or how do I thrive in a rural community, right? And for them, we can , we have networks that are more focused on that engagement around the practice challenges that they face. So meet them, meet the physicians where they are, what are the problems they're facing that immediately present in their life. So help them in those pieces, bring them into the community, and then allow them to experience some grow within that space.
Dr. RezmovitzOkay. So how's it working?
Dr. Arun R.Well, you know, so these networks have been operational. Again, going back, the collaborative mental health network, which the original one was launched in 2001. Um, so that's been operational now for 18 years. And the , uh, the medical mentoring predictions and pain launched in 2007 and we launched the other five networks , uh , which have been , uh , palliative end of life care, medical assistance in dying, early years in practice, rural medicine, and leadership and primary care . Uh , those have been for two years. So where we are, so we're right now , uh, at a point where we've got almost about a hundred, 120, 130 mentors. We've got about 1200 mentees in the program. Um, so we're, we've been growing , uh , quite substantially , uh, over the last few years. We've , uh , you know, we've had , um, funding that's confident, Ministry of Health in recognition of the work that's been done and recognizing that this is an important programs that can help improve primary care capacity, quality of care that's being delivered, as well as meeting that quadruple aim. So we've been able to receive funding from that end. Uh , when we do evaluations that we hear from our, our membership, their satisfaction with the program, but also, you know, the , the impact in terms of the care that they're delivering for their patients. Uh, their feelings of increased confidence and feelings and sense of security around the types of challenges that they're facing and they feel more able to meet those challenges. Uh , so we're hearing a lot of positive stories from our members as well. And just in the last year, we were - based on all the work that we've done in the evaluations, we were fortunate enough to , uh , be nominated and win , uh , an international award, the Ted Freedman Award for Educational Innovation. Um, so that was a great honor. So things have been going quite well in terms of trying to build these programs, expand them. Uh , and really what our goal here is to try and bring as many family physicians as we can into the fold , uh, to experience this and to build these communities.
Dr. RezmovitzAnd so maybe you, you've touched on this or maybe I'm just unclear, but what was the impetus for this change? Like what, what started all of this?
Dr. Arun R.Well, I think it was a recognition , um, that family physicians were struggling with mental health back in 2001 that this was a pain point. So to put a, to put it in, in one way , um, that a lot of family docs were feeling very uncertain on how to manage , uh , complexity in these clinical areas. Um, and, and so in response to that and in response to, I think a larger societal need that we needed to be able to increase primary care capacity to manage mental health, that was the impetus. That was the primary impetus. But I think as we went along, sort of these very unexpected pieces came along around compassion, safe spaces and resilience.
Dr. RezmovitzOkay. So I don't know if you can answer this and I hope you really can, but, but why, why is there so much uncertainty? Because you speak to the older generation who's been practicing for 40 years and they said, I don't know what your problem is. I did a rotating internship for a year and then I opened up my shingle and I went from there. So why all this uncertainty? What's going on?
Dr. Arun R.Well, I think the uncertainty is about increased complexity, right? Uh, and I think, so we had a , uh, last year at our annual conference went Ross Upshur came in and spoke about complexity. Um, and it was a wonderful talk that really kind of surfaced our exponentially growing medical knowledge , uh, and the number of guidelines that have come out and the number - amount of care pathways and standards that are there. That's a lot for even for one condition, you get one condition that you have to manage and you have to consult one guideline or two guidelines in the standard. That's a lot to process for one. Now imagine we are now adding in two conditions or three conditions and there's often times a comorbidity or a concurrent disorder that goes along with many of these sort of complex conditions and the complexity, the number of guidelines and number of standards and drug and tractions, it just exponentially increases. So there in is perhaps an answer to why complexity so much more now. But the reality is that we're facing more of it and it isn't about to go away or suddenly get easier.
Dr. RezmovitzSo do you have a mentoring network for managing guidelines?
