Navigating change in healthcare requires bold leadership, deep empathy, and a commitment to ongoing evolution. In this episode, Alexa Pitoulis, Executive Director of BC Family Doctors, shares her experience leading an organization at the forefront of family medicine advocacy. She dives into the longitudinal family physician payment model, the rapid transformations sparked by the pandemic, and the power of iterative change. Alexa also explores how strategic planning can serve as a tool for connection and collaboration — and why creating space for reflection is essential for sustained progress.
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BC Family Doctors With Alexa Pitoulis, Executive Director
My guest is Alexa Pitoulis. Alexa is the Executive Director of BC Family Doctors, the first non-medical physician to hold that role. In our conversation, she talks about what it means to come in as that professional leader to help grow the professional staff and the organization and enhance its capacity for service as well as advocacy for family doctors across BC.
It is an in-depth look at a sector that many of us think about only as clients but as leaders in the social profit sector, we have a lot to learn from the approach Alexa and her colleagues are taking at BC Family Doctors. Alexa is a creative strategist with many years of experience leading teams in public, private, non-for-profits, and social profit sphere. She is a change leader. She is skilled at moving the whole of an organization forward. Thank you. You can learn a lot of her tips and approaches to that in our great conversation. Thank you so much for reading.
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Welcome, Alexa.
Thanks for having me.
I’m looking forward to the conversation. This is going to be informative. Not only for readers in British Columbia. We’re going to learn how the medical system works through your eyes but also what it is like to be a new executive director in an organization undergoing significant change on a daily basis. Let’s get to it, but before we get into that conversation, tell us who are the BC Family Doctors. What is the organization and how do you operate?
Why Family Doctors Are Essential To Healthcare
Thanks so much. BC Family Doctors is a member driven organization that represents family doctors across British Columbia. We see ourselves as the economic and political voice of family doctors in BC. In that role, we advocate for sustainable, patient-centered primary care and work collaboratively across the healthcare system with Ministry of Health and other stakeholders to strengthen family medicine.
I know family medicine and family doctors are in the news a lot in. Not only in BC, but across the country. One of the things that I come back to as I’m new to my role is recognizing that the data shows that patients who have access to a family doctor consistently show better health outcomes across a variety of indicators. Family doctors are trusted. There’s that cradle to grave relationship that rose and changes over a life stem.
What we’re looking at is how if family medicine is the backbone of our healthcare system. I go back and I do a lot of work and change management. We’ve talked about that before. It’s that principle of, nothing about us without us. Family doctors are being such a noble role in primary healthcare. We need to have an active voice and be participants in what the changes and the evolution of our primary care system look like. That’s where we come in, is trying to harness the voices. We have about 3,500 members across the province, and actively bring those lived experiences into the policy work on the ground.
It’s big and important work. For many of us who know or read about the healthcare system, whether it’s NBC or anywhere across the country. Most of the stories start with, we need more family doctors. Alexa, where are all the family doctors hiding?
Understanding The Family Doctor Shortage
It’s such a great question. We’re in the middle of doing our first ever strategic planning process in the organization and we just got into it. We hear a lot in the news around, they’re not enough family doctors. If we can just recruit and retain more family doctors, problem solve. The reality is, that we will never get to a point again where there are enough family doctors to match the population growth in the way that medicine and family medicine is being practiced since the beginning of our public health care system.
BC Family Doctors: We will never get to a point again where there are enough family doctors to match the population growth in the way that medicine and family medicine is being practiced.
That is a different starting point. The family doctors are there, but everything’s changed since the 1950s when our public health care system was designed. There’s increased patient complexity and chronic illness. Mental health and wellness is so much more in the forefront. There’s different inequities both for both rural and vulnerable populations. Not to mention that we’ve made great strides in medicine. Whereas many years ago, there may have only been one or two options for medication or treatment plans in any given disease or health issue.
Now, there’s such a broad range of what’s available. The nature of the information has changed. The important thing is also because it’s a big and complex system. There’s the way family medicine has not kept up, so there are administrative burdens and outdated ways of working. That’s the boring piece that people don’t want to talk about, but it’s little things that take up disproportionate amount of family doctor time that are hampering access, what family physicians, the number of patients, and how they’re able to work.
