Chaire de Recherche du Canada sur la Gouvernance Clinique des Services de Première Ligne
Mylaine Breton holds a Canadian Research Chair in clinical governance on primary health care.
She is based at the Department of Social Science and Medicine at University of Sherbrooke. She trained as an occupational therapist, followed be an MBA at Université Laval, a doctorate in Health Service Management from University of Montréal in 2009, and a postdoctoral at Université de Sherbrooke and McGill University. Her current research focuses on primary health care to better understanding promising organizational innovations to improve accessibility and continuity such as the implementation of centralized waiting list for patients without a primary healthcare provider and advanced access.
En tant que titulaire de la Chaire de recherche du Canada sur la gouvernance clinique des services de première ligne, Mylaine Breton contribue à la création de connaissances et de pratiques novatrices dans le domaine des services de première ligne. En collaboration avec des décideurs, des cliniciens et des patients, Mme Breton et son équipe de recherche analysent les principales caractéristiques des modèles et des innovations en matière de soins de première ligne qui ont connu du succès. Leurs travaux se concentrent sur l’amélioration des stratégies visant à favoriser des changements efficaces dans les pratiques de soins de santé.
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Today we’re in Canada and I’m talking to Mylaine Breton. Lets talk about your career…
Mylaine Breton: I’ve had an unusual career path because I trained as an occupational therapist and then I decided to do an MBA. It was 25 years ago, I was young, and it was a completely different experience. I wanted to do the MBA because I was in the alpine ski team and I just wanted to continue to ski. And the only place you could do an MBA without any experience was at the University of Laval. So I did an MBA and worked part time during summer as an occupational therapist. Having completed my MBA I moved to Montreal, continued with the alpine ski team, and started a PhD in health care management at the University of Montreal. Without having done a Master’s degree, the step between an MBA and a PhD was huge but I worked really hard. When I completed my PhD, I continued my research career and did postdoc research on primary care. Since then, 2012, I’ve been a research scientist working at the university.
DMacA: Let’s bring you back to the very beginning. What started your interest in occupational therapy?
MB: I wanted to do something clinical. I didn’t have the grades needed to be a physician, so I did occupational therapy. But from first year, I knew that it was not the career I wanted to pursue. I really wanted to be a manager. My mother was a CEO at a hospital and my dream was that I too would be a manager. I felt that I needed a clinical background in order to have sufficient clinical understanding to be a decision maker so that’s why I did occupational therapy, and that’s why I did an MBA. I was now qualified but without any experience and I was too young to have a management position. That’s always been the challenge for me and although I am now a specialist on healthcare management I still don’t have any experience as a manager. Instead of being one myself, I do a lot of research in close partnership with decision makers.
DMacA: Tell me about the MBA. What was it that interested you most during the MBA?
MB: I had trained as a clinician but, when you do an MBA, there are classes in topics such as marketing, management, and accountability so it’s a completely different learning experience. I hadn’t worked, other than in my summer job as an occupational therapist, but everyone in my class was 25 years ago older than me and had lots of work experience. I was used to studying a lot during my occupational therapy training and during the MBA, while everyone else was at work, all I was doing was skiing, going to lectures and studying. Its very different if you work full time and have kids but I was young and didn’t have the same responsibilities so, even without having experience in management, I made the most of this and because I had all this time finished at the top of my MBA class.
Similarly, when I registered for PhD, the normal pathway is to do a Masters in Science first so it was a huge step for me from a methodological perspective. But I’m really pragmatic and that has influenced my career in doing applied research.
DMacA: What was it that made you want to do a PhD?
MB: I didn’t take much time to reflect on that. If you take too much time asking yourself why you are doing a PhD, I guess you won’t do it! Again, I was very young and wasn’t really ready for a job. And I was still on the ski team. So, I didn’t think too much about what it meant. After two years I realised that it was more difficult than I expected. It took six years to complete my degree, which is quite a normal timeline. I had a fellowship so I had enough money to do what I wanted and I didn’t have a partner or children. During that time I learned a lot. I didn’t expect to be a researcher, I’d never had this in mind. But, when I completed my PhD, everybody said – you should continue with research because you’re good, you can do management at any time. It was possible to continue on this research pathway in the Faculty of Medicine so I applied for the post- doctoral fellowship thinking it was a really good opportunity and if I succeed I’ll continue and if not, I’m going to find a job. I was awarded fellowship from the Canadian Foundation for Healthcare Improvement to complete a postdoc at University of Sherbrooke. By now I have two kids and a job at the university. I got a Research Career Award, and then a Canadian Research Chair. So, by this stage, I’m really on the scientific research career path. I’m now publishing and doing all the stuff you need to do as part of a scientific career.
