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In this warm and candid episode of Remarkable World Commentary, host Donna J. Jodhan sits down with her own family physician, Dr. Danielle Manis, a North York family doctor of more than two decades who now serves as Chief and Program Medical Director of Family and Community Medicine at North York General Hospital. Dr. Manis traces her path into medicine, a love of learning, problem-solving, and people, and the example of an influential mentor, Dr. Val Rachlis, and explains why she has never left the community where she trained, practices, teaches, and now leads. She unpacks what comprehensive, continuity-based family medicine really means, and how knowing patients and their families over many years lets her deliver more personal care.
The conversation then widens to how care itself is organized: health-system integration, Ontario Health Teams and the North York Toronto Health Partners, the drive to attach every patient to a family doctor (including a new Get Well Family Health Team and a central intake pathway), and the team-based model that lets nurses, social workers, and dietitians each practice at the top of their scope. Running throughout is a frank, mutual thread on accessibility, Dr. Manis openly acknowledges that her office’s secure messaging portal and intake tools may not yet work for blind patients like Donna, and commits to doing better, before the episode closes on an optimistic note about the future of primary care and the next generation of family doctors.
TRANSCRIPT
Podcast Commentator: Greetings. Donna J. Jodhan, LLB, ACSP, and MBA invites you to listen to her bi-weekly podcast, Remarkable World Commentary. Here, Donna shares some of her innermost thoughts, insights, perspectives, and more with her listeners. Donna focuses on topics that directly affect the future of kids, especially kids with disabilities. Donna is a blind advocate, author, sight loss coach, dinner mystery producer, writer, entrepreneur, law graduate, and podcast commentator. She has decades of lived experiences, knowledge, skills, and expertise in access, technology, and information. As someone who has been internationally recognized for her work and roles, she just wants to make things better than possible.
Donna J. Jodhan, LLB, ACSP, MBA: Hello everybody, and welcome to another episode of Remarkable World Commentary. I’m Donna J. Jodhan, a lifelong disability advocate, and one who sees the world mainly through sound, touch, and stubborn optimism. I’m a law graduate, an accessibility consultant and author, a lifelong barrier buster who also happens to be blind. You may know me from a few headline moments. In November 2010, I won the landmark Charter case that forced the Canadian government to make its websites accessible to every Canadian, not just to sighted ones. And in July of 2019, I co-led the Accessible Canada Act with more than two dozen disability groups, to turn equal access into federal law. And most recently, on June the 3rd, 2022, I was greatly humbled by Her Late Majesty’s Platinum Jubilee Award, for tireless commitment to removing barriers. When I’m not in a courtroom, or in a committee room, or in a pottery studio, you will find me coaching kids with vision loss, producing audio mysteries, or helping tech companies make their gadgets talk back in plain language. Everything I do circles one goal: to turn accessibility from an afterthought into everyday practice. I invite you to think of this show as our shared workbench, where policy meets lived experience, and lived experience sparks fresh ideas. Now, before we jump into today’s conversation, let me shine a quick spotlight on today’s guest, a change maker whose work is every bit as remarkable as the world that we are trying to build. I am absolutely pleased and honored to have my family physician, Dr. Danielle Manis, as our guest today. Welcome, Dr. Danny.
Dr. Danielle Manis: Thank you so much, Donna. What a wonderful introduction that was.
Donna Jodhan: Well, let’s get going. So, Dr. Danny, welcome to the Remarkable World Commentary. I’d like to begin at the beginning. So tell us: what first drew you to medicine, and how did you find your way to family medicine in particular?
Dr. Danielle Manis: This is such a great question, and I’ve come so far from ever thinking about this, so thank you for making me think about it again. It’s been so many years since I chose this path. Part of it was that, as a child, I loved learning. I’m very curious, and I love problem solving, so I was very much drawn to the sciences and the intellectual challenges of solving problems, making a diagnosis, or whatever it may be. But I also really like people. I always default to a positive feeling when I meet new people, and I’m very interested in other people’s lives and experiences, and in playing a meaningful role. So that was how medicine was a draw for me. And when I was lucky enough to get into medical school, which was a little bit easier in those days than it is now, I made my way through all of the courses and all of the different experiences and rotations, and I was interested in everything. That was the common thread: I found everything interesting. But if it was too specialized, I found myself getting bored. So, you know, three weeks in cardiac surgery, literally holding on to someone’s heart while it’s being operated on, sounds really, really cool. But after the second day I thought, okay, this is the same thing over and over again. I like variety. I like not knowing what I’m going to deal with. And then I was really lucky to have some inspirational mentors along the way, and excellent role models, through doing electives and rotations. I already kind of thought I wanted to be a family doctor, because of the meaningful, long-term relationships that family doctors have with their patients. But then I did an elective with Dr. Val Rachlis, who was a leader in our department and a former chief of this department, and a big leader in health care in Canada. And I watched his interactions with his patients, and that was it. I said, yes, this is what I want to be. I want to be that trusted advisor, that expert clinician who really cares about their patients. And that was it. That was it for me.
Donna Jodhan: I can tell you that you are a fine example of one of the best doctors that I have ever interacted with. And I’m not telling you this to give you a big head. I mean it.
Dr. Danielle Manis: Oh, that’s so kind of you, Donna.
Donna Jodhan: I really mean it. For some reason, I thought you were from Montreal.
Dr. Danielle Manis: No, no, no, not from Montreal. I’m actually quite local. I grew up in North York, so I really haven’t strayed too far. I did some undergrad training in London, Ontario, but I did most of my training in Toronto.
Donna Jodhan: Okay. So you’ve built your whole career, your training, your practice, and your teaching, and now your leadership, within the North York General and University of Toronto community. What has it meant to you to put down roots and grow in one community for more than 20 years?
Dr. Danielle Manis: This is hard to even put into words, but I’m going to try, because we are a podcast. There’s something really special about the community that I work in. I can’t really explain the warmth and the collaboration and the open-mindedness and the acceptance. It just creates this culture of wanting to give back and wanting to stay. As a student, I was a medical student at North York General, I was a medical resident at North York General, I joined a practice in North York, and I’ve never left. And when I look around, so many of my colleagues are the same, some of them quite a bit senior to me. If I’ve been here for 25-plus years, some of them have been here 40-plus years. What I see with our young graduates from our residency program is that they want to stick around and stay here and give back, because they’ve had such a wonderful experience in their training that they want to turn around and work with the same group of people, and train the next group coming up. And what it really means, especially in the community-based model that we have, is that it would be very easy to get very isolated and siloed in your office. If you’re a doctor in an office and you work with three or four people, and you’ve never once met any of the specialists at the hospital, or you don’t know anybody who picks up the phone at any of these other clinics, it’s really easy to be isolated. When you’re really embedded, especially in education, or you get involved with Ontario Health Teams or any kind of volunteer opportunities, it just enriches your practice so much. You don’t feel so alone. You feel part of a medical community, and it’s a really wonderful one. So I feel like I’ve gotten to know the community for years and years, through all of our trainees, all of our services, all of our committee work, and my involvement. And I just would not want to be anywhere else.
Donna Jodhan: You know, that’s so refreshing to hear. Some people would say, I can’t wait to get out of this environment and move somewhere else. But giving back is very important to me, and I really appreciate you saying this as well.
Dr. Danielle Manis: Well, I feel like it’s our job, especially as a leader in this department. Retaining our wonderful health care workers is a huge part of our strategy. We have to perpetuate this welcoming community. Practicing medicine and working in health care is very hard; it’s very challenging these days. So it’s not that we don’t have those challenges, it’s that we have a very supportive, positive environment in which to do that kind of work. And it’s part of the mandate, because we need those people to stick around. I need someone to take care of me one day, too.
Donna Jodhan: And your office certainly exudes warmth and welcoming vibes whenever we walk in there.
Dr. Danielle Manis: Nice to hear. I always feel like it’s a very happy family in my office as well, and we’ve been working together now for about 25 years.
Donna Jodhan: Wow. So you’re what’s known as a comprehensive family physician. Some people call it cradle-to-grave care. For listeners who may not know the term, what does full-scope family medicine look like day to day? And why have you stayed so committed to practicing that way?