It’s not just a volume issue. It is changing the way family doctors are what their scope of practice might be. One of the other big changes not incremental at all, is the longitudinal of family physician payment model that started about a few years ago that was led by BC Family Doctors. It’s been a couple few seconds talking about what that is and how that changes things because I want to get into how that program has evolved in your organization.
The Longitudinal Family Physician Payment Model
One of the interesting things that most of the public is not aware of is how family doctors get paid or how doctors get paid in a public health care system. I was speaking with a group of social entrepreneurship students at a university. They’re like, “If they work for government, don’t they just get a salary and of this?” I was like, “No, you’d think that.” There’s an assumption about that as being public health system.
The way many physicians have been paid for a long time is through what’s called a fee-for-service model, so they’re historically being their own business owners. Autonomous business owners running a family practice clinic then billing the government for very specific tasks. When we talk about a number of fee codes that they’re able to build, it’s like over 800 different fee codes. Again, this is another great example of how this fee code payment structure was out of date for the type of practice and the needs of patients and doctors now.
We’ve been reminiscing a little bit in the last few weeks around the COVID-19 pandemic and what occurred during that time period. At that point, Family Medicine was already on very shaky ground in this province and then pandemic hit. It put stream undue pressure on those care providers. That was an impetus for this organization to take a leadership role and sounding the alarm bell around crisis and family medicine.
Along with colleagues and collaborators at the doctors of BC and all so public advocacy group, BC Health Care Matters. There was a famous day at the legislator that opened the doors to some important meetings with Ministry of Health and government in BC. Essentially, the outcome was our team led by Dr. Renee Fernandez, who is the Executive Director at the time and other physicians with doctors BC and the senior ministry staff, basically locking themselves in a boardroom for a series of design and creative conversations that said, “How can we come up with a better way of paying family physicians to support the work they’re doing?
Out of that was this launch to no family physician payment model. That has had a huge impact on stabilizing family practice and improving physician retention. We’re about to launch a two-year anniversary report that has some pretty incredible impacts and the stories around physicians saying, “It was the LFP payment model that has allowed them to stay in pack practice or return to longitudinal family practice.
The Power Of Iterative Change In Healthcare
One of the things is fascinating about that program is it addressing an immediate need that was not just a result of exacerbated by the pandemic, but it was launched very quickly then iterated on, improved and changed in real time almost from day one, which is something that there’s a lot that the social profit sector broadly define can learn from that concept of getting it out there and refining as you go. Rather than waiting for it to be perfect or near-perfect or waiting for the board to develop their appropriate KPIs, and see what the first quarter looks like knowing you’re not going to have it right in getting out there. What about the culture or even just the time for BC family doctors allowed the organization to take that iterative approach?
There was an opening around the crisis of family medicine, but I also do think the pandemic was not a good time to go back to. It was a moment in time where the healthcare system in terms of the stakeholders at playmaking decisions. We’re able to turn on a dime and tested the idea like the example that I love to use. Think about the day before the pandemic hit in March 2020. Family doctors had no fee code for billing for doing a virtual consult or a virtual patient appointment.
Within 48 hours, there was a fee code in place. Family doctors were often running and are we ever going back? Virtual care is now a part of it. It’s just a great example that then was built upon with the longitudinal family payment model. We are able to change quickly and what are the relationships and then the ongoing communication that needs to happen and the processes. They agreed to prompt processes to be able to say, “We’re going to try this.”
Now, there’s lots of discussions now about virtual care. It’s like, “How much is too much? Should you have to see your family doctor once a while?” It’s like you launched it and I think we can all agree, it’s a great benefit to both patients and physicians. At the same time, there’s still an ongoing conversation around, “Probably it makes you go in and see your doctor in person for some things or at some points in time.”
That payment model was the same. It was a huge piece of work and all the stakeholders were rolling up their sleeves to get in that. The interesting part is that there’s a governance structure with all of those collaborators that still in place to continue to make the changes. For example, after the original payment model was launched, there was an expansion into opening it up for physicians who practice in facilities long term-based care and maternity.
