Health Care Transformation in Canada

Physicians and Health Equity:
Opportunities in PracticeC H A N G E T H AT W O R K S . C A R E T H AT L A S T S .

CONTENTS
Executive summary  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . . 3
Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Interventions  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 7Barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Facilitators  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 12
Areas for action  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 15
Conclusion  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 16
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Appendix I: Interview protocol  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 19
Appendix II: Interview participants  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 21

Physicians and health equity:
Opportunities in practice

Executive summary
Health equity is created when individuals have the opportunity to achieve their full health potential. Health equity
is undermined when social and economic conditions, the social determinants of health, prevent or constrain people
from taking actions or making decisions that would promote health. While the majority of these determinants falloutside of the traditional health sector, the implications for health services in Canada are enormous. Most majordiseases including heart disease and mental illness follow a social gradient with those in lowest socio-economic
groups having the greatest burden of illness.
There remains, however, limited published material on opportunities for physicians to address these issues. This
lack of literature does not denote a lack of action. Many physicians are engaged in innovative practices to help
address the needs of the most vulnerable. Recognizing this, the Canadian Medical Association (CMA) interviewed
a number of physicians across the country. It was hoped that their experiences would highlight work being done,
and provide strategies and tools to physicians interested in opportunities to address health equity within their practices.
CMA developed an interview protocol in the fall of 2011 which was then pilot tested. In total, interviews wereconducted with 32 physicians in 29 separate interviews. These physicians represented eight provinces and two territories and were drawn from family medicine, emergency medicine, pediatrics, psychiatry and public health. Oncethe interviews were completed, the content was reviewed and coded. General themes, keywords and responses wereanalyzed. An overview of the results is provided below. For more details please see the Results and Discussion sections of this report.
Physicians were asked to identify common areas of intervention for addressing health equity within practice. The
most common answers in descending order were:
1.	
2.	
3.	
4.	

Linking patients with supportive community programs and services
Asking questions about a patient’s social and economic circumstances
Integrating considerations of social and economic conditions into treatment planning (i.e. cost of medications)
Advocating for changes to support improvements in the social and economic circumstances of the community(i.e., advocating for reductions in child poverty)
5.	 Undertaking advocacy on behalf of individual patients (i.e., letters about the need for safer housing)
6.	 Adopting equitable practice design (i.e., flexible office hours, convenient practice location)
7.	 Providing practical support to patients to access the federal and provincial/territorial programs for which they
qualify
Physicians did identify certain barriers to this work. The most common were:
1.	
2.	
3.	
4.	
5.	

Payment models (in particular 100% fee-for-service)
Attitudes that lead to stigmatized environments and prevent public action
Absence or lack of clinically-oriented information about the programs and services available for patients
Ability to find the time necessary to address these issues within practice
Lack of integration between health and community-based services
3Physicians and health equity: Opportunities in practice

6.	 Lack of knowledge and skills to undertake this type of work
7.	 Practice design
8.	 Lack of services and supports in the community (in particular in rural and remote communities)
9.	 Lack of evidence and research on effective interventions for physicians
10.	 Personal attitudes that include powerlessness in the face of patients’ social and economic barriersInterviewees additionally highlighted facilitators to this work. The most common were:
1.	 Clinical training about how to do this type of work (i.e., service learning programs in medical school andresi­dency)
2.	 Interdisciplinary team-based practice settings
3.	 A relationship with community services and programs
4.	 Clinically relevant resources about the programs and services that were available for patients
5.	 Supportive compensation models (i.e., salary, billing codes for complex patients)
6.	 Continued research that demonstrates efficacy in the clinical environment
7.	 Finding a like-minded community of practiceIn the course of the interviews, participants suggested a number of areas for action. Interviewees saw a key role
for CMA and other national medical groups in advocating for health equity issues. In addition, many felt that anational organization could take the lead in facilitating the development and dissemination of other key supports.
They recommended actions in five main areas: clinical practice, education, compensation, research, and advocacy
and communications. A list of suggested actions is provided in the table below. This is just a preliminary list andfurther refinement is required.

Area of interest

Potential action(s)Clinical practice• Development/refinement of health equity/social determinants of health assessment tool
• Development/modification of clinical practice guidelines to integrate social and economic
factors into medical care
• Development of resources for physicians on programs and services for patients• Development of resources for physicians on accessing provincial/territorial and federal
programs including forms and referral pathways, etc.
• Development/consolidation and dissemination of plain language resources for patients onchronic disease management

Education• Support and encouragement of the integration of the social determinants and health equity inmedical schools• Support and encouragement of service learning in medical schools and residency training• Development of an accredited continuing medical education programs for practisingphysiciansCompensation• Identification of effective compensation models for health equity practice in Canada• Development of these models for other jurisdictions and practice settings

Research• Support of continued research on physician interventions in health equity• Help to assemble the evidence base and best practices and facilitate knowledge translation
across Canada and internationally

Advocacy andcommunications• Develop a national network of health equity physicians• Develop an advocacy strategy for health equity in Canada• Develop an advocacy map/tool for clinicians• Explore the development of health equity leadership and advocacy training resources forphysicians4Physicians and health equity: Opportunities in practice

Improvements in the social and economic conditions of Canadians and greater equity within the health system are key
strategies if population health is to be improved and the sustainability of the health sector ensured. Interviewees identified a series of opportunities for action by physicians across the country. It is hoped that these interventions will provide
Canada’s doctors with a toolbox to address challenges for their patients, which are often overlooked. Barriers will need tobe addressed and facilitators capitalized upon. Leadership at the national level is necessary. Physicians are respected l­eadersin the health care system, within their communities, and at the provincial/territorial and federal levels. This research demonstrates that they possess the necessary skills to undertake greater leadership in speaking out and addressing the social factors that have such a profound impact on health. Action in the areas of clinical practice, education, research, and advocacy
and communication will allow physicians to be active agents for change and play a significant role in ensuring health caretransformation in Canada.