But, even at this stage and 45 years old, I still have in mind that maybe one day I will become a manager. It wasn’t my original intention to have a career in a university and even though I am a senior scientist, perhaps I could still change. But, it has worked out well and being a university scientist is very rewarding. I work hard but my time is quite flexible, we go to international conferences and have lots of interesting opportunities.
“I feel that we are now going back towards more centralization, to the idea of a population based response but, it swings back and forth and, in about 15 years we will probably go back to a more local focus.”
DMacA: Let’s move back to the PhD, because the topic of your PhD was very important and it’s a theme that has stayed with you through your career.
MB: Interestingly, I changed my research topic after the first two years because an opportunity came along to study ‘decision makers.’ My mentor Jean-Louis Denis at that time was very engaged with decision makers in Quebec and more broadly in Canada. It was at a time of huge reform at policy level in Quebec with the creation of a 94 new health care organizations across the province with a population based focus and my director had a grant to study the process. These new structures was the result of the merger of a hospital, long-term care centres and community health centres. As a PhD student, I studied a small part of that and it was fun. My work involved following decision makers and observing them over a two year period. The 12 CEOs of the new health care organization on Montreal island met every two weeks to discuss how to manage and develop local health networks. These meetings were every two weeks and, of course, as this was 15 years ago, these were face to face meetings. I followed these CEOs observing their meeting as the organisation changed to population based responsibility. It was amazing training. I was just listening and taking notes on the main topics of discussion. It was applied research with longitudinal data collection, which was where I was trained. The subject of my PhD topic had not really been my choice but because I was interested in management, it was a good opportunity and the applied research aligned well with my interests.
I feel that we are now going back towards more centralization, to the idea of a population based response but, it swings back and forth and, in about 15 years we will probably go back to a more local focus. At the time of my PhD there was a lot of discussion on population based responsibility related to primary care- asking who were the local clinics and practices. They realised that these practices were in their locality and that they should create a partnership. It seems obvious now but this was the first step. And since then my main focus has been on primary care.
“We have this complex problem of a shortage of family physicians, difficulty registering with a doctor, and the challenge of access. We highlighted the crisis in primary care and asked that every Province take a position. They already know that primary care is problematic. Being registered with a family doctor is important.”
2019–20 Canadian Harkness/CFHI Fellow in Health Care Policy and Practice Canadian Research Chair in Clinical Governance on Primary Health Care Associate Professor, Department of Social Science and Medicine, Université Sherbrooke
DMacA: I’d like to talk to you about your interest in primary care but first let me ask you about your Harkness Fellowship.
MB: This is much more recent (2019) and it was a really amazing time. It’s an international program and it’s aimed at middle career leaders and based around policy. Some Fellows are policy makers and some are researchers. At the time I thought that, as a French-Canadian woman, I would be a good candidate. I went to Boston because it’s close to Montreal. It was somewhat of a pragmatic decision because I had kids in Montreal, but, going to Boston wasn’t a bad choice. With the arrival of Covid in the middle of the year, however, everyone went back home and it was lock-down. We continued virtually but there wasn’t the same opportunity to meet people. The whole idea was to leverage the training in United State and make some connections, which for me was around primary care. It was an amazing opportunity.
DMacA: Let’s now go back to primary care. All those strands within your career are now coming together- your research where the CEOs were talking about primary care, your own interest in primary care, and the Harkness Fellowship. And, to bring us right up to date because I saw that, together with a number of other researchers, you wrote to LaPress in November 24th about the current problems of primary care. Lets talk about that.
MB: In Quebec, 25% of the population do not have a family physician so that’s a huge problem. And we were the first Province in Canada to point this out and make it central. It a problem throughout Canada but worse in Quebec. We have this complex problem of a shortage of family physicians, difficulty registering with a doctor, and the challenge of access. We highlighted the crisis in primary care and asked that every Province take a position. They already know that primary care is problematic. Being registered with a family doctor is important. We tried to voice that and to raise awareness of primary care. I think we did a good job because it’s continued to be in the press on a regular basis and the Prime Minister has also had a lot of questions around primary care.