Staying Open To Constant Evolution
It says a lot about an organization to know that it’s not about just making the first adjustments or one set of changes, but this is going to be a set of changes. It will be a part of the day-to-day operations of the organization to love this model going forward. Within your own organization, how do you stay open to the need for that consistent reiteration of not just this program we’re talking about, but the work of your organization on a daily basis?
There’s a couple of things. That’s a good question. Part of where you are asking the question around why you can’t wait for perfect to get something out and launched as the world’s changing so fast. For example, if we waited for all everything to be perfect and to feel perfect. We would have missed the boat and the world’s changing. You’re launching something for it’s already outdated. With that in mind, again going back to we represent our members who are a Family Physicians and other organizations who have constituents or beneficiaries that they act on behalf of or support.
We talk a lot about trust and what does it look like to build trust and ongoing meaningful conversations and engagement. With your beneficiaries, for us, it’s family doctors. That’s something we take seriously, I suppose. That’s an ongoing thing. It’s the big things and the little things. I know, one thing, for example, we’re quite a small organization with a somewhat narrow scope of work in the broad landscape of healthcare.
We have a lot of members that email or reach out to us saying, “The hair on fire. There’s this is issue that we need to pay attention to or I’m struggling with this thing or that.” Often, it falls over our scope but we take a stance of we want to always listen, hear, and acknowledge that they’re going through or discovering something about that doesn’t work for them and likely colleagues. If we can’t respond or if it’s not in our scope of influence or agency, where can we connect them to? It’s building a relationship of, like we are listening. If it’s not us, we don’t reply not in our job descriptions. Sorry.
Good luck with that.
It’s like, yes, we know it’s hard to figure out where is the right place to raise this issue but your voice matters and your experience matters. We’ll do what we can to make sure you do get connected with someone who can take that information in.
Your voice matters and experience matters. Share on XI’m curious. When you started, this isn’t your first executive director role or sector. You reported to boards before. How different is it reporting to a board of people active in practice and having that advocacy for themselves and for the group of family doctors versus a more conventional social profit organization?
Reporting To A Board Of Practicing Physicians
I love that question because I don’t know if I’ve actively thought about that. One thing I do recognize is they’re highly connected to the work we do and engaged because they’re completely invested. All of our board directors are signing up for the task because they’re one intimately seeped in the profession and also want to be actively involved in the evolution of what their profession looks like. Honestly, everyone I’ve talked to is so invested in like, how can we improve outcomes and experience as for our patients and our community?
That is the heart and soul of family physicians. How is that different? Physicians are detail-oriented. They’re in the day-to-day and that’s their business to know the details and their training. Thank goodness for that. That’s an interesting manifestation when you’re trying to run a governance board of an organization. They want the details on certain things. Where our organization is, it’s a little bit in an evolution of moving from a bit more of a working board from what traditionally was to a governance board but that’s not unlike what other organization’s experience.
I do believe other boards I’ve worked with. You have people with lived experience or expertise and other sectors or other interest areas coming in. They’re interested in the core work. I was running an organization where it was focused around growing farms on schoolyards and youth engagement. There were very few people on my board that had done that in their life, so it is a different level of knowledge and also why they’re showing up to participate.
A lot of guests we have on the show and a lot of the work we get to do with clients across the country, executive directors and CEOs are saying, “I’m concerned about my boards engagement. How do I bring them together to show up as their best selves and bring their best advice to the table?” You’re describing a situation where containment rather than engagement. Maybe the goal is working with the board of containing them to be providing that expertise in that role as part of a governance board. Your balancing different dynamics that the most colleagues that may be reading.
Correct.
I wanted to explore with you a little bit. You started this role, new to BC Family Doctors, and new to working with doctors on a day-to-day basis and you jump right into a strategic planning process relatively soon after joining. What have you learned about your organization as you’ve started this strategic plan ball rolling?
Jumping Into Strategic Planning As A New Leader
For me, strategic planning is such a great opportunity to open people up to conversations. I like to slow the process down. I like to say that, at the end of the process, I don’t care what the final document or one page or looks like. I mostly care that our board and the active members and our team have that felt understanding and common language around, “This is who we are. This is what we’re headed. This is where we’re focused on.”