Background
Health equity is larger than the health care system itself. Recent evidence suggests that 15% of population healthis determined by biology and genetics, 10% by physical environments, 25% by the actions of the health care system, with 50% being determined by our social and economic environment.1 To optimize the health potential ofindividuals, and ensure greater health equity, preventable and avoidable systematic conditions which constrain life
choices must be reduced or eliminated.2 These conditions, known as the social determinants of health, are the circumstances in which people are born, develop, live and age,3 and include: income and income distribution; early
life; education; housing; food security; employment and working conditions; unemployment and job security;social safety net; social inclusion and exclusion; and health services.4
The majority of these determinants fall outside of the traditional health sector. However, the implications for healthservices in Canada are enormous. Most major diseases including heart disease and mental illness5 follow a social
gradient with those in lowest socio-economic groups having the greatest burden of illness. Those in the lowest socioeconomic status are 1.4 times more likely to have a chronic disease, and 1.9 times more likely to be hospitalized forcare of that disease.6 Chronic diseases such as diabetes account for 67% of direct health care costs and 60% indirect
costs.7 According to a 2011 report, low income residents in Saskatoon consume an additional $179 million in healthcare costs than residents classified as middle income earners.8 In Canada, data from the 2007 Community Health
Survey described the Canadians who are most likely to report cost-related non-adherence to prescription medications
as follows: those in poor health (2–4 times), lower household income (2–5 times), and those without drug insurance(3–6 times).9 They estimate that one in 10 Canadians does not adhere to their prescription for reasons of cost.
Examining this data, it is hard to ignore the implications for Canada’s physicians. The question is what can be done forareas that are largely outside of the health sector. Some literature has been published on the role for the health sector
in addressing health inequities.10 Additionally, reviews of specific interventions have been provided.11 However, there
remains limited published material on opportunities for physicians to address these issues. This lack of literature does not
denote a lack of action. Many physicians are engaged in innovative practices to help address the needs of the most vulnerable. Recognizing this, CMA set out to undertake interviews with physicians who had been identified as health equity
champions across Canada. It was hoped that their experiences would highlight the amount of work already undertaken
by Canada’s physicians, and provide strategies and tools to those physicians who were interested in more opportunities toaddress health equity within their practices.

Methodology
CMA developed an interview protocol in the fall of 2011. The complete protocol is found in Appendix I. In
November 2011, this protocol was pilot tested with physicians from the Sandy Hill Community Health Centre in
Ottawa. Once the protocol was approved staff set out to identify participants for the research. Potential participants
were identified in a number of ways. Initial scanning was done using Google searches. Additionally, the web pages ofCanadian medical schools were reviewed. Names were provided through provincial and territorial medical associations. Finally, additional participants were identified by other interviewees as the research was conducted.

5Physicians and health equity: Opportunities in practice

In total 54 physicians were contacted with 37 (68.5%) agreeing to be interviewed, and 32 (59.3%) completing an interview. As some interviews involved more than one physician, 29 separate interview sessions took place. These physicians
represented eight provinces and two territories and were drawn from family medicine, emergency medicine, pediatrics,
psychiatry, and public health. A telephone interview was conducted with one individual with the remaining consultations
being done face-to-face. The list of interviewees is provided in Appendix II.
Once the interviews were completed, the content was reviewed and coded. General themes, keywords and responses
were analyzed. All themes that were mentioned in five or more interviews were included for discussion in therelevant section. The content of the paper and results were then verified with the interview participants. There wasa great deal of consistency in responses to the areas reviewed. This suggests a high level of agreement on common
interventions for physicians, and barriers and facilitators to this work. However, caution must be applied given therelatively small number of physicians interviewed. Further research with a larger sample size would be helpful inverifying these results.

Results
The physicians interviewed practised in a variety of clinical settings. Practice populations ranged from whole communities under the jurisdiction of public health departments, to 10,000–12,000 in large academic family healthteams, to 500 in a First Nations community in rural Nova Scotia. Practice communities included urban and innercity, and rural and Northern practices. Specific subpopulations included child and youth, mental health, women,
Aboriginal and immigrants. Even with this variety, there was consistency in responses.
Physicians were asked to identify common areas of intervention for addressing health equity within practice. They
were asked to consider their own practice setting as well as what would be practical in a generic practice setting.
The most common answers in descending order were:
1.	 Linking patients with supportive community programs and services
2.	 Asking questions about a patients social and economic circumstances
3.	 Integrating considerations of social and economic conditions into treatment planning (i.e., cost of medications)
4.	 Advocating for changes to support improvements in the social and economic circumstances of the community(i.e., advocating for reductions in child poverty)
5.	 Undertaking advocacy on behalf of individual patients (i.e., letters about the need for safer housing)
6.	 Adopting equitable practice design (i.e., flexible office hours, convenient practice location)
7.	 Providing practical support to patients to access the ­federal and provincial/territorial programs for which they
qualify
The first two interventions were identified in almost every interview that took place. While the physicians interviewed have been successful in integrating some or all of these interventions into their practices, they did identify
certain barriers to this work. The most common barriers included:
1.	 Payment models (in particular 100% fee-for-service)
2.	 Attitudes that lead to stigmatized environments and prevent public action
3.	 Absence or lack of clinically oriented information about the programs and services available for patients
4.	 Ability to find the time necessary to address these issues within practice
5.	 Lack of integration between health and community-based services
6.	 Lack of knowledge and skills to undertake this type of work
7.	 Practice design
8.	 Lack of services and supports in the community (in ­particular in rural and remote communities)
9.	 Lack of evidence and research on effective interventions for physicians
10.	 Personal attitudes that include powerlessness in the face of patients’ social and economic barriers

6Physicians and health equity: Opportunities in practice

While a significant number of barriers were identified, interviewees highlighted facilitators which enabled them toovercome some of these challenges. Additionally, they suggested some supports for physicians who were interested
in getting started in this area of work. The most common facilitators included:
1.	 Clinical training about how to do this type of work (i.e., service learning programs in medical school andresidency)
2.	 Interdisciplinary team-based practice settings
3.	 A relationship with community services and programs
4.	 Clinically relevant resources about the programs and ­services that were available for patients
5.	 Supportive compensation models (i.e., salary, billing codes for complex patients)
6.	 Continued research that demonstrates efficacy in the clinical environment
7.	 Finding a like-minded community of practiceNot surprisingly, many of the facilitators spoke directly to an identified barrier (i.e., education about addressing health equity within practice). In the discussion section below we will explore the innovative practices acrossCanada where these interventions are utilized as well as a further examination of the barriers and facilitators. It is
important to recognize that many of these interventions are being undertaken by physicians across the country andnot just by the physicians interviewed. Many regularly undertake actions to address the social and economic needsof their patients. It is hoped that the following sections will serve to enumerate these practices and provide support
for physicians already undertaking this important work. It is further hoped that by identifying barriers and facilitators that targeted action can be taken. Finally, for physicians who have been interested in doing this work but who
were not sure how to get started, the interventions can provide first steps and recommendations for action. The
final section of this paper will examine areas for action at the national level as well as a possible role for CMA.

