Episode 29: Breaking Down the Barriers and Making Care Accessible With Dr. Daniel Pepe

Dr. Pepe, a primary care physician in London, Ontario and the Primary Care Digital Co-Lead of the Western Ontario Health Team, is always looking for ways to explain concepts to patients that break down the barriers and make them true partners in their care.

Show Summary

Dr. Daniel Pepe did his medical training at the Schulich School of Medicine and Dentistry at Western University. He did a surgery residency before moving into family medicine. His wife is also a family physician and together they run the London Lambeth Medical Clinic.

Dr. Pepe is truly a different kind of family physician - he loves the give and take of social media, he questions the status quo, and admits he’s often working on the fringe. Long before the pandemic, Dr. Pepe was using an array of digital tools to improve his interactions with patients. The beauty of these tools he says is that they create more options for patients and they give care providers a fuller and more accurate picture of what’s happening with patients over time.

Digital tools are just one way of approaching patient care. Dr. Pepe says he’s constantly learning from his patients and listening to their stories – those stories are his inspiration for tackling the bigger challenges in our healthcare system.

Dr. Pepe has no interest in labelling patients as non-compliant. It merely means that the physician hasn’t taken the time to explain in plain language the details of what the patient needs to know. It requires a bit of quick thinking on his part, but the resourceful physician uses analogies – stories that connect a patient’s health with their real-life – as a way of building trust.

Mentioned in this Episode

Want to hear more from Dr. Pepe? Check out his Talk with HIROC episode!

Transcript

Dr. Daniel Pepe: What I realize when I talk to patients, you ask them after you talk to them – “Okay. So what do you understand? What is the plan? What are we going to do?" Five times out of 10 people go, "I have no idea". And I appreciate that honesty, because I think sometimes we come from a little bit of a high-and-mighty place where we make lots of assumptions about what people understand, what their previous experiences are, with their ability to navigate, even with their ability to read and write, we make huge assumptions that people know what we're talking about. And then we see people back and we go, "Oh, they didn't take that medication." Thus, non-compliant patient, thus I'm going to refer them here or do this, or I'm going to have a stern talking with them. But, if you actually take the time to try and explain something as analogy, it does one thing for you. It makes you really understand the concepts and you can no longer just hide behind medical jargon and lingo.

Narrator (Intro): Imagine you could step inside the minds of Canada's healthcare leaders, glimpse, their greatest fears, strongest drivers, and what makes them tick. Welcome to Healthcare Change Makers, a podcast where we talk to leaders about the joys and challenges of driving change and working with partners to create the safest healthcare system.

Ellen Gardner: Welcome to Healthcare Change Makers, a podcast from HIROC. I'm Ellen Gardner with Philip De Souza. Today, our guest is Dr. Daniel Pepe. Dr. Pepe did his medical training at the Schulich school of Medicine and Dentistry, at Western University. He did a surgery residency before moving into family medicine. His wife is also a family physician and together they run the London Lambeth Family Medicine Clinic. Dr. Pepe is truly a different kind of family physician. He loves the give and take of social media, he questions the status quo and admits he's often working on the fringe. Long before the pandemic, Dr. Pepe was using an array of digital tools to improve his interactions with patients.

When the COVID outbreak was just starting in Canada, he and a few colleagues moved quickly to develop a web-based tool for doing virtual assessments of all patients.

Digital tools are just one way of improving accessibility to care. Dr. Pepe says he's constantly learning from his patients by listening to their stories and making them true partners in their care.

These are busy days for Dr. Pepe, as he juggles his practice, his role as the primary care digital co-leader of the Western Ontario health team and being a husband and dad to two young children who are at home during the pandemic. Dr. Pepe's lively family formed a fun backdrop for our conversation in January, from his home in London, Ontario.

Ellen Gardner: Welcome Dr. Pepe. Great to have you on Healthcare Change Makers.

Dr. Daniel Pepe: Thank you so much. I'm really excited to be here.

Ellen Gardner: When you spoke with Philip on Talk with HIROC a couple of months ago, you had just been given a Bright Lights Award for the development of a virtual assessment tool. It was at the beginning of the COVID outbreak, in Ontario. The tool, called The Patient Navigator came together in just 10 days. And it's the only tool that uses on-call providers to connect patients directly with a real person. So far, more than 80,000 people have used the tool. So how did you and your team come up with something so effective and so necessary so quickly?