Dr. Danielle Manis: So I’ll say I’m what’s known as an office-based comprehensive family physician. The real comprehensive family physicians are the ones who not only run their clinic in their office, but also come into the hospital and deliver babies, and they might also be working in the operating room as an assistant. And some of them work in the emergency department. There’s a whole bunch of other settings in which family doctors can work, especially if you get into the more rural and smaller communities; that is the model that most of those family doctors do, and it is remarkable. In the city environment, a lot of my colleagues are doing all kinds of interesting work outside of their office. I am office-based. So what does it mean to me? Certainly, I’d like to put the family in family medicine as much as possible. We like to have whole families in our practice. We like multiple generations. We like to have all the siblings, all the kids, and the grandmas and grandpas, because it’s convenient for patients. It’s much easier. When you have a couple in their 80s and they’re both coming to see the same physician, or the parents are bringing their newborn in but they’re also patients, they don’t have to go to different places to get their care. As a physician, I really strongly believe we do better medicine when we understand the patient and their context. So knowing who else is in their family, who they live with, whether they’re dealing with a husband at home with dementia and their caregiver stress, or whatever context we know about the patient, allows us to understand their symptoms and their presentation, and how we can best help them. So that’s really what it means. It’s along the full life span, from birth to death. And there really is no problem that can ever get presented to us where we can say, well, that’s not my department. We will always do our best to address it, figure it out, deal with it, and access the services that people might need. We’re just kind of there for the long haul.
Donna Jodhan: I was certainly so relieved when you took such good care of my mom when she needed your help a few years ago.
Dr. Danielle Manis: [unclear]
Donna Jodhan: Yeah, she’s always asking about you. So, you’ve cared for many of the same patients and families since 2003. What do those long relationships teach you that a single visit never could? And how does that continuity shape the care you give?
Dr. Danielle Manis: It’s really about knowing the patients. I feel so spoiled, because in some ways my practice has gotten a bit more challenging over time, just because we’ve been together a long time, we are all getting older, so we have more health problems, a little more complexity, more things to deal with. So I’m getting a lot busier with the same number of patients I always had. But on the flip side, it’s also easier, because I know my patients. So if someone who rarely ever comes in for any reason, really high-functioning and stoic, comes in with terrible abdominal pain, I approach that a little differently than someone I see once a month with abdominal pain that has had 100 investigations. You just have a sense of, okay, this might be appendicitis, because I’ve never seen this person come in like this. It’s that kind of context. It’s understanding what’s going on at home, what’s going on at work, what is causing them stress, what excites them, what their health literacy is, what their understanding of their symptoms is, whether they prefer to go on medications or prefer to avoid medications. I know this about my patients. So you’re kind of starting ahead, as opposed to having to catch up from the very beginning. And as you might know, I’ve had a locum physician filling in for me a little bit in the last year or so while I’ve been really busy, and he’s wonderful, but there’s a lot of catch-up you have to do when you don’t know people. I already know; I don’t have to go back and spend 20 minutes reading the chart before I go in the room. I already know what I’m walking into.
Donna Jodhan: And, you know, I often hear your voice saying to me, have you booked your mammogram, Donna? Yes, I have. Good, thank you. October the 13th is the big day, so I thought I’d share that with you.
Dr. Danielle Manis: Oh my gosh, that’s a big win. That’s the thing: sometimes we have to have conversations with people many times to try to get buy-in to make a change, like quitting smoking, or eating a bit better, or going for that test. You have to understand their values and their reasons. You’re not going to meet a stranger and have them tell you once, and then you’re just going to do it. Sometimes you have to build that trust over time, and we have to be patient. And sometimes people book their mammograms. That’s great.
Donna Jodhan: I guess it took you a very long time to convince me to go and get it. And I will tell you, I was afraid to go, because those things are painful.
Dr. Danielle Manis: Yeah, they are. And I will say, I know you have your questions, but I was very honored you asked me for this podcast. I don’t feel qualified, because it’s been very eye-opening to learn about your advocacy work, and to really stop and think about how much better we should be doing in my office and in health care for people with blindness. I think, oh my gosh, I’m almost ashamed to have learned that our secure messaging portal is not accessible to you, and that there are so many things we could be doing better. So for me, this is, I’m going to eat some humble pie and say, I want to learn how we can do better to make it accessible. And maybe going for a mammogram is not just about the pain. Maybe getting into the hospital, or wherever you’re going for it, is very challenging, and I think we have to be very sensitive to that, too.
Donna Jodhan: And I will definitely let you know when I go, how it turns out. I would say that your office, they’re very, very aware of accessibility issues, and they’re very attentive to my needs and requirements when I get in there. They don’t hesitate: let me help you take your weight, let me help you with the blood pressure machine, and all that. So I think you and your office are doing a marvelous, marvelous job. And it’s one step at a time. And we work by example and keep going.
Dr. Danielle Manis: Yeah. Well, we’re very lucky, because we’ve managed to retain some of our administrative staff for a very long time, and so they know our patients really, really well also. Ramona just celebrated 20 years with us, if you can believe it. So our medical office admins are very much part of the health care team, and that interaction with patients is so important. They need to know patients as well.
Donna Jodhan: Yeah. Now, you started out as a brand-new family doctor, and you have since been named Chief and Program Medical Director of Family and Community Medicine at North York General. Looking back, what were the moments or experiences that carried you from the front line to leading an entire department?
Dr. Danielle Manis: I’m actually not even sure how this happened to me. I still don’t really know. It was definitely not an ambition of mine to say, oh, I’m going to be a leader and rise through the ranks. It’s a lot of mentorship, a lot of other people seeing leadership potential in me, and then voicing that and giving me the confidence to try to put myself forward for this role. Because it was definitely not something that I ever thought I could do, or even that I wanted to do, because it seemed like quite a lot. And it’s one of the things that, now that I’m in this role, is my mandate and my job: to mentor that in others and to raise other people up into leadership positions. And I will say, as a whole, family doctors are quite humble. They’re very heroic; their job is really difficult. But they just kind of get their nose to the grindstone and take care of their patients and do what needs to be done. And most of them don’t see themselves as leaders, or think they necessarily have the skills to do certain leadership roles. So it does take a lot of what we call shoulder-tapping, to say, hey, are you thinking about doing this? I had a few very memorable people in my department, who I consider to be mentors, reach out to me and say, this role is coming up, and I think you’re the one who should be doing it. And I had to hear it a number of times before I started to think it might actually be true. And then once I got here, it required, and still requires, a lot of coaching and mentorship from the chief who came before me, Dr. David Eisen, who was a huge mentor of mine, and one of the people who had to twist my arm until I finally accepted that maybe I could do this. And the open-door policy around being able to ask questions of anyone, that’s really how you get here. That’s how leadership happens: through support. And I guess it goes back to how wonderful the culture of our department really is.
Donna Jodhan: And such was your humbleness that I did not learn this from you personally. It was Ramona who let the cat out of the bag. Months later, she said, did you know she’s now the big cheese? I said, big cheese of what? And then she told me. I’m so pleased. I think no one else deserves it better than you.
Dr. Danielle Manis: You know what, it’s so nice that you say that, Donna. I sent out an email blast to my patients, and I know you were unable to read it, which is upsetting to me. But I only sent it out because I had decided to hire a locum physician one day a week, because I just needed more time away from the office to do this other role, and I had to explain to my practice why I was doing that. I anticipated a lot of pushback, because people get very attached and territorial with their family doctor. They often don’t want anyone else they don’t know, or they don’t want the after-hours doctor; they just want the person who knows them. And the reality in this world is that most family doctors, we can’t be there all the time for everyone, and many of us do have other roles and responsibilities. So I was really expecting that from my patients, and I got the opposite. I got a lot of, wow, I’m so proud of you. I got emails, I got cards sent to me, congratulations on your role, we’re so proud of you. And I thought, wow, that’s really telling about that relationship and how valuable that is, how much they value their family doctor. And I guess it goes both ways. I’m really grateful for that.
Donna Jodhan: Now, your locum is Dr. Kim?