Discussion
Interventions
There has been a challenge within the health care system and among physicians in particular to become involvedin the social determinants of health and health equity. This is certainly not because of a lack of compassion forpatients, or ignorance of the issues, but because of a feeling that interventions were largely beyond their reach. As
the interviews demonstrated, however, there are key interventions that can be undertaken by physicians at many
levels.
While only the second most common intervention identified, it is important to begin with a discussion of the necessity of a social history as anintervention for physicians. It is a preliminary stra­tegy because the information collected is necessary to support all of the other interventions.12
There are a number of tools that can be used for such a consultationand more are in development.13 Research by Dr. Vanessa Brcic at the
University of British Columbia pilot tested a number of questions physi— Dr. Ryan Meili
cians could ask patients to identify poverty within their practice. The
question “Do you (ever) have difficulty making ends meet at the end of
the month?” was found to be a good predictor of poverty.14 Physicians emphasized the need to ask these questions
in all practice settings and not just disadvantaged areas. Consolidation of the best ideas into a tool that is suitable
for the majority of health care settings is needed. The tool needs to organize information that reflects the realitiesof the patient and helps physicians consider the best options for care. Some suggested integrating such a tool into
electronic medical records.

You still need to ask ­questions about thesocial determinants of health even if you
aren’t working in a disadvantaged population. Why not consider an ­annual social
just like you do an ­annual physical.

Interviewed physicians emphasized the need for community level data. Data within primary care practices could
help to assemble community wide databases of health information, including information on the social determi-

7Physicians and health equity: Opportunities in practicenants of health.15 This data is now regularly collected at the community level in Newfoundland and Labrador and Quebec. It canhelp physicians understand the needs of their practice and what
interventions may or may not be helpful. It can be used to conduct
equity assessments as well. Innovative programs within the Saskatoon
Health Region and the Centre for Addiction and Mental Health inToronto use data collected on health outcomes for various groups tofind barriers and identify ways to ensure greater access and equity for
all patients.

When examining the patient profile it became clear that the vast majority of diabetic
patients requiring dialysis were First Nations
people. When the education program was­examined, participation rates were quite
low among this group. Clearly there wassomething about the education program
which prevented these individuals fromparticipating.

— Dr. Cory Neudorf
Once the social as well as the medical needs of patients have been
identified, physicians will need to integrate the information into planning about treatment decisions. This was the third most common intervention suggested by interviewed physicians.
Physicians regularly take medical risk factors into account when planning treatment protocols. Interviewees suggested
the same should be done for social and economic risk factors. In addition to risk factors, barriers to adherence needed
to be identified when planning treatment. If patients would have difficulty accessing fresh and healthy food or getting
exercise, it would be necessary to examine these barriers before making these recommendations. The cost of medications needed to be considered when determining treatment plans. Some interviewees discussed the use of samples for
disadvantaged populations and ensuring medications would be covered under drug plans if applicable. They noted aswell strategies for securing medications in the most affordable way for their patients.

To address some of the barriers identified in the social assessment andto help with compliance with treatment plans, interviewees often linked
patients with supportive programs within the community; the number one
most common intervention identified by physicians interviewed. There
were many examples of physicians linking patients to programs within— Dr. Gary Bloch the community. Some practice locations even had supportive programs inhouse. Physicians at the North End Community Health Centre in Halifax
highlighted some of the programs that were available through the nutritionist on staff. Examples included local
walking programs and programs designed to teach patients how to cook healthy meals on a budget. Similar programs were identified at community health centres across the country.

When someone has ­diabetes, wethink about what that means ­clinically.
Why don’t we do that for social and­economic data?

For those locations which did not have such supportive programs, they relied on services within the community.
One Ontario initiative is aiming to make such referrals easier for physicians in practice. The Enhanced 18-Month
Well-Baby Visit, is designed to utilize standardized tools to allow physicians to have a discussion with parents onchild development, to identify at risk kids, and to link parents and their children with local community programs
that will support early childhood development.16

Ontario’s enhanced 18-month well-baby assessment
Based on recommendations from an expert panel comprised of the Ontario College of Family Physicians, theOntario Children’s Health Network, and the Ministry of Children and Youth Services, the standard 18-monthwell-baby assessment has been expanded from a well baby check to a more fulsome examination of childdevelopment. Using standardized tools for physicians and parents, this program is seen as offering enormous
potential to identify issues before children reach school. Encouraging more attention to healthy development by
all parents is a population health strategy that can be carried out in the primary care office. The program encourages the use of community resources for early child development. In collaboration with Ontario’s Best Start
Strategy, comprehensive databases of community resources are being developed. Physicians are compensatedby the Ministry of Health for this work. More data about this program is available at www.18monthvisit.ca.

8Physicians and health equity: Opportunities in practice

Further, physicians identified the need to get their patients access to all federal and provincial/territorial assistanceprograms which could offer support to their patients such as disability assistance or extra funding for food (7thmost common intervention). The programs vary by community and province/territory, and include disability,
nutritional supports and many others. Most if not all of these programs require physicians to complete a form inorder for the individual to qualify. For some individuals, these programs make the difference for safe housing andhealthy food. Researchers in Toronto have developed a clinical tool for poverty identifying the programs which
patients can access including old age security and guaranteed income supplements, child benefits and special dietallowances, among others.17 Similar guides would be helpful for physicians in other parts of the country.
Interviewees suggested that there were opportunities for physicians to be
One of the amazing things about being more involved in advocating for improvements in the social and economic
conditions within their communities (4th most common intervention).
a doctor is that we hear peoples’ life
Interviewees highlighted the systemic barriers their patients faced instories along with their medical stories.
meeting the most basic needs. For example, the annual welfare income
We have the opportunity to retell andin Canada varies between $3,247 for a single person to $21,213 for a
act upon these.
couple with two children. The ‘best’ of Canadian programs provides an— Dr. Susan Phillips
income within only 80% of the poverty line. The lowest income is barely
30% of that needed to ‘achieve’ poverty.18 Interviewees commented thatphysicians are in a unique position to advocate for these issues. As respected members of the community, theiropinions add strength to these campaigns and can help to provide a voice for those who are often overlooked.
Interviewees emphasized the duty of physicians to advocate for change at the policy level.
Physicians’ role as health experts allowed them to speak to community
leaders about the need for action in these areas. Participation on theboards of community services was seen as one place for such advocacy
to take place. Membership in provincial/territorial and national medicalorganizations was another venue for such messages to be raised. While
not all physicians will have the time or skills to become full-time advocates, identifying times and places where they can intervene would help toaddress the needs of their patients and their communities.