Dr. Daniel Pepe: It was not something that we really did a ton of planning on, but really said we need something to defend the system. We knew that seeing people in person was probably not the best idea, given the fact that COVID-19 seemed incredibly contagious. And I had been kind of experimenting and dabbling in virtual care before. And so thinking about how we might be able to triage people and figure out essentially who's sick and not sick and who can stay home and just be monitored and who actually needs an escalation and care quickly. It was really how the idea came about. Then, like most things in my career to date, Twitter is a really interesting tool.

So I came across Dr. Damon Ramsey and Dr. Puneet Seth, from InputHealth, They had basically taken their product, which elsewhere in Canada is an EMR electronic medical record, and they had, for lack of a better word, really hacked it and adjusted the functionality of it so that it could do a broad level of screening at a population level, and then allow us to basically funnel patients into different buckets.

Dr. Daniel Pepe: Kind of like, if you imagined, back to The Price is Right, when people played Plinko and the little Plinko chips go into different buckets, that's kind of what InputHealth allowed us to do. Is it, let us say "Not sick, we don't need to do anything. Sort of sick, we should talk to you. Or really, really sick, you should go directly to the Emerg, not talk to anyone". So what we did was we took the Ministry of Health's COVID-19 screening, which I think almost everyone in Ontario has probably seen or used. We took those same questions and content, and we used that as the funnel or filter on the front end.

Dr. Daniel Pepe: And then on the backend, what we were able to do is say, "Who has a family doctor? Who doesn't have a family doctor?", If you have a family doctor, we did our best to connect you directly to your family doctor so that we maintain that continuity because we know that continuity in primary care is really important. And COVID-19 is just another illness like any other illness that primary care providers would manage. If you didn't have a family doctor, we actually had on-call physicians. So they were on-call specialists, they were emergency physicians who are not working, they were family physicians who worked in walk-in clinics that weren't seeing patients in-person. So that combination of clinicians really helped us to actually support patients early on in the pandemic. And, interestingly enough, we actually spread the effort from Windsor all the way up towards Hamilton.

Ellen Gardner: How did you move it so far geographically? Did a lot of people just find out about it organically, or did you do a big promotional push on it.

Dr. Daniel Pepe: Literally, when I saw Damon and Puneet's thing on Twitter, I sent them a message and I said "Is this a real thing?" And they said "Yes, this is absolutely a real thing", to which I then reached out to one of my clinical mentors, Dr. Cathy Faulds and Dr. Alararacki and I said "Guys, I think there's something here, or early enough in the pandemic, that no one has really thought about this. Can we move quickly?" And it's kind of, I think it's Dr. Mike Ryan, who keeps showing the YouTube video from the WHO, where he says "You need to move fast. You don't have to be perfect, but you need to move fast,” and that was really the mentality that we took early on. So we engaged a broad range of clinical stakeholders from the CAPC to the OCFP, to the OMA, to all of our local hospitals, to the LHIN.

Dr. Daniel Pepe: We had on Sunday, a demonstration of the technology with 130 people from basically across Canada, obviously focused in Ontario and Southwestern Ontario. Afterwards, we had a quick debrief and said, "Does this look like something we could use?" We established a task force that met on a daily basis that included people from acute care, primary care home, and community care and public health. We iterated on the technology over the course of that week.

And then, at the end of the week, we decided that we had something that was viable enough to go live, and then it was just learning and sharing. And so every time we expanded from region to region, we would ask, if we went to Elgin, we would say "What does Elgin need?" And if we went to Huron-Perth, we would say "What does Huron-Perth need?" When we went to Windsor Essex, we said "What were the unique challenges there?" So in each region, it was a combination of both administrative and clinical leadership.

It was something really special. I'm not sure, Ellen, I'm ever going to see something that moved at that pace and speed again, but it was a really incredible opportunity to show people, I was talking about the art of the possible. I think sometimes people just think that's in books or in magazines or in the Harvard Business Review. But I actually saw what was possible when people put aside that organizational lens and said, "What is the right thing for the patients right now?" It was pretty cool.

Ellen Gardner: So you were using digital tools long before the pandemic. What is it about those tools that you've found improves your interactions with patients?

Dr. Daniel Pepe: I just started reading, I don't know if you've ever read The Innovator's Dilemma by Clayton Christensen, and I think almost everybody has, and I'm probably the last person to have not read it. Part of the book, he talks about hard disk drives and the kind of 1980s, 1990s, and 2000s. So he talks about, every two years, the size of the drive got smaller and smaller and the capacity of the drive got bigger and bigger. And so that's kind of what I feel like my own perception of digital health is doing, is changing and morphing on a basically annual basis. And the capacity and opportunity that I see in digital health increases over and over again.