“We have an increased population, increasing with immigration and we also have am ageing population. With this growing population, even if we have an increase in family physicians, we are not able to compensate for this imbalance. So we have to think outside the box in way we work.”
RADIO CANADA: Nouveau bras de fer autour du GAP: Bruno Savard avec Mylaine Breton, titulaire de la Chaire de recherche du Canada sur la gouvernance clinique des services de première ligne.
DMacA: Is primary care in Quebec is different from the rest of Canada?
MB: It’s not so different but, Provincially, we don’t have the same primary care model. We have some different structures in government. In Quebec, the main primary care model is the family medicine group (FMG), which is based on the interdisciplinary team. The predominant model is based on the physician, nurse, nurse practitioner, and social worker as part of the team, together with pharmacists. If you’re registered with a family physician practising in a group, its good. But the problem is you need the key to access that care and 25% of the population do not have that access.
DMacA: You’re very interested in the primary care team, the medical home. Tell us more about that model.
MB: I think this is the vision of what we should do, this interdisciplinary team. But even if you are attached to this team, timely access is a challenge. It can be difficult trying to see your provider when you need. This whole idea is to look at how we can support the transformation of practice for those that are registered with a practice. The aim is to better organize the practice, and provide better timely access. In Quebec, and across Canada, we still believe in the advance access model. I know that there has been bad press with some misinformation suggesting that its not working, that it’s not offering a rapid appointments within 48 hours. Maybe that’s a question of urgent care, but the whole model of advance access is to offer the appointment when it’s needed. A lot of appointments are not for urgent care, so you should have an appointment when its needed, lets say, two weeks so that we can better manage the patient. And also, how do you orient the other providers who are working to support the practice. For example, if it’s a musculoskeletal problem, you should go directly to the physiotherapist instead of the physician. Currently you see the physician beforehand and they redirect. We can improve all this in the context of physician shortages and we have a lot of emphasis on how we can work as a team. In Quebec we have a lot of different healthcare providers within the team but maybe we don’t leverage them enough and we still duplicating services. We need to do re-orientate the team because physicians shortages will continue.
We have an increased population, increasing with immigration and we also have am ageing population. With this growing population, even if we have an increase in family physicians, we are not able to compensate for this imbalance. So we have to think outside the box in way we work. We have to look at we can work with other providers to support physicians and how we can support patients with their selfcare. Everybody around the world as we are working on this.
DMacA: You’ve talked about primary care on the ground, but bringing together your Harkness Fellowship and your MBA, but how do you change policy?
MB: That is the question, that’s a huge question. And often the politicians don’t listen to researchers. We know what we should do but we don’t develop our systems on those foundations. Over the last five years. For example, we’ve tried to manage to improve access for the unregistered, and even for the enrolled patients. We are focusing on access, but at some point, it’s not only about access but actually its about continuity. If we put all our emphasis on managing an individual episode of care, creating walk-in clinics, that is not the best foundation for a quality system. But in a policy context, they put a lot of emphasis on developing access. We try to work with politicians, understanding that access is an important value, but emphasising not to forget continuity.
“The four key countries in this network are Belgium, France, Switzerland and Quebec, all countries with French speakers are welcome”
Access this book here: Imaginer les soins primaires de demain.
DMacA: Finally, let me ask you about the International Francophone Group.
MB: That’s a good question. I’m just about to take up the presidency. The four key countries in this network are Belgium, France, Switzerland and Quebec, all countries with French speakers are welcome. In order to respond to a need to learn from each other in our own language (https://gfisp.org/ ) we created this network, and as I am taking up the co- presidency for the next four years, hopefully we can improve membership. We will continue activities such as doing webinars, we organise a symposium every year, and we change countries. We also have a vision of creating a summer school for new trainees in primary care in French.
DMacA: It was just wonderful chatting to you. Thank you very much for taking us through your career from the very beginning to the whole policy thing. And may I wish you every success with the international francophone group. Thank you very much indeed.
Some key research papers
https://link.springer.com/article/10.1186/s12875-021-01543-4
Use of Electronic Medical Record Data to Create a Dashboard on Access to Primary Care https://pmc.ncbi.nlm.nih.gov/articles/PMC10370395/
How the design and implementation of centralized waiting lists influence their use and effect on access to healthcare – A realist reviewhttps://www.sciencedirect.com/science/article/pii/S0168851020301202
Revising the advanced access model pillars: a multimethod study https://www.cmajopen.ca/content/10/3/E799.short