I had a patient who had major surgery
and was no longer able to do her laundry by hand like she had always done.
I wrote a prescription for a washer anddryer and it was actually filled.
— Dr. John Haggie

In addition to system level advocacy, interviewees identified the need to advocate for their patients on an individuallevel (5th). This is something that physicians regularly do for patients in terms of health service access. Physicians
Dr. Gilles Julien and Les centres de pédiatrie sociale“We are an interface for the vulnerable children and the systems they access.”
Disappointed with the lack of progress that he could make in regular practice, Dr. Gilles Julien set out to finda way that he could have a bigger impact on the needs of the children he was treating. With no funding
and armed with only a bicycle he set out to develop a community social pediatric program for Montreal’s
most disadvantaged children. That program has now grown to 12 centres across Quebec, all located in
the areas of greatest need. Dr. Julien and his team help children with the medical, legal, and social determinants. The facility has a staff of many trained health providers and provides children with a supportive
environment where they can access services. The practice is completely interdisciplinary with all practitioners
being involved in a child’s care. When children come to the facility the whole health care team does an assessment of their needs. Clinical as well as legal staff develop an action plan for the child and their parents
and work with the community to make sure it takes place. Regular community and home visits are part ofthe practice model. According to Dr. Julien, this program is 50% integrated services and 50% advocacy forchildren. The program is designed to address the health needs of its patients and protect the legal rights ofthe children involved. Further details about these programs can be found at:www.fondationdrjulien.org/

9

Physicians and health equity: Opportunities in practicecommented that they were involved in advocating for the social and economic needs of their patients as well. Interviewees noted that they wrote
letters to housing agencies for example, to help patients access moresuitable housing. Some physicians utilized prescriptions for social issues.
Additionally, physicians intervened on behalf of patients when they feltthat children had been inappropriately taken from the home and placedin social services. Finally, physicians worked with schools and other— Dr. Kwame McKenzie community agencies to ensure that the best interests of patients were
met. A practice which is very involved in this type of patient level advocacy for children and youth is community social pediatrics. Pediatricians and family physicians work closely with
community organizations and systems to make sure that their patients’ needs are met. The overview of Les centresde pédiatrie sociale provides more details about this innovative approach.

The first thing to do about health equity
is to think health equity and what thebarriers are to people getting access.
Think about times, women with children,
disabled access. Think about how yourolder patients will be looked after.

Building on the work of Dr. Julien, other centres have identified the benefits of the social pediatric approach. The
Hospital for Sick Children in Toronto now has a Social Paediatrics program headed by Dr. Elizabeth Lee Ford
Jones. Other programs are in development across Canada as well. Both Dr. Ford Jones and Dr. Julien are actively
involved in developing medical education programs to support this kind of work in Canada.
Interviewees suggested that physicians could do a great deal for their patients by making sure that their practices wereaccessible and supportive to those most in need (6th). Examples included flexible office hours with many having hours
outside of the traditional 9–5. Many highlighted the necessity of addressing health literacy for patients including
information that was appropriate for all patients. Programs to support those who did not speak English were also necessary. Culturally safe care, especially when working with Canada’s Aboriginal peoples, was a key support.
Offices needed to be located in areas that were convenient for patients. Some suggested locating clinics in areas
where patients already were such as schools or early education centres. In some clinics, outreach workers went
directly to the patients to ensure access. In rural Newfoundland and Labrador for example, a local physician identified the barrier that many women had in accessing cervical cancer screening. This lack of access is one of the reasons that Newfoundland and Labrador has the highest rate of cervical cancer in the country. During the summer
months this physician utilizes a converted camper known as the “Papmobile,” to access women who would nototherwise be screened.
Finally, setting up practices that integrated many
services under one roof was seen as a key facilitator.
One of the groups that faces the biggest barriers tohealth access are the homeless. They are also among
the sickest in Canada. Being homeless is correlatedwith higher rates of both physical and mental illness.19 In Canada, premature death is eight to tentimes higher among the homeless.20 Recognizingthese needs many programs have been set up to try
and reach this population; one of these is Ottawa
Inner City Health.21
While not all practice locations will be able to facilitate
the ease of access such as a program like Ottawa Inner
City Health, all physicians can think of the barriers foraccess when planning their practice design. If barriers canbe identified and eliminated, there is a greater chance forphysicians to address not only the medical needs of theirpatients but to facilitate greater health equity.

10

Ottawa Inner City Health
Established in 2001, this program is a non-profit corporation in Ottawa that delivers primary health care, chronic
and convalescent care, palliative care and addictions
management to the chronically homeless. Partnerships withkey community members, such as local shelters, the Salvation Army, and University of Ottawa ensure the program’scontinued success. All of the services and the layout of
the clinic were designed with direct input from clients andpatients. The goals of the program are to provide dignity
and culturally appropriate care and to work to restore
clients to mainstream society. This program was the first of
its kind and has been used as a model for others acrossthe country. Continued research on interventions and treatment are helping to establish the evidence base for future
work. More information about the program can be found
at: http://ottawainnercityhealth.ca/Home

Physicians and health equity: Opportunities in practice

Barriers
The interventions discussed above highlight some of the key steps that physicians can take in addressing the needsof their patients. However, these practices were not without barriers. The most common barrier was funding models for practice. Many commented on the difficulty in working with these complex patients if one was required tobill on a fee-for-service basis. In certain jurisdictions incentives for physicians were established in such a way thatphysicians would be encouraged to only treat healthy patients with more complex and vulnerable patients actuallyserving to punish physicians financially. Many felt that solo practice fee-for-service physicians would have a hardtime undertaking this type of work in many jurisdictions.
Financial disincentives were not the only reasons interviewees felt thatsolo practitioners might have difficulty in sustaining this type of pracAssisting people to address the health ineqtice. The fourth most common barrier was the additional time required
uities that they face requires time, and manyto undertake this kind of work. Many underlined the time required tofinancial models interfere with the effective
properly treat the needs of these patients and to link them with all ofdelivery of adequate health care.
the necessary supports. Taking the time to write letters, fill out forms,— Dr. Cathy Felderhof and identify resources in the community could be difficult for alreadyoverburdened practitioners. It was the combination of time and financial barriers that led some physicians to comment that practice design could serve as a barrier to effective health equity
work (7th). The absence or lack of clinically-oriented information about programs and services available for patientswas another barrier (3rd). Many stressed that it had taken them a number of years to identify the community supports
available. Further, these programs were often changing and it was difficult to keep up with what was going on in thecommunity. A number commented that patients were often the ones that brought these programs to their attention.
Many identified the need to have some sort of resource for physicians to allow them to keep current on these community supports.
In addition to barriers in identifying services, two other barriI try to spend time coordinating follow-up careers related to community and social services and supports werewith the shelters in the community. It is hit anddiscussed. First, a lack of integration between the health care secmiss though as being the only physician in the
tor and other social services was seen as a major barrier (5th).
ER it is sometimes impossible to find the time
Key challenges included programs being organized in ways thatnecessary.
were different from what the health sector would expect, differing— Dr. Anna Reidbureaucracies, and having many different ways to access programs
and services. Rather than having one way to refer patients to different community programs and services, there was often a multitude of different forms and information required
which could cause a great deal of confusion. Physicians noted the need to streamline the process for patients toeliminate the difficulties they had in accessing needed supportive care. Distrust between community and social
services and the health care sector was highlighted as another issue. The lack of integration also meant that
information relevant to a physician’s treatment planning was often not reported by the community organization or other social service, undermining the quality of patient care. There was a real need for social services andcommunity organizations to become a more integrated part of the health care team.
Further, physicians commented that there was sometimes a lack of services in their communities to support the needs of their patients (8th).
Mental health services were identified as a major gap by many of thephysicians interviewed. Depending on the community, some patients
had to be sent out of their province or territory in order to access thecare that was necessary. A corollary to this is the limited capacity of— Dr. Philip Berger some of the services available. Even if services were available locally,
the wait times were often preventative due to patients’ needs. Thisapplied to medical services as well as community and social support services. The sheer scale of need in some communities could undermine the effectiveness of available resources.