So, two years ago, when I thought about digital health, I thought about "Oh, this is patients being able to email us and ask us questions". And then, a year after that, I would have said no, it's us sending them forms and us tracking their custom vitals. So I know what their score of depression is over time. And then, six months after that, I would have said, no it's secure messaging and secure texting and video visits. And then I would have said, no, it's a secure collaboration amongst teams with primary care in paramedics and home and community care.

Digital health is all of those things. So it's really interesting because it can be as much or as little as you want, but fundamentally, if you think about what primary care is and what the special sauce of primary care is, it's a relationship. It's the fact that I know you, I know your family, I know your story, I know what's normal. And I'm more likely to be able to look at you and say "Oh yeah, this is not what Ellen looks like. You look really sick today", versus someone who's never met you before.

Dr. Daniel Pepe: And so the way that I think about digital health now is really it provides us an opportunity to continue that longitudinal relationship and enhance it to either deliver care for a specific issue over time, instead of just a visit in the office. And it also allows us to treat an issue asynchronously. So, for a lot of patients in the pandemic now, it gives us an opportunity for them to raise a concern, for me to ask clarifying questions, for them to provide history or a photo or a short video for me to provide some initial management strategies. And then for us to look at that problem and say "Okay, does this need an in-person visit? Does it need a referral? Does it need imaging? Does it need labs? And do you need to come in to do that? Or can we do that without a visit?"

Dr. Daniel Pepe: For some of the more complex patients that we have in the practice, I always tell the story of a patient that I have. I met him, I think, almost two years ago. He had a stage 4 kidney disease, which is just before the stage where you would go on dialysis. And I had had this long conversation with him and we talked about dialysis and no dialysis and what that would mean. He didn't have any family in London, the city or the region, but he did have a partner at home who was looking after him. And they had not dementia, but just some cognitive impairments. So they would be forgetful, but they weren't dangerous at home, they weren't leaving the stove on or things like that. For him, his only goal was to stay home. He said "I just want to stay home. I don't care how long I live. I don't want to go to a nursing home. I don't want to be transported to and from hospital. I don't want to spend all my days in clinic". And I said "Okay, we can do this."

Dr. Daniel Pepe: And so what we did was we set him up with a technology called Reacts, which is essentially secure texting and video visits. And what it allowed us to do was actually communicate between myself, his family that was in the US, the home and community care team, as well as community paramedics. And so whoever went to see him would drop a message in this thread. So it's kind of like you've get a WhatsApp for your life and everyone can comment on what was happening. So when the paramedics saw him, they would drop the line. When I did a house call, I would drop a line. And when the home care community care people saw him, they would drop a line.

Dr. Daniel Pepe: So we created, in essence, what is an asynchronous patient record. But the cool thing is that for a typical patient like him, before he had met me, he was in Emerg every two or three weeks. And sometimes he was admitted and sometimes he wasn't. From the time we started this virtual circle of care, the number of times he went to Emerg, over the course of 15 months was zero, which I thought was pretty amazing.

Ellen Gardner: I wonder if you were surprised when the pandemic hit and all of a sudden those tools were very interesting to your colleagues.

Dr. Daniel Pepe: Yeah, I was totally shocked because I was kind of the fringe, like "Why are you spending extra money? Why are you spending extra time? This doesn't make any sense. It's not helpful". Then I was getting "How do you do that? Can you show me? How are you still collecting money for forms, even though you're not seeing people?" And I'm like "Oh, there's this thing called e-transfer."

So there were all these really cool little niche fringy things that immediately came into the fore. Dr. Keith Thompson is another doc in our Primary Care Alliance here in London Middlesex. He had been doing virtual house calls with digitally-enabled peripherals. And he was looking after those vulnerable patients that are on ventilators and some other things. So he supports patients through Participation House. And I think, like me, Keith was kind of viewed as a fringe provider, but as soon as the pandemic came on, it was like "Man, that is where we need to be". Sometimes those forces shift, how things go.

But the other cool thing, Ellen, is that when you do things virtually, it actually creates a capacity to see more vulnerable patients in person. What I've found as the pandemic has gone on, this is kind of the next iteration of where are we going now, because it actually lets me do more house calls. For patients where technology doesn't work or they can't hear me on the phone, or if I saw them in the office, they couldn't see me easily through a mask or hear me because there's peripheral noise in the office.