Dr. Danielle Manis: No, my locum is Dr. Taglione. So Dr. Kim is actually my resident. They’re both young men, so I can see why you might confuse them. But yeah, Dr. Kim is my resident; Dr. Taglione is my locum.
Donna Jodhan: Okay. I met both of them.
Dr. Danielle Manis: Yes, wonderful.
Donna Jodhan: And it was Dr. Taglione who said you have to go and get your mammogram.
Dr. Danielle Manis: Yeah, so maybe he gets the credit. That’s fair.
Donna Jodhan: No, he doesn’t get the credit, because afterwards, I kept hearing your voice saying, Donna, have you booked your mammogram? Oh, gosh. So, what I find remarkable is that you didn’t step away from seeing patients when you took on leadership. You still practice. Why was it so important to you to keep one foot firmly in the clinic, even as chief?
Dr. Danielle Manis: It will always be important to me. From a professional standpoint, being a family physician is my number one role and my number one priority. There’s a very strong sense of responsibility to our patients, because we know them; that’s a core value of being a family physician. The role I have is called a clinical chief, and that’s for a reason. All of the department chiefs at our hospital are clinical, meaning they’re still doing their patient-facing work in addition to being leaders of their departments. And I think it really is necessary, to inform the leadership role, to be in the trenches, day to day, doing health care in our system, to really understand what our department members are dealing with every day, what our patients are dealing with every day, and then using that to inform leadership and system change. But really, on a personal level, I’m a family doctor first, before I’m a leader. I’ve had other, I guess we’ll call them side gigs, professional jobs along the way, in education and leadership, but that was always a complement to being a family physician. And it will always be that way. That’s just the way it is.
Donna Jodhan: May you stick around until I pass on.
Dr. Danielle Manis: Oh, I don’t know about that. We’ll see.
Donna Jodhan: So your defining work is something called health system integration. In plain language, what does that mean, and why should it matter to an ordinary patient sitting in the waiting room?
Dr. Danielle Manis: So, health system integration. I was going to say it’s kind of like the Holy Grail: when our system is perfectly integrated, then we can all die happy. But it’s actually a work in progress, so I think it has to be looked at as a process. It is absolutely the goal: making a system that works better for everybody, both the patients and those who provide care. And I think anybody who’s had pretty much any interaction with the health care system could probably attest to the fact that there are bumps along the way. There are communication gaps, there are unnecessary delays, and extra duplication of efforts, that just make health care a little bit less accessible and less seamless than it should be, and probably more expensive and less efficient, and overall, just not helping the health of our population. So absolutely everything I’m working on is to try to improve that. And I don’t mean me; there are tons of leaders and people across the province who are working on integrating our health system. There are a million different ways that that looks, from allowing electronic systems to speak to one another, so that information can be found wherever you’re seeking care, or maybe one day, like our provincial government has announced, working towards a single electronic record for the whole province. Wouldn’t that be something? Or processes that mean referrals happen more seamlessly. So if I need to send someone to see a dermatologist, I don’t spend time going on a map and looking for dermatologists, and sending them a letter to find out that they won’t take my patient, and then doing that all over again. There should be seamless portals where I can pop this information into a portal, and the system will find my patient a dermatologist in their area that’s available. Poof, it’s done. It’s faster, it’s less work for me, it’s less waiting for the patient, and it’s less on the receiving end of the referral. So these are all the kinds of things that are being worked on. They require a huge amount of time and money. Digital tools, as you can imagine, are a big part of it; privacy legislation is a big part of it. So this is going to take a lot of effort, but we’re already making good strides, and there are a lot of neat programs in place that make care much better already. And there’s still a long way to go.
Donna Jodhan: You helped lead one of Ontario’s first Ontario Health Teams. For anyone hearing that phrase for the first time, like myself, what exactly is an Ontario Health Team, and what does it change about the way care is delivered?
Dr. Danielle Manis: You’re really hearing that term for the first time. And that says to me they need to do better PR, because they need to get the word out there. So, what is an Ontario Health Team? The model was devised about seven or eight years ago. Essentially, the whole province is divided up into health regions, and each one has a health team. Each team is basically a collaborative body that incorporates all the health care providers and patient representatives within that region. Ours is called the North York Toronto Health Partners. They were all developed at the same time, but it was definitely one that developed quickly and matured very quickly, under fantastic leadership. And it incorporates not only a primary care network, but also our hospital, our not-for-profit partners in the community, our home care agencies, and a patient care advisory council. So the idea is that it’s working towards that seamlessness, the idea of stitching together silos that are providing care in the same geographic area, having them work together as collaborators to provide services and pool their resources.
Donna Jodhan: That’s a big job, isn’t it?
Dr. Danielle Manis: It’s a huge undertaking. It’s been, I think, hugely successful. Obviously, the primary care side is what I’m most involved in, and the OHTs have really been delivering on the mandate of creating primary care attachment, making sure that pretty much everyone in our neighborhood has access to a family doctor or family health team. The OHTs have been a big vehicle for making that work come to fruition, among many other amazing initiatives. And we’re great partners with North York General; they really support this work, as do Baycrest and all kinds of others. I don’t want to start naming them, because I’ll miss some, but I think we have over 20 partners. It’s a very tight-knit, collaborative group of health care providers and agencies that have a shared goal, which is equity-deserving care in our communities, seamlessness of care in our communities, and just basically making our community healthier and our system function better.
Donna Jodhan: A phrase that comes up often in your world is patient attachment, along with the challenge of so-called unattached patients. Can you explain what that means, and what you and your partners are doing to help people find a family doctor?
Dr. Danielle Manis: So, unattached essentially refers to somebody who doesn’t have a family doctor or access to primary care. And it was identified, this is no secret, it’s been all over the media the last several years, that more and more Canadians did not have that. The reasons are very complex. A lot of it has to do with burnout and remuneration in family medicine, and people quitting, and people not choosing to do family medicine, or not choosing to do it in a comprehensive way, narrowing their practice down. And lo and behold, we had lots of people without family doctors. So there have been a lot of great policy shifts across the country to try to address that. One of them, in Ontario, has been this task force led by Dr. Jane Philpott, to basically attach all Ontarians to primary care. I think the year was 2029; I might be wrong about when that is. So what’s been happening in our Ontario Health Team is, money flows if you create a proposal that is robust and meets the needs of the mandate of that committee. And so we’ve been successful with getting some of that funding, and creating some. We actually have a new family health team in North York, which is a huge win, because new family health teams don’t come along that frequently. It’s called the Get Well Family Health Team, and that’s run by Dr. Kevin Lai. So that’s a big deal, that a new family health team was formed. And some of our existing family medicine groups and family health teams were able to expand and accept more patients, because they got more funding for things like nurses and dietitians and administrators, basically having more people on the team who can help pick up some of that workload, which can therefore allow everybody to take care of more patients. So far, we’ve been doing quite well. And one of the big wins, again, because the system can be a bit confusing, was the fairly recent creation of a central intake pathway. So anybody in North York who needs a family doctor can simply go to a website or call a phone number, explain who they are, and there’s an intake person who can help match them to a family doctor in North York. All of this takes a lot of work, and we’ve been quite successful in attaching many of our unattached patients. I don’t have the numbers right in front of me.
Donna Jodhan: Is that website accessible, Doctor?
Dr. Danielle Manis: Well, it’s funny, if you hear me clicking, I’m clicking on it right now. I have to find out if it’s accessible. How can I tell if it’s accessible?
Donna Jodhan: I guess I would have to go in and have a look.
Dr. Danielle Manis: Okay. Well, I can tell you what the website is, and then you can go in and have a look.
Donna Jodhan: Sure.
Dr. Danielle Manis: So it’s the North York Toronto Health Partners website, https://northyorktorontohealthpartners.ca. And if you can navigate through it, there’s a button right at the top, a red bar at the top, that says, do you need a family doctor? Click here. And that actually takes you directly to our central navigation portal. You can fill out an online form, or call them if you like.
Donna Jodhan: I would be interested to see how accessible the form is.
Dr. Danielle Manis: Yeah, it’s in multiple languages, that I can tell you for sure. I don’t know about the accessibility for people who are visually impaired. But we can have a look together, and then you can let me know, and then I’ll know who to contact if it’s not okay.