It would be helpful to patients for forms for
welfare, etc., to be available in physicians’
offices. Rather than having to send people toanother location for a form that we ultimately
have to fill out.

11

Physicians and health equity: Opportunities in practiceThe scale of the problem was identified as another challenge by the interviewees. Physicians could feel a sense of powerlessness in the face of thesocial and economic challenges that their patients faced (10th). The burden of poverty and disadvantage is so great in some areas that it could feelthat no actions could truly address the need. It was suggested that somephysicians would be unwilling to even ask their patients about these issues
due to an ethical concern that they couldn’t do anything to help if an issue
was identified. Additionally, a lack of knowledge and skills to address theseissues could serve as a barrier to some physicians (6th). In particular, socialand economic considerations had not been part of medical training in thepast. Working with community and social services was new and advocacy
skills were lacking for many. Interviewees suggested further that physicians
often felt reluctance to intervene in areas outside of their medical expertiseeven if the health consequences were clear.

We had an elder who had been sent
south for care. When she was ready to
be discharged there were problems as
the support services were not available
locally. Her family took the initiative towork with the Department of Healthto secure what was necessary. This
collaboration, and the family’s financial
resources, was the only way that she
was able to come home to be with herfamily.
— Dr. Sandy Macdonald

This lack of knowledge was often identified in parallel with another barrier; the lack of evidence about effective interventions for physicians (9th). The medical model requires certain levels of evidence for physicians to utilize interventions within their practices. As there is limited published evidence on what physicians can do to address the social
determinants and health equity, this could serve as a stumbling block for many.
Negative attitudes in the health care setting were seen as a barrier to healthequity work. It was the second most common response by interviewees.
More complicated patients could be labeled as difficult and faced stigmatization. Additionally, disadvantaged groups often had negative experienceswith the health system making them defensive and further undermining
any relationship with physicians. Discrimination and push back was identified as an issue, particularly when the challenges patients faced in comply— Dr. Jeff Turnbull ing with treatment instructions were not understood. These attitudes were
found not only for the socially marginalized but for patients with complex
medical needs. These attitudes could be translated into lack of access or suboptimal care; a real barrier to equitable
health services. These negative attitudes were common in the general public as well. Action to reduce health inequities was hampered by a lack of interest by other Canadians who often blamed these individuals for their problems.
Interviewees felt that the inability for most Canadians to understand what it truly meant to be disadvantaged or
marginalized, led to discrimination and difficulties for their patients, including further social exclusion. This lack ofinterest by the public translated into a lack of action by politicians at all levels. Myths related to poverty and otherareas of disadvantage were seen as the biggest barriers to getting people to take action to address the social andresulting health needs of these patients.

We have to overcome the judgmentsthat people make about these populations. If they are there because it is theirfault then they can be ignored. We
have to move beyond the sense that it issomeone else’s problem.

Facilitators
Although a number of barriers were identified, physicians suggested some key facilitators as well. The facilitator
mentioned most often was education for physicians. A 2001, Health Canada report called for greater integration of
the social determinants in medical curricula, and a greater emphasis on providing medical students with firsthandexperiences in the community and with distinct populations.22 Additionally, the CanMEDS Physician Competency
Framework, identifies health advocate as a key role for physicians.23 Teaching physicians about the CanMEDS
competencies is a mandate of all Canadian medical schools.
Most if not all medical schools include information about the social determinants of health within their curriculum. Recognizing that this is sometimes difficult information to convey in a didactic setting, there is an increasing emphasis on programs which allow students to get first hand experiences working in the community andwithin disadvantaged populations. These programs, such as the Making the Links program at the University of

12Physicians and health equity: Opportunities in practice

Saskatchewan, help students gain the skills to workwith diverse populations.
Programs for medical residents are being implemented across the country. Interviewees highlighted
programs at the University of Toronto, the Universityof Alberta and McGill University, which provide physicians with the opportunity to work in underserved
and vulnerable communities. The McGill program
uses community-oriented primary care as a model.
Residents begin the program with a walking tour ofthe community, and community members make regular presentations. Additionally, residents make casepresentations about the social and economic issues
their patients encountered and the impact on medical outcomes. Residents in the Queen’s University
Family Medicine program can now use community
advocacy as a genesis for their research projects.

Making the Links — University of Saskatchewan
Established in 2001, this program is a non-profit corporation in Making the Links places students as volunteers in a
fully interdisciplinary student-run clinic in the inner city of
Saskatoon, in Northern Saskatchewan communities, andin a small town in Mozambique. Students learn a modelof social accountability developed by the University of Saskatchewan’s College of Medicine known as CARE (clinicalactivity, advocacy, research, education and training).
Through their experiences, they integrate the impact of thesocial determinants on population health into their learning, forge important relationships and convert theory into
practice. More details about this program can be found
at: www.medicine.usask.ca/leadership/social-accountability/initiatives/mtl1/index.html or www.makingthelinks.
usask.ca

Interviewees identified the need for education for those physicians alreadyin practice. Particular focus on the impact of the social determinants on
medical outcomes and potential interventions were emphasized, as wellas education about advocacy and community involvement. They noted— Dr. Len Moore that an accredited continuing medical education program would be helpful to reach interested physicians. Further, some suggested that practisingphysicians needed opportunities to go into the community to see some of
the challenges faced by the most vulnerable first hand. The programs in medical school as well as in practice canhelp provide physicians with the tools to work within these communities and will go a long way in reducing thenegative attitudes that are such a barrier.

You need to make it easy for physicians
to access services and connect theirpatients with supports.