Dr. Arun R.Not yet. Not yet, but maybe that's one we could look at.
Dr. RezmovitzI don't know about that. I think you just put that in the mental health , um, category. So, so , um, what are the metrics that you're using then to , to measure whether or not you've been successful?
Dr. Arun R.Great question. So I think, yeah , uh , best way to answer that is our metrics have been qualitative and quantitative. They have been mainly around , uh , what are the report of our clinicians. So what are they finding? What did they identifying , uh, as changes around , uh , their knowledge, their competence , um, their confidence , uh, which then translates and the next part that we measure is what are they doing in terms of the behavior? So are they seeing more patients? Are they seeing more complex patients? Are they referring less often or they're supporting their colleagues? And then of course, we also ask, you know, what kind of impact does that have on your patients? And so we look at measuring those different construct of different areas with quantitative and qualitative measures. So that's our current measurement piece. But we are looking at larger measurement pieces that are, when you're looking at health admin data to start to understand, you know, what is that , uh, uh, outside , um , more "objective" , uh, data around changing behavior.
Dr. RezmovitzSo I'd be interested . So when you talk about patients and that's what I mean, we look at QI, we look at Edwards - W Edwards Deming , we look at the IHI, we look at, you know, like you mentioned the quadruple aim and we look at the impact , uh, on patients. All right. The patient experience. So what, what are the metrics specifically that you're looking at for patients and how do we improve the patient experience as providers? Like how would being part of the mentoring network improve? Um, the patient experience?
Dr. Arun R.Yeah, I mean, I think you can talk about a number of things. We can talk about accessibility, right? So access to care. So can you access care where you live? Are you having to wait extraordinary periods of time because your clinician feels that they can't help you, can't manage you at this point and they want and they don't necessarily have to refer you. So a great example, we have of a , an anecdote or a story from one of our members is that, you know, they work in a rural, remote area. Uh, they had a patient suffering with chronic pain. They weren't quite sure. They didn't have the knowledge base and the comfort to be able to manage them. They had them on a wait list, which was four years to be seen. Um, but by joining the mentorship groups, talking to their mentors, they felt more comfortable to communicate, to meet, to work with that patient and then be able to deliver care where they lived in that remote sector , uh, and not wait four years to be seen by the pain clinic, wherever that was. So those kinds of things, those kind of metrics around accessibility I think are important from a patient side. Um, we want to see, of course , uh , what we also want to see is the type of interactions that clinicians and the patients are having. So can we change, can we shift that needle in the conversation? Are we able to, are our clinicians able to better engage with patients, have those important conversations with their patients? That really led to continuity. Um, rather than it sort of being very abrupt, sort of piecemeal, segmented meetings around these different clinical care issues that they may have. Um, so those are the, some of the metrics we want to see. But of course I think we'd love to expand into areas around , uh , patient satisfaction about this, what types of interactions that they're having. Are they finding their relationship with their clinicians changed , uh, by helping equip our clinicians to better understand how to engage with, for example, substance use disorder patients. So whether it's opioid use disorder, alcohol use disorder, can we change the type of interactions they're having? Is it become less confrontational? Right? Does it become more , uh, more collegial? How, what's happening there? So I think those are other important measures that we want to see. Cause especially when we talked to some of our patients and the substance use disorder area, we , we hear that an important part of them, an important, important part of their success in rehabilitation is having a primary care provider that they can depend on and they can go to and they know is going to be there to support them. And if we can support, if we can help those primary care providers achieve that and to be that support for them, I think that's a really good metric.
Dr. RezmovitzYeah. I really like that metric, it's a, it's a common metric that we , I don't think we measure enough, which is , um, do you feel supported? You know, do you feel cared for? Do you feel supported? And , uh , how often do we ask the patient experience, you know, do you feel cared for and you hope that they're all going to say 100% - yes. I feel cared for. How often are we asking our faculty do you feel cared for and supported?