Dr. Daniel Pepe: So we also have to think about that and how technology actually creates capacity for us to do that direct one-on-one care. I think that's the risk of technology, that sometimes we say, "Oh, well, everything's going to be virtual". I think the answer to that is no. Things that should be virtual can be virtual and we should do them that way, but it should also create capacity for us to actually care for the most vulnerable in-person. And we should look at how it frees up our time and energy so we can actually really do a good job for those patients, who are probably at the highest risk.

Ellen Gardner: Dan, your mom is a nurse, which I'm sure has affected your medical career. What were some of the lessons she taught you and how has she influenced your style of practice?

Dr. Daniel Pepe: I can remember picking her up. She would work at 3:00 to 11:00, was like a really common shift and all the kids would pile into the van and we'd go pick her up from South Street and she'd always be late. Like always, I mean, we'd be there at 11:00, 11:15, 11:20, 11:30. She was always dedicated to her patients, always. She always put the patients first. She always put herself second when she would delay her breaks and not take lunch and make sure that everyone was looked after because when she was younger, she was sick and she knew what it was like to be in that hospital. And she realized that, for those patients, sometimes you're the only connection that they have. And so I've taken that along with me, I think, in my own primary care practice and thought about what is the right thing for the patient and how do we do the right thing for the patient?

Dr. Daniel Pepe: It's not about me as a provider, it's not about us as a system, but how do we control the things that we can control? The one thing that I can control is how we treat people on a one-by-one interaction. So that's what it's really taught me. And then when I think about there's a common nursing adage, where they talk about the right patient, the right dose, the right time, the right medication. I've really adopted that into primary care to say "What is the right way to do this visit? What is the right care to provide this particular patient? What is the right means to communicate with them?"

And all of that really helps inform I think my own approach. But it's interesting when you have a nurse in the family, because I think, if my mom was a physician, I would think for about the evidence and the treatments and making sure that I've got the best decision that I'm making.

But what I learned from my mom is that sometimes you don't actually need to have the best evidence or you don't need to have the cure for someone, but you need to care for them. And I think that especially comes true when we're doing things like palliative care and home visits, where I can't offer anything to necessarily make someone's condition curable. But what can I do? I can treat their symptoms. I can help with their shortness of breath. I can give them a warm blanket. I can take out their garbage if they have extra garbage, like those little things that sometimes we wouldn't view as healthcare are actually healthcare.
And so, aside from my mom grilling me when I was trying to interview for medical school and saying "Sit up straight. Don't stutter. Speak clearly", and all of those other things, I think she's left me with a lot of small lessons that I didn't even realize were lessons, but dramatically impact how I care for patients and how I approach my own primary care practice.

Ellen Gardner: When you started your medical journey, you went into surgery. So was it kind of going back to maybe things that your mom had taught you about all-around care and the full person that really brought you back to family medicine?

Dr. Daniel Pepe: So I still love surgery, full disclosure. It's so fun. And the general surgeons at Western are incredible. I think part of the thing that drew me to general surgery was the team effort. And so many people don't even kind of have a concept of this, but the general surgeons that I worked with did everything. They did the medicine, they did the intensive care, they did the nursing coordination, they did the discharge planning, and I just loved how they owned the problem, whatever that problem was, be it appendicitis or colon cancer or hernia. They really owned it. They took responsibility for it and they cared for someone from end-to-end. And so I always joke that everyone thinks that general surgery and primary care couldn't be more far apart, but really I saw the general surgeons as the generalist and acute care. It was my own kind of personal health about a year and a half into general surgery that I knew I couldn't do the job that I wanted to do as a surgeon. And so that's what actually led me to switch from general surgery to primary care.

Ellen Gardner: In your conversation with Philip, you had talked about working with surgeons and how impressed you were with their ability to break down complex procedures into simple stories and pictures. That experience confirmed your belief in the power of analogies and, as Philip aptly named them, "Danalogies". So why are analogies a great way to help patients understand their own health and illnesses?