Strategic planning is such a great opportunity to open people up to conversations. Share on XI learned a lot. I asked quite a lot of questions around, especially the Physicians. The other thing I’ve learned is, there are a lot of opportunities for family doctors to step into different leadership roles in the myriad of healthcare organizations. I wanted to know what their experience is with strategic planning had felt like and had been. That’s always indicative. It helps focus how you design. More than anything, it’s so inspiring, again, going to the position justice session with what we hear in the media. It’s like, “Healthcare is in a crisis.” It’s era closures and doctor shortages. At the same time, the healthcare workers and the family physicians themselves are so invested.
They care so much and they’re so smart. They’re bringing the concerns of their patients into that strategic planning process. They’re frustrated with the slowness of how the systems change works and looking for like, how do we cut through some of the bureaucracy and get things moving? In a lot of ways, they’re entrepreneurs. Family doctors have a real entrepreneurship energy. That’s pretty exciting to be able to harness that entrepreneurial spirit in the work of health care systems change.
BC Family Doctors: Family doctors have an entrepreneurial energy to them. It’s pretty exciting to be able to harness that entrepreneurial spirit in the work of healthcare systems change.
One of the things when we’re working with the client, we’re doing strategic planning. We frame it is a tool. Strategic plan is a tool. Tools have jobs to do. What job do you need the strategic plan to accomplish? Almost always what we hear back is, we don’t want to things. We don’t want to plan. We put on a shelf and it’s job is to gather dust. We hear that in almost any engagement that we do that, “We don’t want to plan. Let’s put it on the shelf and gathers dust.” You’re describing a very dynamic environment that you’re operating with. What have you learned about the tool you need your strategic plan to do?
Embracing Disruption As A Catalyst for Change
Looping straight back to what we were talking about. One of the things I’ve learned about this organization is we haven’t quite figured out the words for it, but it’s this like disruptive catalyst, because we are able to speak very frequently on behalf of our family doctor members, we’re able to say and create things like this new payment model. What is our role as a disruptor? Not in a negative way, but demonstrating what’s possible and how can we be creative influence in either convening or bringing people together or testing the ideas that are like the payment model that’s had such a ripple effects. I’m excited to find more things like that we can take on.
Evolving with no destination.
There’s something around, though, with that spirit. One thing that I’ve learned from other roles I’ve taken in doing systems change and when we’re talking big systems, healthcare, food systems, and education. It’s important that people can not only public and policy makers can have an experience of what’s possible. It’s so hard for our minds to even imagine a completely different way of interacting with systems, if that makes sense.
I always take direction from Einstein’s great wisdom around he can’t solve the problems in front of us using the same mind that we to get us here. For me, the LFP payment model is a great example of that. It’s given this lived up and running example of what’s possible, what can be done quickly like a diverse group of stakeholders with high stakes and then we’re all committed to evolving it and making sure that it continues to meet the needs of physicians across the province as it goes.
Anyone reading our conversation at this point knows that you’re comfortable with and committed to change and doing it in a thoughtful constructive measured way, but doing it. As a leader, how do you keep the rest of your leadership team, the rest of your organization and the staff team as open to or as aware of the need for change on a daily basis?
Leading Through Constant Change And Uncertainty
I’m pausing because I’m trying to image like, you need to have not everything changing all at once. I often look at nested circles where change happens. Where if you’ve got a team that’s working on doing big systems change, you need to also know that what are the things that I can count on for my day-to-day that aren’t going to change constantly? It’s managing the change at different levels. I know I thrive on change, but you also need to pace yourself. There’s some things that there’s the different rates of change.
I’m not sure if I’m quite answering your question, but it takes time. You need to make time for people to digest but also to actively reflect for themselves but within the team or the groups that you’re working with. It’s important to name the changes that are going on so it’s not like, “I’ve come on. I’m in a very new role. We’ve doubled the size of our very small team in a short amount of time.” That’s a huge amount of change happening internally in the organization.
You need to make time for people to digest, but also to actively reflect for themselves. Share on XWhile at the same time, we are doing work in a system that’s changing very rapidly. Recognizing the time and space that it requires to support people to process what’s going on all those levels and to also adjust. For me, the big piece is when you’re in the work of embracing change and forward evolution, I’m always asking, what’s the rate of change that we’re doing this certain project at? What do we have control over or an agency over? What don’t we have control over?