In addition to education for physicians, some interviewees discussed the effectiveness of resource guides for physicians which identified community programs and services as well as provincial/territorial and federal patient support programs (4th). Many resource guides have been put together for physicians and other health providers. The
Mobile Outreach Street Health program, which is affiliated with the North End Community Health Centre in
Halifax, developed a guide for providers to let them know about programs and services such as shelters that wereavailable for the street-involved and homeless. Programs at the University of Alberta and McGill University havedeveloped pathways for various issues such as addictions that can be used by physicians when determining how toaccess services.24
While these guides were seen as helpful by some it was noted that they
are often not kept as up to date as necessary. Having a person in the community that they could call that had this information at hand might bean additional option. A centralized website for physicians to use was suggested as well. Additionally, greater integration between primary care andthe local public health departments might facilitate this kind of information sharing. Innovative programs in a couple of communities had publichealth services co-located in clinical practice.

Relationships with the community arehugely important and make physiciansbetter at practising medicine.
— Dr. Jill Konkin

Some suggested that strong relationships with the community were a bigger facilitator to undertaking this type ofwork (3rd). They indicated that having a relationship and a point of contact made it easier for their patients to accessservices and helped them address the needs within their practices. These relationships also enabled greater advocacy

13

for patients, and allowed physicians to be aware of the providers, groups, and even businesses who would provide themost supportive environments for their patients. While many noted that it took time to establish these relationships,
they underlined the necessity of these ties in ensuring that comprehensive care could be provided and health equity
addressed.
Physicians interviewed identified a number of practice design facilitaIf you have a team then you become
tors that made this type of work possible. The first was interdisciplinary
more powerful. You notice these issues
team-based practice (2nd). Many of the physicians interviewed worked
in general practice but feel helpless toin fully interdisciplinary models with a wide range of health providers.
address them. Team practice makes it
Many commented that this type of practice was the only way to ensure
possible to address these issues morethat their patients’ needs were met. Further, team practice enabledcompletely.
greater information to be gathered about their patients. The College
of Family Physicians of Canada has embraced a new model of primary— Dr. Gilles Julien
care called the Patient’s Medical Home. One of its tenets is the need forphysicians and other health professionals to work in partnership. Greatercollaboration is associated with improved health outcomes and increased patient satisfaction.25
Interviewees emphasized the importance of supportive compensation models
that allowed for this type of work (5th). In particular, salary models, or fee codes
for complex or vulnerable patients were seen as key facilitators. For example, thegenesis for the Inner City Health program in Toronto was a plan which allowed
physicians to get paid on an hourly basis. This helped to overcome the barrier caused by the lack of health cards for many of Toronto’s homeless. Equity— Dr. Vanessa Brcic measures for immunization are now part of pay-for-performance in Saskatoon.
Additionally, interviewees mentioned that funding for physicians to hire social
workers or community practice nurses could also facilitate this work. Similar
funding resources for other jurisdictions and practices would greatly facilitate the uptake of this type of work by physicians
across the country. Physicians identified the need to find a like-minded group of practitioners and supportive networks(7th). This type of work while rewarding, could be a challenge and could be isolating. A network of physicians and otherpractitioners could provide support as well as serve as a venue to share best practices and research.

There is a need to bring all the research together and create the evidence base. So much work is being
done and we need to highlight what
has been learned.

Finally, the physicians emphasized the role of continued research in supporting health equity work (6th). As was identified, a lack of evidence is a barrier for physicians. Physicians interviewed highlighted work they were involved in as well as
the work of other colleagues. Samples included research at the University of Alberta on improving services for homelessand street involved people; work in Saskatoon and Toronto to conduct health equity assessments and needs based planning; assessments of interventions such as the enhanced 18-month well-baby assessment, and the social paediatrics model;
reviews of the impact on attitudes of medical students and residents who had participated in service learning programs,
and ongoing research at the Centre for Research on Inner City Health at St. Michael’s Hospital in Toronto. As moreof this research is published and shared, more work can be undertaken. The need for greater knowledge translation was
highlighted by many of the physicians interviewed. It is hoped that this current study can contribute to the evidence necessary for physicians to capitalize on opportunities to address the social determinants of health and health equity.
Community Health Centre Model
Many of the physicians interviewed practised in community health centre models. These facilities integrate
a number of health and social services in an interdisciplinary team setting. Physicians are generally paid asalary to allow greater flexibility in addressing patient needs. Providers work collaboratively to address theoften complex needs of their patients and to identify the best course of action. Centres are usually locatedin areas of disadvantage and have flexible hours to accommodate patients who have faced barriers to access. This model incorporates all three of the practice design facilitators identified by interviewed physicians.
More information on this model is available at: www.cachc.ca/

14

Areas for action
In the course of the interviews, participants identified a number of areas for action. Interviewees saw a keyrole for CMA and other national medical groups in advocating for health equity issues. They identified theneed for a comprehensive and strategic approach. Some felt there was a need to frame the social and economic concerns of patients as a basic health campaign. In addition to this advocacy, many felt that a nationalorganization could take the lead in facilitating the development and dissemination of other key supports. A
preliminary list of potential actions is provided below.
These actions should not be seen as a complete list but merely suggestions that will require further refinement anddiscussion. Experts will need to be assembled to ensure that any interventions, tools or programs are as effective as
possible. In addition to the interventions discussed above, these suggestions underline the sheer volume of workthat can be done by physicians and physician organizations to address health equity in Canada.

Area of interest
Clinical practicePotential action(s)• Development/refinement of health equity/social determinants of health assessment tool
• Development/modification of clinical practice guidelines to integrate social and economic factors
into medical care

• Development of resources for physicians on programs and services for patients• Development of resources for physicians on accessing provincial/territorial and federal
programs including forms and referral pathways, etc.

• Development/consolidation and dissemination of plain language resources for patients on chronic
disease management

Education• Support and encouragement of the integration of the social determinants and health equity inmedical schools• Support and encouragement of service learning in medical schools and residency training• Development of an accredited continuing medical education programs for practisingphysiciansCompensation• Identification of effective compensation models for health equity practice in Canada• Development of these models for other jurisdictions and practice settings

Research• Support of continued research on physician interventions in health equity• Help to assemble the evidence base and best practices and facilitate knowledge translation
across Canada and internationally

Advocacy andcommunications• Develop a national network of health equity physicians• Develop an advocacy strategy for health equity in Canada• Develop an advocacy map/tool for clinicians• Explore the development of health equity leadership and advocacy training resources forphysicians

15

Physicians and health equity: Opportunities in practiceConclusion
Socio-economic factors play a larger role in creating (or damaging) health than either biological factors or
the health care system. Improvements in the social and economic conditions of Canadians and greater equity
within the health system are key strategies if population health is to be improved and the sustainability of
the health sector is to be ensured. The physicians interviewed for this study have identified a series of opportunities for action by physicians across the country, both in practice and through continued advocacy. It is
hoped that these interventions will provide Canada’s doctors with a toolbox to address challenges for theirpatients that are often overlooked. Barriers identified will need to be addressed, and successful facilitators
will need to be expanded and shared across the health sector. Leadership at the national level is necessary to
promote change and provide a sharing of knowledge among all stakeholders. Physicians have long been respectedleaders in the health care system in their communities and at the provincial/territorial and federal levels. This
research demonstrates that they possess the necessary skills to undertake greater leadership in speaking out
and addressing the social factors that have such a profound health impact. Action in areas of clinical practice, education, compensation, research, and advocacy and communication will allow Canada’s physicians tobe active agents for change and will help them provide a voice to those who are often powerless to speak forthemselves. These initiatives will allow physicians to play a significant role in ensuring health care transformation in Canada.