Dr. Daniel Pepe: What I realize when I talk to patients, you ask them after you talk to them "Okay. So what do you understand? What is the plan? What are we going to do?" Five times out of 10 people go, "I have no idea". And I appreciate that honesty, because I think sometimes we come from a little bit of a high-and-mighty place where we make lots of assumptions about what people understand, what their previous experiences are, with their ability to navigate, even with their ability to read and write, we make huge assumptions that people know what we're talking about. And then we see people back and we go, "Oh, they didn't take that medication". Thus, non-compliant patient, thus I'm going to refer them here or do this, or I'm going to have a stern talking too with them.
But, if you actually take the time to try and explain something as an analogy, it does one thing for you. It makes you really understand the concepts and you can no longer just hide behind medical jargon and lingo, because once you take a complex problem and explain it as an analogy, it really means that you need to understand all of the details, and you need to account for all of those details as we kind of transfer that complex medical knowledge into something more simple. So that's one thing that it does for us.

Dr. Daniel Pepe: But then the second thing is it actually allows patients to be at the same level as us when we're having a discussion. And I think that helps in terms of things like informed consent. So when we're talking about procedures, when we're doing an injection in the office, or starting someone on a medication, or explaining how a medication works, if we can explain that in simple terms, the patients are much more, A, willing to take a medication, B, able to monitor for side effects, and C, able to have an open discussion with us because they feel like we have come down, look them in the eye and had a real conversation with them versus physicians who I see, who only speak in jargon because that's all they know. I feel that sometimes the relationship and the trust that they're able to build with the patient is limited. And they aren't able to build that same trusting relationship.

Ultimately in healthcare that's what we're trying to do. We're trying to build trust with patients. Then over time, what we're trying to ensure is that, as you talk to them, they continue to rely on our information because they've had a good experience in the past, and that's enhanced the amount of trust that they have with us.

So one of my favourite questions that I ask patients is "What do you do?" And they'll tell me what they do, and then I will try and make the analogy fit to their employment, whether they are an actuary, a teacher, a plumber, a chef, whatever, because if you can take it in and give them something applicable in their life, and I think that's a skill that not a lot of healthcare providers, A, care about, or B, think that matters, and I would argue that it matters to a great degree, because if you can connect with that person within their life or to something in their life, it means so much more to them than just saying, "Oh yes, you have atherosclerosis and you need to a stent, an angioplasty and blah, blah, blah."

Ellen Gardner: You must have to come up with these analogies pretty quickly on the spot then. So I've got to ask you, maybe you could give me an example of one that you've used recently.

Dr. Daniel Pepe: So I'll give you one about colon cancer, because I'm about to screen my practice. Every three months, we do like a regular screening. And so colon cancer is a common one that we talk about and people will always go like "Oh, why do we have to do the poop tests?" And I'm like "Well, the reason you have to do the poop test is so we can catch colon cancers before they're really advanced cancers". And they're like "Well, what does that mean?" I'm like, "Well, do you have a lawn? Have you seen grass?" And most people have seen grass, they've seen grass or the sky, so that's okay, that level sets everything. So when you talk to them about grass, you say "Well, have you seen a dandelion or weed?" And they say "Well, yeah. I've seen a dandelion."

Dr. Daniel Pepe: You say "Okay. So, if we are able to identify in your stool that there is a dandelion, or there's an early colon cancer or something that we call a polyp, have you ever pulled up a weed?" And most people say "Yeah, I've pulled out a weed", and you asked them "Was that hard or easy?" And they go "Well, that was pretty easy". So that's really the purpose of why we do colon cancer screening, is it allows us to identify colon cancers before they are that big nasty spiky two-foot weed that, even if you put on gloves, you can't quite pull it out of the ground because the spikes still come through your gloves and hurt your hands. And so that's a common analogy that we'll use for colon cancer screening to explain to people the value of early identification of polyps before the progression of those polyps to something more significant. When patients go "Oh, why do I have to do that colon cancer screening?" I'll just be like "little weed or big weed?" And they're like "Right. Okay. Sounds good."

Dr. Daniel Pepe: It sounds hilarious. And it flies in the face of all the pathology and physiology and everything else. I can share with people all of the papers, I could show them all of the U.S. Preventive Task Force guidelines and all of the Choosing Wisely guidelines. And they go "Yeah, I don't care. I don't want to touch my poop". But if you give them something that they can understand, they're like "Okay, this makes sense."

Ellen Gardner: Well, I hope you know that Philip and I want you to collect all those ‘Danalogies’ and create a book or an amazing video of all of them!

