France Légaré | Doyenne of Shared Decision Making and Knowledge Translation

France Légaré: Well, I don’t know if there had been a plan, an a priori trajectory. I hold a first degree in architecture.  It was not possible for me to enter medicine at a younger age so I entered another profession that was attractive to me which blends what we’ll call science with a more artistic aspect; creativity, if I might say so. And I loved every moment of it.  I certainly got from architecture that you need to be, what we will call ‘client-centered’ and be extremely sensitive to the context.  Just to say that I see much more similarity with what I’m doing now than maybe one would expect from looking outside the profession. Now, back as being a clinician, as I was yesterday and the day before, you need to be ‘client centered’, and this is definitively one of the key principles of being a general practitioner or family physician, and you need to start from the perspective of the person coming into your office.

 

I studied in family medicine and started to practice in 1990 but as soon as I started my clinical duty I also entered the Masters degree in Public Health which I did part-time, as I was a young GP and I was starting a practice etc. 

I’ve been extremely fortunate and lucky, because there’s a lot of luck in this also, that I met the right people.  I’m still within the same clinical team as in 1990s.  And then when I started my Master’s degree in Public Health, I was very fortunate again to cross the paths of two very exceptional individuals at the time.  One was a health service researcher, one of the best experts in behavior change. He introduced me to studying behavior; behavior change.  His name is Gaston Godin. He held a Canada Research Chair at the time, and Sylvie Dodin, a clinician, in women’s health so again, I am also very grateful to her. I was very lucky because with them I really learned and got my first very basic tools to do research with them.

 

DMacA: What strikes me is that you started off with architecture, which was very creative and client-centered, and then you moved to public health and you did your PhD in population medicine, which is a very different angle to healthcare.

 

FL:  I was a clinician at the individual level, which is being a GP so I’d meet with people on a one-to-one but, yes, I had some interest in public health or as we sometimes also call it, community health, because it deals with the community.  You need to better understand the population that you provide service to. You’re being exposed to a more social aspect of health, you know, those social determinants of health which are quite important.  One being, among others, ‘behavior’.  That’s the connection and, being a clinician, again I stress that I still see patients, real patients.  We know that sometimes we have a need for a toolbox where we tell patients, or we discuss with them, the need to change behavior of some sort- either having to take a medication, a treatment, but also nutrition, exercise etc.  So it’s very very connected.

 

When you do this type of degree you get exposed to other things, and I got exposed to other aspects, but that was the one where, as I said, I put in a bit more time because my supervisor introduced me to behavior change and how you intervene to change behavior- this whole idea of motivational interviewing,  theory of planned behavior etc which is quite useful as a toolbox  in the one-to-one (consultation) as a clinician and also as a public health doctor. To me everything is connected.

 

DMacA: This seems a very nice opportunity to talk about your main research interest at the moment, which is shared decision making.

 

FL: Thank you for bringing it up. So I went from changing behavior, for which I still have the toolkit to work on, to helping people make informed, we say value congruent decisions.  At the time we were trying to change the prescription behavior of doctors, we were trying to change the adherence to medication of patients.  And in those same years, mid 90s or late 90s,  I met with Annette O’Connor, University of Ottawa, who actually became my PhD supervisor a few years after.  And I was then struck by the fact that there are many options in health and sometimes you may not be well equipped to be certain that one option is much better than another, especially in whole area of prescription of drugs or uptake of drugs.  So, why not present the options to the patient and discuss with them, discuss risk and benefit, and what matters most to them.  So, I went from actually trying to change behavior of prescriptions and uptake of medication to actually trying to emphasize informed choice that matched with what matters most to patients. That’s the shift that naturally occurred and that brought me to shared decision making, patient decision aids etc.  And that’s the topic I chose when I did my PhD in Population Health which again is linked to the health of the population, obviously, but I did focus on how do we help clinicians in primary care to integrate the patient voice and making decisions about their treatment,  diagnosis,  test etc.

 

DMacA: I’d like to ask you about something very different now… are there issues relating to the francophone and anglophone research community?