16

Physicians and health equity: Opportunities in practice

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Physicians and health equity: Opportunities in practice17.	 Bloch G. Poverty: A clinical tool for primary care. Toronto (ON): Family & Community Medicine, University of Toronto; 2011.
Available: http://www.healthprovidersagainstpoverty.ca/system​/files/Poverty%20A%20Clinical%20Tool%20for%20Primary%​
20Care%20%28version%20with%20References%29_0.pdf (accessed 2012 Feb 10).
18.	 National Council of Welfare. Poverty Trends in Canada: Solving Poverty Information Kit. Ottawa (ON): Her Majesty the Queenin the Right of Canada; 2007. Available at: http://www.ncw.gc.ca​/l.3bd.2t.1ils@-eng.jsp?lid=140 (accessed 2011 Mar 21)
19.	 Mikkonen J, Raphael D. Social Determinants of Health: The Canadian Facts. Toronto (ON); 2010. Available: http://www​.thecanadianfacts.org/The_Canadian_Facts.pdf (accessed 2011 Jan 14).
20.	 Mikkonen J, Raphael D. Social Determinants of Health: The Canadian Facts. Toronto (ON); 2010. Available: http://www​.thecanadianfacts.org/The_Canadian_Facts.pdf (accessed 2011 Jan 14)
21.	 Hay D, Varga-Toth J, Hines E. Frontline Health Care in Canada: Innovations in Delivering Services to Vulnerable Populations.
Ottawa (ON): Canadian Policy Research Networks; 2006. Available: http://cprn.org/documents/45652_en.pdf (accessed 2012
Feb 10)22.	 Cappon, P Co-Chair. Social Accountability: A Vision for Canadian Medical Schools. Ottawa(ON): Health Canada; 2001. Available
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20for%20Canadian%20Medical%20Schools%20-%20Health%​20Canada.pdf. (accessed 2012 Mar 13).
23.	 Frank JR Ed. The CanMEDS 2005 Physician Competency Framework: Better standards. Better physicians. Better Care.
Ottawa (ON): The Royal College of Physicians and Surgeons of Canada; 2005. Available: http://rcpsc.medical.org/canmeds​/CanMEDS2005/CanMEDS2005_e.pdf (accessed 2012 Mar 13).
24.	 Doyle-Trace L, Labuda S. Community Resources in Cote-des-Neiges. Montreal (QC): St Mary’s Hospital Family Medicine Centre;
2011.; Mobile Outreach Street Health. Pocket MOSH: a little MOSH for your pocket: A Practitioners Guide to MOSH and theCommunity We Serve. Halifax (NS) Available: http://www​.cdha.nshealth.ca/mobile-outreach-street-health (accessed 2012 Mar 5).
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PMH_A​_Vision_for_Canada.pdf (accessed 2012 Jan 27)

18

Appendix I: Interview protocol

Clinic name _____________________________________________
Address ________________________________________________
Principle contact _________________________________________
Contact phone number ____________________________________

Thank you for agreeing to speak with me. The focus of this interview is on the practical actions that physicians cantake to help address the health inequalities that arise from disparities in the social determinants of health/socioeconomic status within their practice and their communities. We would like to collect success stories and examples
of innovations, programs or practice policies that we hope can be translated to other physicians for use in theirpractices.
There are sixteen open-ended questions. There are no right or wrong answers – I am collecting descriptions andexperiences in order to prepare a background paper that we will provide to the Board and General Council of theCanadian Medical Association regarding the potential for Canadian physicians to create greater health equality intheir practices.
Documents provided to the General Council may be seen by members of the public and the press. The names ofindividuals will not be used. Please indicate if you prefer that the clinic is anonymized in any written report.
In the event that we would like to identify your practice or practice location, we will provide you with a copy of thedraft documents so that you may review the content, and we will seek specific permission before publication to alarger audience.
Before beginning, I would like to clarify one definitional issue. In several of the questions I have used the phrase“practice population.” I would define this as the number of patients for whom you have an active chart (i.e., theycome in to see you at least once in the last two years). If you are in group practice, you can answer either about
q Your own roster of patients orq The entire group practice of patients, whichever you prefer

Demographics
Goal of Questions — We need information to help us describe the type of practice in which the intervention
is used. We need to know the composition/type of the practice, as well as get a sense of the patient population
served, e.g., under-serviced populations, visible minorities or special risk populations, neighborhood vs. client
chosen site.
1.
2.
3.
4.

Is this clinic a particular category of clinic? [e.g., Community Centre, Family Health Team, etc.]
How many physicians (FTE) work in this clinic ­setting?
How many and what type of other professionals work in this clinic setting?
Roughly how large is your practice population?

19

Physicians and health equity: Opportunities in practice

5. Describe the population served by your practice (e.g., under-serviced populations, visible minorities or special
risk populations, neighborhood vs. self-referral).What would you consider to be some of the determinants of
their level of health?
6. Are you able to readily determine this from some form of database (e.g., electronic medical record)?

Opportunities for intervention
Goal of Questions — to describe the intervention used to address health inequality AND the essential facilitatorsof the interventions.
7. What opportunities would you say that you as a primary care physician have to address these determinants ofhealth and the resulting health inequalities? Can you provide any specific examples?
8. Did you work with other academic or health services to develop the intervention or was it initiated internally?
Was there a formal process for implementation? Evaluation? Has the intervention been published?
9. What are the facilitators and barriers for carrying out this work?
10. Are there other physicians or groups that you think we should speak to?
11. If the Canadian Medical Association were to create a network of health equity physicians, would you be interested in participating?

Linkages to other sectors
Goal of questions — We need to know about linkages to other sectors because part of our underlying theory isthat interventions for health equality will include agencies from outside of the health care sector. We need to know
how they ‘grew’ the linkages so that we can provide ‘tips’ to other clinicians who may wish to adopt the intervention.
12. Which health and social service agencies provide support to your practice population?
13. Do you have any links or referral mechanisms with these agencies or is it more of an informal relationship?
14. What were the facilitators in establishing linkages with health and social service agencies?
15. What were (or are) the barriers that limit your ability to work well with health and social service agencies?