Donna Jodhan: So the clock is starting to wind down, but I have this for you.
Dr. Danielle Manis: Sure.
Donna Jodhan: You are a real champion of team-based primary care: nurses, social workers, pharmacists, dietitians, and more, all working side by side. What does a true care team make possible that one physician alone simply can’t? And what do you mean when you talk about everyone practicing at scope?
Dr. Danielle Manis: So, I’m old enough to remember not being in a team. When I first started practice with my colleagues, it was just four physicians and one and a half administrators, and that was it. No nurses. We had no access to mental health supports for our patients. We had no dietitians. Which really just meant we did everything ourselves, which is okay, everybody’s happy to roll their sleeves up and get to work. But what happens is, if you’re trained to do a certain set of skills, but someone else can also do some of those skills, then you can do the higher-level skills. If you’re not busy giving vaccines to babies, that’s fine, I don’t mind doing that, but now that I’m in a team-based model, I’ve got a nurse who can do that. And, to be honest, a nurse who can do a lot of things better than I can do them, because that’s their expertise. So they can spend time counseling the patient on all their screening and prevention maneuvers, or diet, or exercise, or how to take their medications properly, and doing their height and weight and giving them vaccines, all of that stuff that I can also do. But the idea of everybody working at the top of their scope of practice, doing the job that they’re trained to do, just means that you build capacity in the system. It’s more efficient, and you can actually take care of more people and do more things. And so that’s really where team-based care excels. Again, it also goes back to one person not being able to be everything to everyone. If you can’t be in the office seven days a week, but you have somebody who can answer messages and answer the phone, you create more access for people to their health care team. But we also have to rethink, we’ve talked a lot about how valuable that one-on-one relationship is with the family doctor, we do need people to start opening their minds to this team-based model, and to understand that yes, their family doctor might be kind of the anchor of the team, but that’s their team, too. Getting care from the nurse, or the dietitian, or the social worker, or the administrator who answers the phone, is care. That counts as access, and those people are really there to help take care of them. Because I think it also contributes a lot to burnout when people feel they have to do everything themselves, and this is where we saw people leaving family medicine. So when teams work well together, everybody is happier. The people providing the care, and the patients, they get a little bit more access, they get more expertise from people who know how to do different things, and ultimately things just run better. So it really is the ideal model.
Donna Jodhan: I think, for me, I’ve had to get used to the team-based approach. I remember, at first, Nurse Emily, I didn’t want to see Nurse Emily. No way would I want to see poor old Nurse Emily. But I’ve gotten used to her. I understand her function, and she’s there to help.
Dr. Danielle Manis: Yeah, and she really does have expertise. She’s a certified diabetes educator. She’s got expertise that I don’t have. That’s the other thing: I really felt the absence of it in my early practice years, around mental health support. It’s shocking, really, how much of our days we spend dealing with mental health problems. I think it’s the bulk of what family doctors are doing these days, at least it is for me. And I’m no psychologist or social worker. If you have no access to that support for the patients, and they can’t pay for it, it’s a huge burden, and we’re not really equipped for it. Now I have social workers I work with. I can refer my patient to someone who has that skill set, or a dietitian who can help them work through how to manage their IBS and their high cholesterol. I don’t have that skill set, and it’s not just that I don’t have the time, I don’t actually know how to do it well. I’m not trained for it. So it really does elevate the level of care across the board, to have all of these other experts in their areas working together.
Donna Jodhan: And I’ll share with my listeners: a few years ago, when my mom fell, I just thought, oh gosh, am I going to lose my girl here? What’s going to happen? You sent me to a social worker on your team, who really, really helped me out. With that team-based approach, where would I be?
Dr. Danielle Manis: Yeah. And I don’t have the skills that she had. So I’m really grateful for that, because I think you needed that, and I needed you to have that. We’re really, really lucky to work with wonderful professionals.
Donna Jodhan: So, Dr. Danny, we’re almost at the end of our podcast, and I have this personal question for you. Would you like to see any of your kids in family medicine?
Dr. Danielle Manis: You know, I would, but the ship has sailed, because my kids have chosen their paths, and medicine is not happening for them. But would I recommend it for them? 100%. I think it is such a rewarding career. And yes, there are challenges, and yes, it is difficult, and it is hard work; the inbox management is a bit of a plague upon all of us. That being said, I’m so hopeful for the future. I’ve already seen, I think, transformational change just in the past four or five years, in terms of care models and OHT work and changes in remuneration. And I see our young trainees coming through, our medical students and our medical residents. I’ve been teaching trainees for many, many years, and there’s a feeling of optimism. It’s palpable in the last couple of years of our trainees. I just think that they’re coming in at such a great time. And primary care is primary. There were a lot of years where the focus was always on acute care and hospital care and surgery, and in medical education there’s what they call this hidden curriculum, where there’s a quiet messaging that, you know, if you’re just going to be a family doctor, if you’re too smart to be a family doctor, why aren’t you being a surgeon, or something like that? And I think we’ve really done a great job of reversing that messaging, and understanding that family medicine physicians are specialists, and that generalism is a specialty, and it does take a very challenging skill set. It is intellectually rewarding and difficult. It is emotionally rewarding and difficult. Sometimes I liken it to parenting a little bit: parenting is all-encompassing, and you’re exhausted at times, and it’s exasperating at times, because you care so much, but at the same time it’s incredibly rewarding. And I feel the same about family medicine. It’s hard, but it matters, and the rewards are so great. I just feel really optimistic about it. There’s no other career I would have wanted for myself. I would definitely have encouraged my kids to go down that road if they had any inkling of an interest. And I’m delighted to mentor any of our medical students and aspiring residents into family medicine, because I think it’s fantastic.
Donna Jodhan: I’m kind of sorry that none of them decided to follow in your footsteps. Oh, dear.
Dr. Danielle Manis: Oh, they’re their own people, and that’s great. And I’m here to support them. That’s perfect.
Donna Jodhan: There is one particular resident that I met, and I told you this, I thought she was one of the best residents. I don’t remember her name. Nice young lady.
Dr. Danielle Manis: How many years ago?
Donna Jodhan: Roughly about two or three years ago.
Dr. Danielle Manis: That was probably Zahra.
Donna Jodhan: Could be.
Dr. Danielle Manis: Zahra Bahira. Did she have an accent? She’s from Iran.
Donna Jodhan: A little bit of an accent, but she was, oh my God. I said, this is our future.
Dr. Danielle Manis: Oh, well then I’m going to have to send this to her, if it was her. It could have been someone else; I’ve had a few female residents. I’ve had a mix of different residents over the past years, but some wonderful ones. I had Nicole Schooley; she was a resident during COVID, so probably five, six, seven years ago.
Donna Jodhan: No, not her.
Dr. Danielle Manis: Not her. So maybe it was Zahra. Yeah, we’ve had some wonderful, wonderful trainees. I can’t say a bad word about any one of them. I would be delighted for them to take care of me in my old age.
Donna Jodhan: You have a long way to go.
Dr. Danielle Manis: Don’t worry.
Donna Jodhan: It has been a pleasure having you. And if you ever wanted to come back and talk about what’s going on in your neck of the woods, please reach out to me and let me know, because I’d be delighted to have you again.
Dr. Danielle Manis: Thank you, Donna. I’m honored to know you. And it’s funny, as much as I say I love knowing my patients, the first I ever heard of you being in a pottery studio was during your introduction. So, clearly some things to learn about you still.
Donna Jodhan: Well, there you go. So thank you very, very much. I wish you a great summer. And I think I’m supposed to see you at the end of September.
Dr. Danielle Manis: Perfect. Have a wonderful summer. Thank you so much for having me.
Donna Jodhan: Thank you, Dr. Danny. Take care now.
Dr. Danielle Manis: Bye-bye.
Donna Jodhan: Bye-bye.
Podcast Commentator: Donna wants to hear from you, and invites you to write to her at donnajodhan@gmail.com. Until next time.
Donna J. Jodhan, LLB, ACSP, MBA
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Related
Remarkable World Commentary Episode #97: Interview with Dr. Danielle Manis, Chief, Department of Family and Community Medicine, North York General Hospital
🎙️ Listen to this Podcast.