 

FL: I think that when you think, you think in your language.  It is challenging to say that it’s universal and that everyone will understand.  Even within the field I am in, shared decision making, we’ve done what I call the literal traduction- translation which is decision partagé but it doesn’t always mean the same.  Even this morning with one of my students who was defending part of her PhD thesis in French, something similar was happening. One of the key interviewers was from France (?)*, another one from was from Quebec, and even the words matter; what do you mean, define this concept, is this what this means or do you mean this, rather.  My understanding is that it may actually be connected to some topics of interest that you will have in your capacity to actually push forward. It’s an observation and I’m not a neuro scientist. 

But, yes, when you speak words in a specific language, and you think in a specific language, you try to express yourself in a specific language, and you’re being asked- is this what it means- obviously there is some, not divergence but, differences.

 

In Health Services Research it’s even more important to some extent because, when you do what we call ‘Knowledge Translation’, mobilization of knowledge. If you work with a policy maker in the Province of Quebec, or my colleagues at the clinical sites, or patients, and French is their first language, and that’s where they feel the most comfortable, you need to run your project in French but you need to co-construct it in French. If you go the way of co- construction, sometimes it’s quite hard to bring it back and forth.  I’ve been involved with many pan-Canadian networks and projects but it’s not that easy.  There are differences and you need to be cognisant of them.  Everybody knows that in Canada right now, where one policy is of reconciliation, the First Nations have multiple different languages and they say it very clearly that it’s something that is of great importance for them to do research, to stay healthy etc.  So I would suspect that it has an influence but it doesn’t mean that we cannot talk to each other.

 

DMacA: Now let me bring you back to your own research but from a different angle, because I’d like to ask you about your recent awards. You’ve had a number of awards and the most recent I think is the Chevalière. Tell me a little bit about this.

 

FL: Yes, in English it would be ‘Knight’. It happened last year which would mean that, a year prior to that, a group of people knew about my work and felt that it has an impact, and asked if they could submit my candidacy. It was built around the contribution that they felt

had an impact,  they felt they wanted to put it forward, but I would suspect also that any award, and that’s my vision on this, has to do not with your own person, but that you bring the voice of others you’ve worked with or that you may actually give a voice to, which is:  I’m a GP and, again that was stressed as a characteristic, so they also wanted to praise general practice.

 

Then, there was the voice of the patient.  And I got this award last year at the same time as a partner patient got one as well.  A group of people submit the file but, actually, I think that the committee wanted to highlight elements that are not necessarily linked to my own personal contribution but are linked to something else that they wanted to highlight, which mainly was to be a GP and, being with my other colleague who was a patient partner, that the society be reminded that the patient voice is quite important. That’s how I see it and I approach it.

 

DMacA: It’s a wonderful achievement and it’s a great tribute to Primary Care /Family Medicine and it’s a great honor for everyone in family medicine.  So congratulations,  it’s just wonderful.  Let me ask you finally about the future and your research ideas for the future because your research funding has just been renewed.

 

FL: I hold a Canada Research Chair as I’ve had since 2006, two cycles called the junior, which is a level two, and now my second cycle of senior, level one.  Again, I’m very grateful to Canadians and always being reminded that I do this because Canadians work very hard themselves- and I owe it to them.

Our focus is threefold, as we say.  The idea of patient engagement, providing the voices of patients during the clinical encounter or outside the clinical encounter, and what matters most to individuals when they make a health related decision, is something we want to scale so we’re very much into scale right now. We love that the area of implementation science, if I might say so.  So scaling, paying attention to those in societies in Canada who have the least voice and making decisions about the health because, we’ve done a couple of surveys and we have a sense of where it’s not happening at all and where it’s happening a little bit.  We’re still doing this or and want to do it further.

 

And as you mentioned,  I’ve been exposed to many graduate students coming from French speaking Africa and French is gaining visibility internationally.  We suspect there are about 320 million French speaking people in the world so we’re also now working much more with the global south and focusing a bit more with the French speaking global south where there are different issues pertaining to patient engagement. The science of scale is also, not only of great interest but they have the skill. So that’s another focus.

 

And the third focus is this idea of training the next generation, capacity building. This is capacity building within the medical field  because, I’m still doing clinical work and yesterday and the day before there was a resident in family medicine with me, but also a graduate student that I’m very privileged to accompany, and who comes from a diverse country or culture.  So, we can build capacity and help them launch their own,  not just a research program, but their professional life and future network.  That’s really the focus right now.

 

 DMacA: That idea of capacity building and future proofing primary care is a wonderful note to end on. France, it has been an absolute pleasure talking to you, thank you very much indeed.