Recommendations for other physicians
16. What recommendations would you make to other physicians who are interested in taking a more active role inaddressing the social determinants and health inequalities in their practices?

20Appendix II: Interview participants
Dr. David Allison

Public health — medical officer of health, Eastern HealthDr. Anne Andermann

Family physician — public health — chair, Community Oriented Primary Care Committee, Family Medicine Centre, St. Mary’s Hospital; assistant professor, Department of
Family Medicine, Faculty of Medicine, McGill University; regional medical officer, First
Nations and Inuit Health Branch, Health Canada, Quebec Region; public health physician, Regional Public Health Department, Cree Health Board (CBHSSJB)
Family physician — St. Michael’s Family Health Team; medical director, St. Michael’s
Inner City Health program; chief, St. Michael’s Hospital, Department of Family andCommunity Medicine
Family physician — St. Michael’s Family Health Team; St. Michael’s Inner City Healthprogram; assistant professor, Department of Family and Community Medicine; University of Toronto, Health Providers Against Poverty
Family physician — Sandy Hill Community Health Centre
Family physician — Clinician Scholar Program, Department of Family Practice; Clinical
Assistant Professor, University of British Columbia; locum in rural and urban interdisciplinary practices
Family physician — The North End Community Health Centre (worked at the clinic for
25 years, former director, retired)
Psychiatrist — associate clinical professor, Department of Psychiatry and Behavioural
Neuroscience, McMaster University, division of Child Psychiatry; staff, McMaster Children’s Hospital; associate, Department of Family Medicine at McMaster; associate,
Department of Child Psychiatry, University of Toronto and Sick Children’s Hospital;
associate member, Offord Centre for Child Studies.
Family physician — Shea Heights Community Health Centre — Academic CHC
FRCP emergency medicine — Royal Alexandra Hospital; faculty, Department of Emergency Medicine; faculty, Medicine and Dentistry, University of Alberta; co-director,
Edmonton Inner City Health Research and Education Network; founder and mentor ofinner city health elective, residency program at Faculty of Medicine and Dentistry, University of Alberta
Family physician — Shea Heights Community Health Centre — Academic CHC, assistant professor, Faculty of Medicine, Memorial University
Family physician — Mount Carmel Clinic (CHC), Inuit Health Program of the J.A. Hildes Northern Medical Unit, University of Manitoba
Family physician — Pictou Landing First Nation Health Centre, Canso Medical Centre,
Eastern Memorial Hospital, Canso

Dr. Philip Berger

Dr. Gary Bloch

Dr. Rob Bourrier
Dr. Vanessa Brcic

Dr. Margaret Casey
Dr. Jean Clinton

Dr. Stephen Darcy
Dr. Kathryn Dong

Dr. Norah Duggan
Dr. Anne Durcan
Dr. Cathy Felderhof

Dr. Elizabeth Lee Ford
Jones
Dr. John Haggie
Dr. Trevor Hancock
Dr. Anne Houstoun

Pediatrician — infectious diseases specialist and clinical researcher, The Hospital for Sick
Children, Department of Pediatrics; professor, Pediatrics, University of Toronto; head,Social Pediatrics, The Hospital for Sick Children, Toronto
General surgeon, chief of staff, James Paton Memorial Hospital
CMA past president
Public health — professor and senior scholar, School of Public Health and Social Policy,
University of Victoria; former public health consultant, BC Ministry of HealthFamily physician–obstetrics — The North End Community Health Centre

Mount
Pearl, NL
Montreal

TorontoTorontoOttawaVancouver

Halifax
Hamilton

St. John’s
Edmonton

St. John’s
Winnipeg
New
Glasgow,
NS &Canso, NS
TorontoGanderVictoria
Halifax21

Physicians and health equity: Opportunities in practiceDr. Gilles Julien
Dr. Jill Konkin

Dr. Sandy MacDonald
Dr. Kwame McKenzie

Dr. Ryan Meili

Dr. Len Moore
Dr. Cory Neudorf

Dr. Susan Phillips
Dr. Jane Philpott

Dr. Andrew Pinto

Dr. Brian Postl
Dr. Anna Reid
Dr. Todd Sakakibara

Dr. Konia Trouton
Dr. Jeff Turnbull

22

Pediatrician — Centres de pédiatrie sociale (one of the founders of social pediatrics
in Canada), Department of Pediatrics, McGill University
Family physician — associate dean, Community Engagement (responsible for indigenous, inner city, global and rural health); Faculty of Medicine and Dentistry, University of Alberta; rural Alberta practice for 16 years and continues to do rural locums
Family physician and anesthetist — Qikiqtani General Hospital; director, Medical
Affairs, Department of Health and Social Services, Government of Nunavut
Psychiatrist — senior scientist, Social Equity and Health Research section; deputy
director, Continuing and Community Care Schizophrenia Program, Centre for
Addictions & Mental Health; professor, Department of Psychiatry, University ofTorontoFamily physician — Westside Community Clinic; head, Division of Social Accountability, College of Medicine, University of Saskatchewan; co-founder, Student Wellness Initiative Toward Community Health (SWITCH) — student run health centre— and Making the Links program for medical students
Family physician — Sandy Hill Community Health Centre
Public health — chief medical health officer, Saskatoon Health Region; assistantprofessor, College of Medicine — Department of Community Health and Epidemiology, University of Saskatchewan
Family physician — Queen’s Family Health Team; faculty, Department of Family
Medicine, Queen’s University; member CFPC Equity and Diversity Committee
Family physician — Health for All (Family Health Team); Markham Family Medicine Teaching Unit, University of Toronto Department of Family and Community
Medicine; founder of “Give a Day to World AIDS” movement
Family physician — PH — St. Michael’s Family Health Team; family physician andpublic health and preventive medicine specialist,St. Michael’s Hospital; research fellow at the Centre for Research on Inner City Health; Health Providers Against Poverty
dean of medicine, University of Manitoba
ER — emergency physician, Stanton Territorial Hospital, Yellowknife; CMA President
Family physician — Three Bridges Community Health Centre; associate director,
Division of Inner City Medicine, University of British Columbia, Department of
Family Practice; mentor, Community Health Initiative by University Students
Family physician — Vancouver Island Woman’s Clinic; member, College of Family
Physicians of Canada Equity and Diversity Committee
Internal medicine — founder and medical director, Ottawa’s Inner City Health Project, Chief of Staff, Ottawa Hospital, former CMA president

Montreal
Edmonton

IqaluitTorontoSaskatoon

OttawaSaskatoonKingston
MarkhamTorontoWinnipeg
Yellowknife
Vancouver

Victoria
Ottawa