In this warm and candid episode of Remarkable World Commentary, host Donna J. Jodhan sits down with her own family physician, Dr. Danielle Manis, a North York family doctor of more than two decades who now serves as Chief and Program Medical Director of Family and Community Medicine at North York General Hospital. Dr. Manis traces her path into medicine, a love of learning, problem-solving, and people, and the example of an influential mentor, Dr. Val Rachlis, and explains why she has never left the community where she trained, practices, teaches, and now leads. She unpacks what comprehensive, continuity-based family medicine really means, and how knowing patients and their families over many years lets her deliver more personal care.
The conversation then widens to how care itself is organized: health-system integration, Ontario Health Teams and the North York Toronto Health Partners, the drive to attach every patient to a family doctor (including a new Get Well Family Health Team and a central intake pathway), and the team-based model that lets nurses, social workers, and dietitians each practice at the top of their scope. Running throughout is a frank, mutual thread on accessibility, Dr. Manis openly acknowledges that her office’s secure messaging portal and intake tools may not yet work for blind patients like Donna, and commits to doing better, before the episode closes on an optimistic note about the future of primary care and the next generation of family doctors.
TRANSCRIPT
Podcast Commentator: Greetings. Donna J. Jodhan, LLB, ACSP, and MBA invites you to listen to her bi-weekly podcast, Remarkable World Commentary. Here, Donna shares some of her innermost thoughts, insights, perspectives, and more with her listeners. Donna focuses on topics that directly affect the future of kids, especially kids with disabilities. Donna is a blind advocate, author, sight loss coach, dinner mystery producer, writer, entrepreneur, law graduate, and podcast commentator. She has decades of lived experiences, knowledge, skills, and expertise in access, technology, and information. As someone who has been internationally recognized for her work and roles, she just wants to make things better than possible.
Donna J. Jodhan, LLB, ACSP, MBA: Hello everybody, and welcome to another episode of Remarkable World Commentary. I’m Donna J. Jodhan, a lifelong disability advocate, and one who sees the world mainly through sound, touch, and stubborn optimism. I’m a law graduate, an accessibility consultant and author, a lifelong barrier buster who also happens to be blind. You may know me from a few headline moments. In November 2010, I won the landmark Charter case that forced the Canadian government to make its websites accessible to every Canadian, not just to sighted ones. And in July of 2019, I co-led the Accessible Canada Act with more than two dozen disability groups, to turn equal access into federal law. And most recently, on June the 3rd, 2022, I was greatly humbled by Her Late Majesty’s Platinum Jubilee Award, for tireless commitment to removing barriers. When I’m not in a courtroom, or in a committee room, or in a pottery studio, you will find me coaching kids with vision loss, producing audio mysteries, or helping tech companies make their gadgets talk back in plain language. Everything I do circles one goal: to turn accessibility from an afterthought into everyday practice. I invite you to think of this show as our shared workbench, where policy meets lived experience, and lived experience sparks fresh ideas. Now, before we jump into today’s conversation, let me shine a quick spotlight on today’s guest, a change maker whose work is every bit as remarkable as the world that we are trying to build. I am absolutely pleased and honored to have my family physician, Dr. Danielle Manis, as our guest today. Welcome, Dr. Danny.
Dr. Danielle Manis: Thank you so much, Donna. What a wonderful introduction that was.
Donna Jodhan: Well, let’s get going. So, Dr. Danny, welcome to the Remarkable World Commentary. I’d like to begin at the beginning. So tell us: what first drew you to medicine, and how did you find your way to family medicine in particular?
Dr. Danielle Manis: This is such a great question, and I’ve come so far from ever thinking about this, so thank you for making me think about it again. It’s been so many years since I chose this path. Part of it was that, as a child, I loved learning. I’m very curious, and I love problem solving, so I was very much drawn to the sciences and the intellectual challenges of solving problems, making a diagnosis, or whatever it may be. But I also really like people. I always default to a positive feeling when I meet new people, and I’m very interested in other people’s lives and experiences, and in playing a meaningful role. So that was how medicine was a draw for me. And when I was lucky enough to get into medical school, which was a little bit easier in those days than it is now, I made my way through all of the courses and all of the different experiences and rotations, and I was interested in everything. That was the common thread: I found everything interesting. But if it was too specialized, I found myself getting bored. So, you know, three weeks in cardiac surgery, literally holding on to someone’s heart while it’s being operated on, sounds really, really cool. But after the second day I thought, okay, this is the same thing over and over again. I like variety. I like not knowing what I’m going to deal with. And then I was really lucky to have some inspirational mentors along the way, and excellent role models, through doing electives and rotations. I already kind of thought I wanted to be a family doctor, because of the meaningful, long-term relationships that family doctors have with their patients. But then I did an elective with Dr. Val Rachlis, who was a leader in our department and a former chief of this department, and a big leader in health care in Canada. And I watched his interactions with his patients, and that was it. I said, yes, this is what I want to be. I want to be that trusted advisor, that expert clinician who really cares about their patients. And that was it. That was it for me.
Donna Jodhan: I can tell you that you are a fine example of one of the best doctors that I have ever interacted with. And I’m not telling you this to give you a big head. I mean it.
Dr. Danielle Manis: Oh, that’s so kind of you, Donna.
Donna Jodhan: I really mean it. For some reason, I thought you were from Montreal.
Dr. Danielle Manis: No, no, no, not from Montreal. I’m actually quite local. I grew up in North York, so I really haven’t strayed too far. I did some undergrad training in London, Ontario, but I did most of my training in Toronto.
Donna Jodhan: Okay. So you’ve built your whole career, your training, your practice, and your teaching, and now your leadership, within the North York General and University of Toronto community. What has it meant to you to put down roots and grow in one community for more than 20 years?
Dr. Danielle Manis: This is hard to even put into words, but I’m going to try, because we are a podcast. There’s something really special about the community that I work in. I can’t really explain the warmth and the collaboration and the open-mindedness and the acceptance. It just creates this culture of wanting to give back and wanting to stay. As a student, I was a medical student at North York General, I was a medical resident at North York General, I joined a practice in North York, and I’ve never left. And when I look around, so many of my colleagues are the same, some of them quite a bit senior to me. If I’ve been here for 25-plus years, some of them have been here 40-plus years. What I see with our young graduates from our residency program is that they want to stick around and stay here and give back, because they’ve had such a wonderful experience in their training that they want to turn around and work with the same group of people, and train the next group coming up. And what it really means, especially in the community-based model that we have, is that it would be very easy to get very isolated and siloed in your office. If you’re a doctor in an office and you work with three or four people, and you’ve never once met any of the specialists at the hospital, or you don’t know anybody who picks up the phone at any of these other clinics, it’s really easy to be isolated. When you’re really embedded, especially in education, or you get involved with Ontario Health Teams or any kind of volunteer opportunities, it just enriches your practice so much. You don’t feel so alone. You feel part of a medical community, and it’s a really wonderful one. So I feel like I’ve gotten to know the community for years and years, through all of our trainees, all of our services, all of our committee work, and my involvement. And I just would not want to be anywhere else.
Donna Jodhan: You know, that’s so refreshing to hear. Some people would say, I can’t wait to get out of this environment and move somewhere else. But giving back is very important to me, and I really appreciate you saying this as well.
Dr. Danielle Manis: Well, I feel like it’s our job, especially as a leader in this department. Retaining our wonderful health care workers is a huge part of our strategy. We have to perpetuate this welcoming community. Practicing medicine and working in health care is very hard; it’s very challenging these days. So it’s not that we don’t have those challenges, it’s that we have a very supportive, positive environment in which to do that kind of work. And it’s part of the mandate, because we need those people to stick around. I need someone to take care of me one day, too.
Donna Jodhan: And your office certainly exudes warmth and welcoming vibes whenever we walk in there.
Dr. Danielle Manis: Nice to hear. I always feel like it’s a very happy family in my office as well, and we’ve been working together now for about 25 years.
Donna Jodhan: Wow. So you’re what’s known as a comprehensive family physician. Some people call it cradle-to-grave care. For listeners who may not know the term, what does full-scope family medicine look like day to day? And why have you stayed so committed to practicing that way?