It’s like an active checking in process with myself and my staff and in this case, with my board. Sometimes, we have to slow things down or let go of certain things that we can’t do, or we have to let go of things because we have to react and respond to things that are out of our control but come up so urgent. It’s that active engagement on the different levels of work within an organization.
Do you ever have moments? I’m sure with you, they’re probably just moments not days or weeks. Which is like, could everything just stop for a minute?
Maybe this is just an age thing with me, but those moments just don’t appear. You have to create them and it’s an active conversation is. What’s urgent? What do I have to do in this moment? Knowing that the moments for everything to stop and take a break or build in the thinking time and the focus time is so important. In terms of work design, I’m a geek. I love thinking about even just being aware of how we respond to email in a day in the work and how it either takes away or contributes to our quality of thinking. Often, when I make a great decision to not respond to something quickly, something changes or it goes away. We have to build that in for ourselves and our teams.
Balancing Urgency With Reflection As A Leader
It is that two by two of important versus urgent. If something’s important and urgent, we’re going to drop everything and deal with it. What I find the most successful leaders are very deliberate as you just described and spending time in those things that are important but not necessarily urgent. That thinking time about where the organization is going or where they want to take their team or where they themselves as leaders are going is what contributes to valuable sustained change over a longer period of time.
Having spent a little time with you and your colleagues of the last couple of months, I’d be surprised if you find a lot of opportunities for those stop and think moments. You’re working with people who think in 7 or 10-minute increments in terms of their appointments. How have you found your leadership style changing in this role that you’re in with working with doctors which you hadn’t been doing before?
I’m not sure if my leadership style is changed, in taking on different leadership roles, I’m always asking why me at this moment with these people in this organization. I’ve done a lot of work over the last decade to look at, why was I called upon in that role and what did I have to offer? To your point around the timing of their was, there is, and has been a crisis in family medicine and going back to that and the pandemic.
For me, one of my core contributions that I make is something around trustworthy transitions. We’re moving beyond that crisis time, to now it’s almost like a relaxing of the nervous system to be able to get creative of and say, “What are we evolving to for this nest work? What is the role of family physicians? What do we want that to be? How can we make sure they have a voice in crafting that in a way that responds to what we know patients and communities are saying?”
To circle back to my leadership style. It is about not getting swept up into the urgent reactive sort of we’re in crisis mode of behavior because that’s not where we’re at. That’s not what is being called for. It’s more about remembering who I am as a leader and why I’m here at this moment and continually to offer those spaces for a breath for reflection for that creative energy to come forth. Not to mean that we don’t move quickly in response to things all the time. In terms of when my highest use is at this moment, it’s to bring that generative strategic energy and create the time and space for our doctors, our physicians and our partners to be engaged in that.
Looking Forward: Collaboration And Positive Energy
It’s a helpful reflection and some good advice for people who may be reading who have big change happening in their own organizations. Thank you for sharing that. Alexa, what are you looking forward to?
It’s a great group of humans that I’m working with, so invested. The healthcare sector is new to me, so that is being a huge learning curve but also exciting. In terms of like the geekiness on the running and work side and on the governance side, our strategic planning process is about giving us a solid focus for myself in the team. I’m excited about it. We were in the middle of sold out. They’re not per pay but focus groups.
We have a lot of energy. We generated some momentum and energy amongst our membership and our board. I’m excited to then move that strategic planning process into what’s next. What can we do? For me, one of the things that people who have worked in healthcare will know this, but there are so many different organizations in healthcare between health authorities and divisions of family practice. Dr. ZBC and the Ministry of Health being such a huge ministry in BC. There’s a lot of players everywhere.
For me, the exciting part is, how do we create a strategic plan and an aim for the next few years that is unifying and is calling in our partners? It’s different from the for-profit sector where you’re trying to find your niche and your brand. We are trying to find our niche, but in a way that we need to be working collaboratively. There’s too much work to be done. How are we using it as an energizer for positive collaboration going forward?
I love that final question. How are you using this for positive energy going forward and positive contribution going forward? That is a question I hope all of our readers and all leaders across the social profit sector asking themselves every day. Alexa, thank you so much for being on the show.
Thanks so much for having me. It’s been fun.