Dr. Arun R.Right. Both important questions. I think we have to ask those of both groups and I, you know, I think that's one of the pieces that I think that's coming out of this compassion work is that to have more compassion, to have more compassionate care available for our patients, they have to have that compassionate spaces for our clinicians and we have to pay attention to both.
Dr. RezmovitzYeah. Um, so how do you create , um, a safe space?
Dr. Arun R.So I think when we , so when we're talking about creating those safe spaces , uh, it's about how we engage with people, right? So when someone's asking a question, making sure we're responding in a timely fashion, making sure the types of responses are appreciative of the question being asked, not belittling or at any point in time ever sort of criticizing that, a lack of knowledge or a lack of understanding or , uh, those, those are not ways that we want to create those safe spaces. Right? Uh, so always sort of that very positive reinforcement , uh, rapidity with responses to people. Uh, and making sure that when we're framing our answers that , uh, as we're talking to our mentees, that we frame the answers that are relevant to the work in the spaces that they're in. Right? Uh , so you'd have, you have to, you have to sort of make sure that you understand where they are, where they're working, understanding their context. Uh , and so part of creating that safe spaces is in the mentors that we choose. Uh, and so we're not necessarily, again, all of our mentors aren't based in ivory towers or tertiary care centers or academic centers, but actually finding mentors out in the community that don't work very far away from our mentees. So they really understand what that space is and the challenges that they're facing. So, you know, understanding , uh, quick responses and making sure that there's a lot of positive reinforcement in the conversations that are taking place.
Dr. RezmovitzSo then how do you go from a , a safe space to a brave space?
Dr. Arun R.Interesting.
Dr. RezmovitzHave you ever been encountered a brave space? And I ask you this because I've been doing a lot of work on creating brave spaces, which is different from the safe space. Um, I find that a safe space is really hard to guarantee, right? Because I don't know what's gonna trigger you. Whereas a brave space is quite actionable because I can, I can guarantee that I will support you 100%. You know what you're talking about. You're preaching amazing work here, which is support, right? We can support. It's something that is actionable. We can fully support each other. And yet we see , we see it everyday where people just do not support each other. So how can we create that? Like how do you know that you've got the safe space and you move on to the brave space where you're like, Oh, you know what? I feel safe enough where I can take risks, where I can start, you know, taking a chance and actually treating that patient on my own so that I can improve accessibility. Um, how , how can I , um , feel brave enough where I have that not only the , the content expertise now, but I feel like I'm going to advocate, I'm going to lead, I'm going to collaborate. How do you get people into the brave space?
Dr. Arun R.Wow, that's a great question. Um, I think that brave spaces are outgrowth of the safe space, I don't think we necessarily view it as everybody that's in a safe space will migrate into a brave space. But I think there are individuals that have a certain , uh , passion, a certain interest in the area , uh, or in a field or topic. And they will look to migrate into that brave space. Uh, and I think what ultimately moves them or potentially moves them into that brave space is having those role models, right? Having people that they can model themselves after to look - how can, how does - sort of get into that space around advocacy? Um , sort of really being a champion, really taking risks or not, not just risk, but risks from their confidence side of things. Right? I feel confident, I'm going to take that chance. So for example , uh , yeah, I'm ready to start prescribing or started doing a buprenorphine Naloxone induction, I'm ready for that. Right? I'm going to take that jump. So moving from that, safe to that brave, I think in part, and not everyone will make that transition, but I think you gotta have a good set of role models. So you gotta have a good set of mentors who believe in your community who are committed and bought into your community and are willing to really help lead those individuals into those brave spaces. Um, and that's an , it comes back to that , that deep sense of community and community attachment and commitment.
Dr. RezmovitzOkay. Crazy question. Yeah. Where can one find a mentor?
Dr. Arun R.Ah, well, you know, technically we're supposed to be able to find mentors everywhere, right?
Dr. RezmovitzThat's true.