Dr. Daniel Pepe: Yes! We’ll have to string them all together at some point and, and share them, because I think what they do is they make health accessible. And I think that's where we need to go, is we need to continually break down the barriers and say "Why do people not understand this? Why do people not participate?" I hate the word non-compliant, but why are people non-compliant and how can we improve their compliance, really non-compliance, as a proxy metric for like why don't people understand what we're asking for? And usually, it's because we're using project manager-speak or process maps or something else that's totally irrelevant to a patient. And, if we just did things that made sense for them, they'd be like "Oh, okay."

Ellen Gardner: You're a strong believer in the importance of patients owning their own narratives. And you've called those stories "One of the best risk mitigation strategies". Why does listening to a patient's stories help the patient, but it also reduces the workload for the care provider?

Dr. Daniel Pepe: Yeah. This is one that's taken a while for me to understand. And I think the reason it's taken a while is that, as you're coming through as a trainee, you always want to have the answer, you want to provide the best solution, you want to fix the problem. I think it's why I was drawn to surgery. Because like "Appendix. Bad appendix. Take out appendix. Okay, this is good. You had a problem. You don't have a problem now". But what I've learned over time is that a lot of problems that present in medicine do not present like the textbook. That sounds super, super cliché, but it just gets reinforced all the time. When I see people in clinic, where they present with one very vague non-specific symptom and it gets at the Polaroid analogy, which is just that sometimes the only thing that provides diagnostic clarity, meaning the only thing that helps us find the definition or the diagnosis that a patient is suffering from, is time.

Dr. Daniel Pepe: And so, by allowing patients to own their narrative, by allowing them to define the terms, by allowing them to clarify "What do you mean by dizziness? Or what do you mean by lump in your throat? Or what do you mean by pain below your navel? Or what do you mean by catching pain in your leg?" Because people will use all sorts of words and terms to describe their illness and that's good, but what our job is, is to categorize, understand and clarify what those symptoms are. From a risk mitigation strategy, I think where that comes from is that, by allowing the patient to tell the story and not defining the patient's narrative or not taking over for the patient four seconds into their visit, what it allows us to do is really understand that story at a depth that we don't traditionally do. And again, this goes back and ties into what we were talking to with digital technology.

Dr. Daniel Pepe: And sometimes we don't have 40 minutes to listen to a patient tell their whole story, but what we can do is we can say, "Keep a diary of your symptoms". And so with, the asynchronous messaging platform used in our practice, one of the most common things that I do when I don't know what's happening with the patients, I'm like "Can you just take notes? Tell me what makes it better? What makes it worse? How long does it last? When does it come? If you ever had anything in the past? Is there anything that triggers it? And what are you worried about?" And I'll have them write these things out and I'll get notes maybe once a week from patients.

Now, I have probably a more radical view of the patient narrative, which is that I do think patients should actually own their own record and be the steward of it. And that's one of the things that I really want to try and push forward, and some of the leadership work that I'm doing is allowing you to actually hold your story rather than me holding your story and needing to control things.

Ellen Gardner: So when you talk about patients having full access to their own health records, and that's something that you think is really important, and it's something you want to work on, how are we going to evolve the system to make that happen?

Dr. Daniel Pepe: I think, if I had to say where do we start, it starts with sharing the records first and foremost with patients. So it's making sure that they actually have the access to their records. And so when someone has an x-ray report, we share with them. When someone has a CT scanner scan report, we share with them. When we develop a plan with patients, we actually share that plan with patients and say "Here are the plan steps one, two, and three". And so, initially when we do that sharing of information, it's really going to be a push from primary care or specialists or the hospital to the patient. And it's clunky because the system is not directed or enabled in that way.

Dr. Daniel Pepe: But I think what we need to do, as we share that information with patients, we then need to measure the impact of that. And we need to ask ourselves, what did this prevent, or what did this enable, or what did this allow us to do? But that will take time because the system is not set up or configured at all in that way, to actually allow us to do that.

Ellen Gardner: I wanted to ask you how you would reimagine walk-in clinics.

Dr. Daniel Pepe: Yeah, it's interesting. When I think about how we're going to re-imagine care, walk-in clinics, primary care, you have to think about what the starting point is. And I think what we have to enable people to do is we have to provide a combination of both access to care, and also ensure that patients have the ability to self-manage so that when they have a problem or identify a problem, they can first find the information they need. So, if you say "I've got a sore knee", you can find reliable information to say "Okay, here's the instructions on how you take Tylenol, Advil and apply Voltaren.” And if someone in that history said "And I'd also recently fell down the stairs". We could say "Hmm, okay, that's a trauma and we should probably get an x-ray for your knee."