Dr. Danielle Manis: So I’ll say I’m what’s known as an office-based comprehensive family physician. The real comprehensive family physicians are the ones who not only run their clinic in their office, but also come into the hospital and deliver babies, and they might also be working in the operating room as an assistant. And some of them work in the emergency department. There’s a whole bunch of other settings in which family doctors can work, especially if you get into the more rural and smaller communities; that is the model that most of those family doctors do, and it is remarkable. In the city environment, a lot of my colleagues are doing all kinds of interesting work outside of their office. I am office-based. So what does it mean to me? Certainly, I’d like to put the family in family medicine as much as possible. We like to have whole families in our practice. We like multiple generations. We like to have all the siblings, all the kids, and the grandmas and grandpas, because it’s convenient for patients. It’s much easier. When you have a couple in their 80s and they’re both coming to see the same physician, or the parents are bringing their newborn in but they’re also patients, they don’t have to go to different places to get their care. As a physician, I really strongly believe we do better medicine when we understand the patient and their context. So knowing who else is in their family, who they live with, whether they’re dealing with a husband at home with dementia and their caregiver stress, or whatever context we know about the patient, allows us to understand their symptoms and their presentation, and how we can best help them. So that’s really what it means. It’s along the full life span, from birth to death. And there really is no problem that can ever get presented to us where we can say, well, that’s not my department. We will always do our best to address it, figure it out, deal with it, and access the services that people might need. We’re just kind of there for the long haul.
Donna Jodhan: I was certainly so relieved when you took such good care of my mom when she needed your help a few years ago.
Dr. Danielle Manis: [unclear]
Donna Jodhan: Yeah, she’s always asking about you. So, you’ve cared for many of the same patients and families since 2003. What do those long relationships teach you that a single visit never could? And how does that continuity shape the care you give?
Dr. Danielle Manis: It’s really about knowing the patients. I feel so spoiled, because in some ways my practice has gotten a bit more challenging over time, just because we’ve been together a long time, we are all getting older, so we have more health problems, a little more complexity, more things to deal with. So I’m getting a lot busier with the same number of patients I always had. But on the flip side, it’s also easier, because I know my patients. So if someone who rarely ever comes in for any reason, really high-functioning and stoic, comes in with terrible abdominal pain, I approach that a little differently than someone I see once a month with abdominal pain that has had 100 investigations. You just have a sense of, okay, this might be appendicitis, because I’ve never seen this person come in like this. It’s that kind of context. It’s understanding what’s going on at home, what’s going on at work, what is causing them stress, what excites them, what their health literacy is, what their understanding of their symptoms is, whether they prefer to go on medications or prefer to avoid medications. I know this about my patients. So you’re kind of starting ahead, as opposed to having to catch up from the very beginning. And as you might know, I’ve had a locum physician filling in for me a little bit in the last year or so while I’ve been really busy, and he’s wonderful, but there’s a lot of catch-up you have to do when you don’t know people. I already know; I don’t have to go back and spend 20 minutes reading the chart before I go in the room. I already know what I’m walking into.
Donna Jodhan: And, you know, I often hear your voice saying to me, have you booked your mammogram, Donna? Yes, I have. Good, thank you. October the 13th is the big day, so I thought I’d share that with you.
Dr. Danielle Manis: Oh my gosh, that’s a big win. That’s the thing: sometimes we have to have conversations with people many times to try to get buy-in to make a change, like quitting smoking, or eating a bit better, or going for that test. You have to understand their values and their reasons. You’re not going to meet a stranger and have them tell you once, and then you’re just going to do it. Sometimes you have to build that trust over time, and we have to be patient. And sometimes people book their mammograms. That’s great.
Donna Jodhan: I guess it took you a very long time to convince me to go and get it. And I will tell you, I was afraid to go, because those things are painful.
Dr. Danielle Manis: Yeah, they are. And I will say, I know you have your questions, but I was very honored you asked me for this podcast. I don’t feel qualified, because it’s been very eye-opening to learn about your advocacy work, and to really stop and think about how much better we should be doing in my office and in health care for people with blindness. I think, oh my gosh, I’m almost ashamed to have learned that our secure messaging portal is not accessible to you, and that there are so many things we could be doing better. So for me, this is, I’m going to eat some humble pie and say, I want to learn how we can do better to make it accessible. And maybe going for a mammogram is not just about the pain. Maybe getting into the hospital, or wherever you’re going for it, is very challenging, and I think we have to be very sensitive to that, too.
Donna Jodhan: And I will definitely let you know when I go, how it turns out. I would say that your office, they’re very, very aware of accessibility issues, and they’re very attentive to my needs and requirements when I get in there. They don’t hesitate: let me help you take your weight, let me help you with the blood pressure machine, and all that. So I think you and your office are doing a marvelous, marvelous job. And it’s one step at a time. And we work by example and keep going.
Dr. Danielle Manis: Yeah. Well, we’re very lucky, because we’ve managed to retain some of our administrative staff for a very long time, and so they know our patients really, really well also. Ramona just celebrated 20 years with us, if you can believe it. So our medical office admins are very much part of the health care team, and that interaction with patients is so important. They need to know patients as well.
Donna Jodhan: Yeah. Now, you started out as a brand-new family doctor, and you have since been named Chief and Program Medical Director of Family and Community Medicine at North York General. Looking back, what were the moments or experiences that carried you from the front line to leading an entire department?
Dr. Danielle Manis: I’m actually not even sure how this happened to me. I still don’t really know. It was definitely not an ambition of mine to say, oh, I’m going to be a leader and rise through the ranks. It’s a lot of mentorship, a lot of other people seeing leadership potential in me, and then voicing that and giving me the confidence to try to put myself forward for this role. Because it was definitely not something that I ever thought I could do, or even that I wanted to do, because it seemed like quite a lot. And it’s one of the things that, now that I’m in this role, is my mandate and my job: to mentor that in others and to raise other people up into leadership positions. And I will say, as a whole, family doctors are quite humble. They’re very heroic; their job is really difficult. But they just kind of get their nose to the grindstone and take care of their patients and do what needs to be done. And most of them don’t see themselves as leaders, or think they necessarily have the skills to do certain leadership roles. So it does take a lot of what we call shoulder-tapping, to say, hey, are you thinking about doing this? I had a few very memorable people in my department, who I consider to be mentors, reach out to me and say, this role is coming up, and I think you’re the one who should be doing it. And I had to hear it a number of times before I started to think it might actually be true. And then once I got here, it required, and still requires, a lot of coaching and mentorship from the chief who came before me, Dr. David Eisen, who was a huge mentor of mine, and one of the people who had to twist my arm until I finally accepted that maybe I could do this. And the open-door policy around being able to ask questions of anyone, that’s really how you get here. That’s how leadership happens: through support. And I guess it goes back to how wonderful the culture of our department really is.
Donna Jodhan: And such was your humbleness that I did not learn this from you personally. It was Ramona who let the cat out of the bag. Months later, she said, did you know she’s now the big cheese? I said, big cheese of what? And then she told me. I’m so pleased. I think no one else deserves it better than you.
Dr. Danielle Manis: You know what, it’s so nice that you say that, Donna. I sent out an email blast to my patients, and I know you were unable to read it, which is upsetting to me. But I only sent it out because I had decided to hire a locum physician one day a week, because I just needed more time away from the office to do this other role, and I had to explain to my practice why I was doing that. I anticipated a lot of pushback, because people get very attached and territorial with their family doctor. They often don’t want anyone else they don’t know, or they don’t want the after-hours doctor; they just want the person who knows them. And the reality in this world is that most family doctors, we can’t be there all the time for everyone, and many of us do have other roles and responsibilities. So I was really expecting that from my patients, and I got the opposite. I got a lot of, wow, I’m so proud of you. I got emails, I got cards sent to me, congratulations on your role, we’re so proud of you. And I thought, wow, that’s really telling about that relationship and how valuable that is, how much they value their family doctor. And I guess it goes both ways. I’m really grateful for that.
Donna Jodhan: Now, your locum is Dr. Kim?