Dr. Arun R.In all sorts of places. And there's so many organizations that look at mentorship in so many different ways. Um, you know, from our end and our mentorship networks , uh, you, if you're looking for that mentorship, you know, Ontario College of Family Physicians has their website and they have a page devoted to the collaborative mentoring networks, which then gives you information and really sort of a fairly seamless , um, access to mentors in any of these networks. So as a family physician, you can join any one of these networks , uh, at your discretion and fill in your survey and off you go, you have connected to a mentor that's locally, that's co-located with you. And usually more than one, it's often two or three. So that's one way you can find mentors in our mentorship network. And I think it's , uh , probably one of the more easy ways to be able to connect it to a mentor.
Dr. RezmovitzAnd let's assume for a second that you're a thriving family physician who's got their , um , everything's actually working and you say, you know what, I just have way too much time on my hands. I want to give back. Is there any opportunity to mentor other people?
Dr. Arun R.Absolutely. So if you've got an interest in any of these topic areas that's there on the web, on the mentorship network webpage, yeah, absolutely would, we would welcome people to identify themselves as interested mentors. Uh , and we have a whole process in place where you can submit an application and uh , go through references and all of those other pieces where we're looking for new mentors and were keen to bring new mentors into the various programs, especially around , uh, the chronic pain and addictions program.
Dr. RezmovitzSo you said earlier that you had about 1200 people. And so what's the denominator? What are you looking for? What's the , um ,
Dr. Arun R.Yeah, so this is great. So I mean, in terms of where we are right now - and we're funded by the Ministry - and so what we're looking at about is a total of 1400 people as what we've been funded for. Uh , so 1400 mentees, about 140 to 150 mentors is the numbers - the denominators that we're looking at. So there's definitely some space to grow. We definitely have a room for at least a 200 other extra - 200 plus extra mentees to join , uh, the networks, any one of them.
Dr. RezmovitzAwesome. Um , it sounds like the mentorship network that you guys have created and uh , is really based on support. Um , and it seems to have a big impact , uh, using the triple aim as a, an opportunity to support the physicians, an opportunity to support the patients, and opportunity then to support the system that they're in and then possibly the costs , um, that, that , um, are impacted by having a better overall health care system.
Dr. Arun R.Right. Yeah. And it's , it , it really builds into that whole notion of that the , uh , patient medical home, right. Which really kind of encompasses all of those pieces. And that's what we're really trying to do is how do we , uh, improve that home for our patients? How do we help support our patients to stay in their medical home and receive care in that home for as long as they can.
Dr. RezmovitzProbably with, with support.
Dr. Arun R.That that's what we believe.
Dr. RezmovitzI agree with you. Um, so do you have any last parting words, inspirational quotes that you want to discuss or, or , or tell people about?
Dr. Arun R.Um , you know, I think this, the podcast really is about small changes and big impacts. And, and I just reading, I think it was just the day before yesterday or yesterday was , uh , Ghandi's birthday, right? And it's his 150th birthday. And I think one of his real quotes is be the change you want to see. Right? And so if we're really talking about support and communities, it's like , I think it's up to us, right? As family physicians to be part - to create these communities, to reach out, to support each other. Um, it's challenging times. There's a lot happening, a lot changing, a lot shifting. And I think , uh , this is a time for us to really come together and support each other and be that change that we want to see.
Dr. RezmovitzI agree wholeheartedly. Arun , uh, be the change you want to see in the world. Uh , take that first step. Uh, if you don't know how to make that first step, I would suggest getting a mentor. Um, thank you so much for coming in and , uh, look forward to , um, a long relationship together. Thank you.
Dr. Arun R.Thanks for the opportunity.
Dr. RezmovitzThis podcast was made possible through the support of the Department of Family and Community Medicine at the University of Toronto. Special thanks to Allison Mullin, Brian Da Silva, and the whole podcast committee. Thanks for tuning in. See you next time.