Dr. Daniel Pepe: We should allow you to get that x-ray maybe without even seeing a provider to get things going, but then that should be connected to a primary care provider. Because I think one of the challenges of revisiting and redefining things like walk-in clinics is that it doesn't enhance the continuity. And I think the secret sauce of primary care in our healthcare system, if we really want to look at mitigating risks and enhancing people's cares, we have to keep them with the continual team and provider. And I think we do a disservice to people when we're constantly changing who they see, because every time they see someone different, they have to start from the story over again. They have to say "Okay, what happened when you were young? What are your allergies? What are your medications? What surgeries have you had?"

Dr. Daniel Pepe: Sometimes that works well and makes sense when you're seeing a specialist who's trying to address a problem, but other times it can be really challenging when you've got a problem and every time you go in, let's say with a bit of hearing loss, you're seeing a different physician and that different physician takes a different viewpoint.

And so I think where we would start by re-imagining care, is we would reimagine what it means to actually have a care provider. We would look at the system and say, "Everyone gets a provider over time. And that provider is going to stick with you". And so that's where I would start. With a dedicated primary care provider, we can anticipate, plan and identify problems. And I think the reason why some primary care providers are more successful than others is that there's an inequity in access to resources.

Dr. Daniel Pepe: So if you're a patient of mine, you may get access to certain things like secure messaging or virtual visits or home visits. Whereas, if you are a patient of someone else's office, you'd get access to a dietician and a social worker and a physiotherapist. And so we have to ask ourselves in the system, "Why is it that just because you have a different doctor, you get different access to resources?" We should actually be saying "If you have a primary care provider, you get access to all of these things and develop common criteria". But I think part of the whole idea of how do we change the system is, first, we have to listen to patients and we have to listen to caregivers. And I do not think we have done a good job of that to date, myself included.

Ellen Gardner: With the rollout of the COVID vaccine, we've seen how primary care is asserting itself as a core part of the strategy. Are you seeing a renewed sense of pride among the primary care community? Do you think that primary care is truly a catalyst for change in our system?

Dr. Daniel Pepe: I think the long and short answer to that is, yeah. So, when I first came into primary care, I think it was like "Oh, you're not a surgeon. You don't have a white coat. You're not going to be..." There was that thought that there was a discrepancy or difference between those specialties. I can tell you, from the time that I left residency to now, it's a 180. So, I feel a sense of pride when I go to the office, I feel a sense of pride when I get to say I'm someone's family physician. And I think the sector does too. And I think that's a big difference from when we started our work in primary care is that I don't think we were necessarily viewed as a sector. I don't think we were viewed as a collaborative.

There's lots of work that we need to do to make sure that everyone's on the same page and that we're providing a high level of care, but I think there's been a huge, huge change whereby people feel a dramatic sense of pride.

Dr. Daniel Pepe: And I think to your point, Ellen, if you look at the COVID 19 vaccines, even here in London, we had, I think, 150 people sign up in 24 hours. And I was at the COVID vaccine clinic this weekend and we had, I don't know, 15 or 20 vaccinators, and most of them were primary care providers of some stripe. One of the things, even if you look within Ontario Health teams and the London Middlesex Primary Care Alliance, we had worked with the Thames Valley Health team and other stakeholders and we had actually hired Janet Dang as a Primary Care Transformation Lead. That was a role that basically did not exist a year ago. And now, when I log through my Twitter feed, I see people follow me and I look at what they do and it's Primary Care Transformation Lead. And so I think that people are really getting on this wave of primary care is the engine and primary care is the thing that's going to help us be successful.

Philip De Souza: Awesome conversation, Dan. And, as I hear you speak, I'm really like... You kind of epitomize the title of our show Healthcare Change Makers, because I can feel it – that you push boundaries, you speak up, you have that focus on patients, but more importantly, that your vision of making healthcare accessible is something that resonates with many. And I guess, my question is, and you kind of alluded to it earlier, actually, when you mentioned social media. We're noticing a lot of social media chatter, obviously for good. Amongst the healthcare community, there are a variety of frontline folks who are speaking up and who are sharing their viewpoints and who want to make that change. Right back to your first question, you mentioned how you saw something on Twitter, and then you said "Is this real?" I guess my question to you in the roundabout way, what have you learned from that process?