Dr. Danielle Manis: No, my locum is Dr. Taglione. So Dr. Kim is actually my resident. They’re both young men, so I can see why you might confuse them. But yeah, Dr. Kim is my resident; Dr. Taglione is my locum.
Donna Jodhan: Okay. I met both of them.
Dr. Danielle Manis: Yes, wonderful.
Donna Jodhan: And it was Dr. Taglione who said you have to go and get your mammogram.
Dr. Danielle Manis: Yeah, so maybe he gets the credit. That’s fair.
Donna Jodhan: No, he doesn’t get the credit, because afterwards, I kept hearing your voice saying, Donna, have you booked your mammogram? Oh, gosh. So, what I find remarkable is that you didn’t step away from seeing patients when you took on leadership. You still practice. Why was it so important to you to keep one foot firmly in the clinic, even as chief?
Dr. Danielle Manis: It will always be important to me. From a professional standpoint, being a family physician is my number one role and my number one priority. There’s a very strong sense of responsibility to our patients, because we know them; that’s a core value of being a family physician. The role I have is called a clinical chief, and that’s for a reason. All of the department chiefs at our hospital are clinical, meaning they’re still doing their patient-facing work in addition to being leaders of their departments. And I think it really is necessary, to inform the leadership role, to be in the trenches, day to day, doing health care in our system, to really understand what our department members are dealing with every day, what our patients are dealing with every day, and then using that to inform leadership and system change. But really, on a personal level, I’m a family doctor first, before I’m a leader. I’ve had other, I guess we’ll call them side gigs, professional jobs along the way, in education and leadership, but that was always a complement to being a family physician. And it will always be that way. That’s just the way it is.
Donna Jodhan: May you stick around until I pass on.
Dr. Danielle Manis: Oh, I don’t know about that. We’ll see.
Donna Jodhan: So your defining work is something called health system integration. In plain language, what does that mean, and why should it matter to an ordinary patient sitting in the waiting room?
Dr. Danielle Manis: So, health system integration. I was going to say it’s kind of like the Holy Grail: when our system is perfectly integrated, then we can all die happy. But it’s actually a work in progress, so I think it has to be looked at as a process. It is absolutely the goal: making a system that works better for everybody, both the patients and those who provide care. And I think anybody who’s had pretty much any interaction with the health care system could probably attest to the fact that there are bumps along the way. There are communication gaps, there are unnecessary delays, and extra duplication of efforts, that just make health care a little bit less accessible and less seamless than it should be, and probably more expensive and less efficient, and overall, just not helping the health of our population. So absolutely everything I’m working on is to try to improve that. And I don’t mean me; there are tons of leaders and people across the province who are working on integrating our health system. There are a million different ways that that looks, from allowing electronic systems to speak to one another, so that information can be found wherever you’re seeking care, or maybe one day, like our provincial government has announced, working towards a single electronic record for the whole province. Wouldn’t that be something? Or processes that mean referrals happen more seamlessly. So if I need to send someone to see a dermatologist, I don’t spend time going on a map and looking for dermatologists, and sending them a letter to find out that they won’t take my patient, and then doing that all over again. There should be seamless portals where I can pop this information into a portal, and the system will find my patient a dermatologist in their area that’s available. Poof, it’s done. It’s faster, it’s less work for me, it’s less waiting for the patient, and it’s less on the receiving end of the referral. So these are all the kinds of things that are being worked on. They require a huge amount of time and money. Digital tools, as you can imagine, are a big part of it; privacy legislation is a big part of it. So this is going to take a lot of effort, but we’re already making good strides, and there are a lot of neat programs in place that make care much better already. And there’s still a long way to go.
Donna Jodhan: You helped lead one of Ontario’s first Ontario Health Teams. For anyone hearing that phrase for the first time, like myself, what exactly is an Ontario Health Team, and what does it change about the way care is delivered?
Dr. Danielle Manis: You’re really hearing that term for the first time. And that says to me they need to do better PR, because they need to get the word out there. So, what is an Ontario Health Team? The model was devised about seven or eight years ago. Essentially, the whole province is divided up into health regions, and each one has a health team. Each team is basically a collaborative body that incorporates all the health care providers and patient representatives within that region. Ours is called the North York Toronto Health Partners. They were all developed at the same time, but it was definitely one that developed quickly and matured very quickly, under fantastic leadership. And it incorporates not only a primary care network, but also our hospital, our not-for-profit partners in the community, our home care agencies, and a patient care advisory council. So the idea is that it’s working towards that seamlessness, the idea of stitching together silos that are providing care in the same geographic area, having them work together as collaborators to provide services and pool their resources.
Donna Jodhan: That’s a big job, isn’t it?
Dr. Danielle Manis: It’s a huge undertaking. It’s been, I think, hugely successful. Obviously, the primary care side is what I’m most involved in, and the OHTs have really been delivering on the mandate of creating primary care attachment, making sure that pretty much everyone in our neighborhood has access to a family doctor or family health team. The OHTs have been a big vehicle for making that work come to fruition, among many other amazing initiatives. And we’re great partners with North York General; they really support this work, as do Baycrest and all kinds of others. I don’t want to start naming them, because I’ll miss some, but I think we have over 20 partners. It’s a very tight-knit, collaborative group of health care providers and agencies that have a shared goal, which is equity-deserving care in our communities, seamlessness of care in our communities, and just basically making our community healthier and our system function better.
Donna Jodhan: A phrase that comes up often in your world is patient attachment, along with the challenge of so-called unattached patients. Can you explain what that means, and what you and your partners are doing to help people find a family doctor?
Dr. Danielle Manis: So, unattached essentially refers to somebody who doesn’t have a family doctor or access to primary care. And it was identified, this is no secret, it’s been all over the media the last several years, that more and more Canadians did not have that. The reasons are very complex. A lot of it has to do with burnout and remuneration in family medicine, and people quitting, and people not choosing to do family medicine, or not choosing to do it in a comprehensive way, narrowing their practice down. And lo and behold, we had lots of people without family doctors. So there have been a lot of great policy shifts across the country to try to address that. One of them, in Ontario, has been this task force led by Dr. Jane Philpott, to basically attach all Ontarians to primary care. I think the year was 2029; I might be wrong about when that is. So what’s been happening in our Ontario Health Team is, money flows if you create a proposal that is robust and meets the needs of the mandate of that committee. And so we’ve been successful with getting some of that funding, and creating some. We actually have a new family health team in North York, which is a huge win, because new family health teams don’t come along that frequently. It’s called the Get Well Family Health Team, and that’s run by Dr. Kevin Lai. So that’s a big deal, that a new family health team was formed. And some of our existing family medicine groups and family health teams were able to expand and accept more patients, because they got more funding for things like nurses and dietitians and administrators, basically having more people on the team who can help pick up some of that workload, which can therefore allow everybody to take care of more patients. So far, we’ve been doing quite well. And one of the big wins, again, because the system can be a bit confusing, was the fairly recent creation of a central intake pathway. So anybody in North York who needs a family doctor can simply go to a website or call a phone number, explain who they are, and there’s an intake person who can help match them to a family doctor in North York. All of this takes a lot of work, and we’ve been quite successful in attaching many of our unattached patients. I don’t have the numbers right in front of me.
Donna Jodhan: Is that website accessible, Doctor?
Dr. Danielle Manis: Well, it’s funny, if you hear me clicking, I’m clicking on it right now. I have to find out if it’s accessible. How can I tell if it’s accessible?
Donna Jodhan: I guess I would have to go in and have a look.
Dr. Danielle Manis: Okay. Well, I can tell you what the website is, and then you can go in and have a look.
Donna Jodhan: Sure.
Dr. Danielle Manis: So it’s the North York Toronto Health Partners website, https://northyorktorontohealthpartners.ca. And if you can navigate through it, there’s a button right at the top, a red bar at the top, that says, do you need a family doctor? Click here. And that actually takes you directly to our central navigation portal. You can fill out an online form, or call them if you like.
Donna Jodhan: I would be interested to see how accessible the form is.
Dr. Danielle Manis: Yeah, it’s in multiple languages, that I can tell you for sure. I don’t know about the accessibility for people who are visually impaired. But we can have a look together, and then you can let me know, and then I’ll know who to contact if it’s not okay.