Dr. Daniel Pepe: What you see when you look at the healthcare space, be it hospitals, be it primary care, be it specialists, it's a much more a level playing field. And it's really interesting because there's an opportunity to learn and share. This is going to sound corny, it's more real because it's actually coming from people, it's not filtered through a comms department, it's not filtered to make sure that it checks all the boxes. It's just what people are saying or feeling in the moment. So it's more visceral and I think that visceral sharing allows us to actually drive more change and to really see what's going on.

It also, I think, to a large degree, helps us scale because no longer do we need to wait for official channels, we don't have to wait for a bulletin to get faxed out. So, if you're doing something in the moment and you're doing a drive-through flu shot clinic, you can tweet that out and be like "Hey, look what we're doing".
And then if somebody likes it, they send you a DM and they go, "Hey, how did you do that?" And I go "Oh, I did this". Then all of a sudden you've got two clinics doing that. Another example of that is, if you look at the public health units, each public health unit on Twitter has their own kind of message and style. And I was reading on Ottawa Public Health's communications yesterday, on their 11-tweet thread. And I thought "Wow, that's great". So I retweeted that to my followers. But there's a lot of lessons to be learned. And I think what it does is it accelerates the sharing.

Philip De Souza: You're absolutely right. That knowledge sharing and the second step of scaling, which I think is critical, it's something that we at HIROC value because we know that the knowledge to make change, all our subscribers have that, every subscriber across Canada is making change in their communities. It's just a matter of getting that knowledge out there. So that people could say "Oh, How did you do that? Let's connect". Not only is the connection made, but that whole process of learning together and scaling, I don't know, it's amazing to see.

Dr. Daniel Pepe: The scale is the thing that we need to actually accomplish and achieve. Because I think if you want to talk about change-making transformation, it's scale. The good ideas exist. But what we need to do is we need to figure out what are the financial, political, social, whatever barriers that's preventing that scale and enable the scale, because I think the technologies that dramatically change how we deliver care exist. It's just the will and leadership to say, "Okay, now let's go make it happen". And if we fail, fine. Fail, and then learn from it, never do it again and go on to the next thing.

Ellen Gardner: Okay. We are moving into the lightning round. I'm going to ask you a few questions, Dan, and just tell us the first thing that pops into your head.

Dr. Daniel Pepe: Okay. I'm ready.

Ellen Gardner: What was your first job?

Dr. Daniel Pepe: So I was a millwright's assistant, so I built cabinets and did some work for kitchen cabinetry.

Ellen Gardner: What's the last thing you do before you go to bed at night?

Dr. Daniel Pepe: Oh, this is embarrassing. I check my phone like everybody, I'm sorry. It's an addiction.

Ellen Gardner: What's something surprising you've learned about yourself during the past year?

Dr. Daniel Pepe: How much coffee I can drink in a single day.

Ellen Gardner: Name your go-to resource when you're stuck and you need an energy or a creative boost.

Dr. Daniel Pepe: So, in the last three weeks, it's been my bike. I cycle.

Ellen Gardner: What's one thing people could do that would improve their health?

Dr. Daniel Pepe: So they can put their phones down. Just for that extra five minutes a day.

Ellen Gardner: Tell us about your worst habit.

Dr. Daniel Pepe: Okay. So late-night snacking, I will make chicken fingers at 11 o'clock at night and enjoy them. They're just delicious.

Ellen Gardner: I'm sure your kids enjoy that kind of habit.

Dr. Daniel Pepe: Yeah.

Ellen Gardner: Finish this sentence: "If I wasn't in health care, I'd be working as a..."

Dr. Daniel Pepe: A woodworker. It's been a cool habit that's come out over time. I just finished my pandemic project of building matching nightstands for my wife and I, and the drawers are aligned and they open and close. So I'm pretty proud of that. But yeah, that's probably what I'd do. Something in the trades.

Ellen Gardner: Well, I really want to thank you, Dan, for just giving us so many amazing insights into your practice and family medicine, in general. It's been wonderful talking to you.

Dr. Daniel Pepe: Thank you guys so much. I remember listening to the Change Makers podcast when it first came out and so it's a little bit surreal actually being interviewed to be on the podcast. I really appreciate the opportunity.

Thank you for listening. You can hear more episodes of Healthcare Change Makers on our website HIROC.com and on your favourite podcasting apps. If you like what you hear, please rate us or post a review. Healthcare Change Makers is recorded by HIROC's Communications and Marketing team and produced by Podfly Productions. Follow us on Twitter at @hirocgroup or email us at communications@hiroc.com. We'd love to hear from you.