Donna Jodhan: So the clock is starting to wind down, but I have this for you.
Dr. Danielle Manis: Sure.
Donna Jodhan: You are a real champion of team-based primary care: nurses, social workers, pharmacists, dietitians, and more, all working side by side. What does a true care team make possible that one physician alone simply can’t? And what do you mean when you talk about everyone practicing at scope?
Dr. Danielle Manis: So, I’m old enough to remember not being in a team. When I first started practice with my colleagues, it was just four physicians and one and a half administrators, and that was it. No nurses. We had no access to mental health supports for our patients. We had no dietitians. Which really just meant we did everything ourselves, which is okay, everybody’s happy to roll their sleeves up and get to work. But what happens is, if you’re trained to do a certain set of skills, but someone else can also do some of those skills, then you can do the higher-level skills. If you’re not busy giving vaccines to babies, that’s fine, I don’t mind doing that, but now that I’m in a team-based model, I’ve got a nurse who can do that. And, to be honest, a nurse who can do a lot of things better than I can do them, because that’s their expertise. So they can spend time counseling the patient on all their screening and prevention maneuvers, or diet, or exercise, or how to take their medications properly, and doing their height and weight and giving them vaccines, all of that stuff that I can also do. But the idea of everybody working at the top of their scope of practice, doing the job that they’re trained to do, just means that you build capacity in the system. It’s more efficient, and you can actually take care of more people and do more things. And so that’s really where team-based care excels. Again, it also goes back to one person not being able to be everything to everyone. If you can’t be in the office seven days a week, but you have somebody who can answer messages and answer the phone, you create more access for people to their health care team. But we also have to rethink, we’ve talked a lot about how valuable that one-on-one relationship is with the family doctor, we do need people to start opening their minds to this team-based model, and to understand that yes, their family doctor might be kind of the anchor of the team, but that’s their team, too. Getting care from the nurse, or the dietitian, or the social worker, or the administrator who answers the phone, is care. That counts as access, and those people are really there to help take care of them. Because I think it also contributes a lot to burnout when people feel they have to do everything themselves, and this is where we saw people leaving family medicine. So when teams work well together, everybody is happier. The people providing the care, and the patients, they get a little bit more access, they get more expertise from people who know how to do different things, and ultimately things just run better. So it really is the ideal model.
Donna Jodhan: I think, for me, I’ve had to get used to the team-based approach. I remember, at first, Nurse Emily, I didn’t want to see Nurse Emily. No way would I want to see poor old Nurse Emily. But I’ve gotten used to her. I understand her function, and she’s there to help.
Dr. Danielle Manis: Yeah, and she really does have expertise. She’s a certified diabetes educator. She’s got expertise that I don’t have. That’s the other thing: I really felt the absence of it in my early practice years, around mental health support. It’s shocking, really, how much of our days we spend dealing with mental health problems. I think it’s the bulk of what family doctors are doing these days, at least it is for me. And I’m no psychologist or social worker. If you have no access to that support for the patients, and they can’t pay for it, it’s a huge burden, and we’re not really equipped for it. Now I have social workers I work with. I can refer my patient to someone who has that skill set, or a dietitian who can help them work through how to manage their IBS and their high cholesterol. I don’t have that skill set, and it’s not just that I don’t have the time, I don’t actually know how to do it well. I’m not trained for it. So it really does elevate the level of care across the board, to have all of these other experts in their areas working together.
Donna Jodhan: And I’ll share with my listeners: a few years ago, when my mom fell, I just thought, oh gosh, am I going to lose my girl here? What’s going to happen? You sent me to a social worker on your team, who really, really helped me out. With that team-based approach, where would I be?
Dr. Danielle Manis: Yeah. And I don’t have the skills that she had. So I’m really grateful for that, because I think you needed that, and I needed you to have that. We’re really, really lucky to work with wonderful professionals.
Donna Jodhan: So, Dr. Danny, we’re almost at the end of our podcast, and I have this personal question for you. Would you like to see any of your kids in family medicine?
Dr. Danielle Manis: You know, I would, but the ship has sailed, because my kids have chosen their paths, and medicine is not happening for them. But would I recommend it for them? 100%. I think it is such a rewarding career. And yes, there are challenges, and yes, it is difficult, and it is hard work; the inbox management is a bit of a plague upon all of us. That being said, I’m so hopeful for the future. I’ve already seen, I think, transformational change just in the past four or five years, in terms of care models and OHT work and changes in remuneration. And I see our young trainees coming through, our medical students and our medical residents. I’ve been teaching trainees for many, many years, and there’s a feeling of optimism. It’s palpable in the last couple of years of our trainees. I just think that they’re coming in at such a great time. And primary care is primary. There were a lot of years where the focus was always on acute care and hospital care and surgery, and in medical education there’s what they call this hidden curriculum, where there’s a quiet messaging that, you know, if you’re just going to be a family doctor, if you’re too smart to be a family doctor, why aren’t you being a surgeon, or something like that? And I think we’ve really done a great job of reversing that messaging, and understanding that family medicine physicians are specialists, and that generalism is a specialty, and it does take a very challenging skill set. It is intellectually rewarding and difficult. It is emotionally rewarding and difficult. Sometimes I liken it to parenting a little bit: parenting is all-encompassing, and you’re exhausted at times, and it’s exasperating at times, because you care so much, but at the same time it’s incredibly rewarding. And I feel the same about family medicine. It’s hard, but it matters, and the rewards are so great. I just feel really optimistic about it. There’s no other career I would have wanted for myself. I would definitely have encouraged my kids to go down that road if they had any inkling of an interest. And I’m delighted to mentor any of our medical students and aspiring residents into family medicine, because I think it’s fantastic.
Donna Jodhan: I’m kind of sorry that none of them decided to follow in your footsteps. Oh, dear.
Dr. Danielle Manis: Oh, they’re their own people, and that’s great. And I’m here to support them. That’s perfect.
Donna Jodhan: There is one particular resident that I met, and I told you this, I thought she was one of the best residents. I don’t remember her name. Nice young lady.
Dr. Danielle Manis: How many years ago?
Donna Jodhan: Roughly about two or three years ago.
Dr. Danielle Manis: That was probably Zahra.
Donna Jodhan: Could be.
Dr. Danielle Manis: Zahra Bahira. Did she have an accent? She’s from Iran.
Donna Jodhan: A little bit of an accent, but she was, oh my God. I said, this is our future.
Dr. Danielle Manis: Oh, well then I’m going to have to send this to her, if it was her. It could have been someone else; I’ve had a few female residents. I’ve had a mix of different residents over the past years, but some wonderful ones. I had Nicole Schooley; she was a resident during COVID, so probably five, six, seven years ago.
Donna Jodhan: No, not her.
Dr. Danielle Manis: Not her. So maybe it was Zahra. Yeah, we’ve had some wonderful, wonderful trainees. I can’t say a bad word about any one of them. I would be delighted for them to take care of me in my old age.
Donna Jodhan: You have a long way to go.
Dr. Danielle Manis: Don’t worry.
Donna Jodhan: It has been a pleasure having you. And if you ever wanted to come back and talk about what’s going on in your neck of the woods, please reach out to me and let me know, because I’d be delighted to have you again.
Dr. Danielle Manis: Thank you, Donna. I’m honored to know you. And it’s funny, as much as I say I love knowing my patients, the first I ever heard of you being in a pottery studio was during your introduction. So, clearly some things to learn about you still.
Donna Jodhan: Well, there you go. So thank you very, very much. I wish you a great summer. And I think I’m supposed to see you at the end of September.
Dr. Danielle Manis: Perfect. Have a wonderful summer. Thank you so much for having me.
Donna Jodhan: Thank you, Dr. Danny. Take care now.
Dr. Danielle Manis: Bye-bye.
Donna Jodhan: Bye-bye.
Podcast Commentator: Donna wants to hear from you, and invites you to write to her at donnajodhan@gmail.com. Until next time.
Donna J. Jodhan, LLB, ACSP, MBA
Global Leader In Disability Rights, Digital Accessibility, And Inclusive Policy Reform
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Published in Remarkable World Commentary