20 Episode results for "Canadian Medical Association Journal"
Antivaccine sentiment as power: the Montral vaccine riots of 1885
"With yields on fixed income investment sitting near record lows investors are looking for ways to boost returns the challenge most traditional investment options offering higher returns often require taking on more equity risk. Enter private credit get access to potentially higher returns historically test us stability and added diversification typically reserved for institutional investors and definable with private credit pool stability equity like returns visit mba dot ca slash private dash credit for more information. Many adults may not be aware that simply being over fifty puts them at increased risk for shingles help prevent shingles in patients over fifty six shingles is indicated for the prevention of disaster h that are shingles in adults fifty years of age or older. Consult a product monographic. Gmc dot ca slash slash pm for contraindications warnings and precautions adverse reactions interactions dosing administration information to request a product monograph or to report an adverse event. Please call eight hundred three eight seven seven three seven four learn more at thanks chamonix dot ca any bac protests. Such as the one at dodger stadium in los angeles. january of this year are not new. There have been many such protests throughout history. One can't help but draw parallels between historical protests and the ones happening now during the covid nineteen pandemic. I'm dr dorian dish. Our deputy editor for the canadian medical association journal today. I'm talking to dr jonathan berman. A physiologist at the new york consumer technology medical school and a science educator. He's joining me today to talk about one particular protests that turned violent the montreal vaccine riot of eighteen eighty five. Jonathan is the author of sammy. J humanities article on antibac- seen sentiment during a smallpox outbreak. I reached him in arkansas. Hello jonathan how are you bad. How're you doing. Good well just before we get going into the the world of and smallpox. Can you tell me a little bit about your work and your area of study. Sure and it might seem odd. I'm a physiologists appear physiologists and not a physician or historian. My primary area of study is how the kidney handles sodium in the effects on hypertension so very different from vaccine resistance movements. Yeah no kidding. I sort of caught my attention. It got me curious. What got you interested in vaccine resistance movements. I've so i've always been following that story for at least fifteen years In the news and as people responded to it and about four or five years ago i was involved in leading a protest called the march for science and one of the things i observed in that was a number of people who identified themselves as pro science whatever that means but then would also make statements that indicated to me that they were anti vaccine. It was surprising to me that someone could identify as pro science and anti vaccine. So i did kind of a deep dive researching reading every publication. Every book i could find trying to understand that turned into a book. It's sort of what led me to. Cma j. so in your cma j. paper. You take us back to a time when smallpox was a massive health concerned globally and before. We unpack what has become known as the eighteen. Eighty five montreal vaccine riot. Could you talk about smallpox. And its relevance to life in the eighteen hundreds so at the time i would expect someone probably thought about smallpox the way we would think about something like whooping cough a we know that still exists but probably not a part of our daily lives for most people any more largely through the discovery and use of vaccination and the late part of the eighteenth century. So there were still outbreaks with smallpox in eighteen. Eighty five and it could be very devastating disease. The mortality rate varied but above ten percents Often left survivors with debilitating scars. And it was highly contagious. So even in eighteen eighty five there was still a lot of disagreement about the nature of disease so there were theoretical questions about how smallpox works and it had been discovered that smallpox could transmit person to person but at the time miasma theory of disease was still very common existence of viruses was not yet known so a lot of the the theoretical biology was not yet in place to understand smallpox. You just alluded to people already. Even though he didn't know what us smallpox kind of new at the smallpox vaccination might work. Is that what you're saying. Yes so smallpox vaccination had been studied and the the the field of statistics was new and it didn't have the same tools we have now but attempts have been made to statistics to study it and it was fairly straightforward to observe that you could vaccinate someone with with cowpox vaccine lymph attempt to to give them smallpox and they wouldn't get it so what was vaccine lymph so it came from a variety of sources cowpox virus. In the same family to smallpox pustules would be burst with the lancet And the material the us will be taken and prepared or saved called vaccine lymph and then over time that might be transmitted from person to person so you might give cowpox to one person and then take some of that cowpox from their pustule and move onto the next person. sure so. This was the time well before. Refrigeration was available so i i'm imagining That someone would come to the house. Save save you had someone who's had pustules And that and that would be the moment of opportunity to vaccinate as how it worked so there were a lot of problems with preserving vaccine lymph so there might be some available at a given time because there was cowpox That occurred or horsebox was used sometimes And there were attempts to preserve it through doing things lake taking a silk thread and impregnating it with Lymph and then. Drying it and a lot of these methods were unreliable. Which meant that. Sometimes when vaccination was needed they weren't able to produce a a reliable source of vaccine in your studies of smallpox vaccination. Did you get a sense of the mechanics of audit for example where there big clinics for people with lineup round the block. I'm curious how it rolled out. My understanding is it was done in a variety of ways. there were vials of vaccine. Lymph at one point that were eventually prepared so you would have a glass vile with limp and then you would go to your primary care physician or the equivalent back. Then and at certain times they might have vaccine lymph available and if they had enough patients who wanted to be vaccinated they might Vaccinate them and then transfer lymph one patient to another to keep sort of keep the culture going of cowpox now. Part of what led to these tensions in eighteen. Eighty five a shift in power the municipal government trying to become the people who did vaccination and setting up centralized methods of recording vaccination performing vaccination and sort of taking that relationship between the physician and the patient away from the physician. and so. that's one of the. I think one of the important underlying factors in what led to the the riots. That's fascinating and select. Brings us back to the story. And i wanna just recap for our listeners. Who have not read the article so tell us a little bit of boats. What happened in montreal in eighteen. Eighty five and the bit of the backstory around the first of all the outbreak. And and then what happened leading up to the to the riots themselves right so this has been described in in a lot of detail by by other authors but in brief there was an outbreak of smallpox. Going on in montreal. It had been carried there by a railroad conductor and there was supposed to be a special clinic for smallpox patients but it was closed because there weren't enough smallpox patients so you is admitted to To a regular hospital and hit through his betting it spread to the city and got out of control and then there was a series of mistakes with potentially contaminated vaccine and Low vaccination rates in miss communications and so by september of that year there were a lot of tensions and that tied into a great deal of social equity between overall wealthier. Anglophone largely protestant population and francophone largely catholic population. And just like wealth. Inequalities today can lead to very different health outcomes. The francophone community was much more affected by smallpox in this outbreak. So a lot of anti vaccine sentiment developed that was tied into tensions that already existed along class lines and religious lines and language lines and that eventually spilled over into a riot when there was talk of vaccination becoming mandatory and in that riot there was a lot of property damage and no one was killed but some people were injured. And so that is interesting to me because of of what it might illustrate to us today about what situations might lead to a violent protests or two most vitriolic protests in terms of covid nineteen vaccination. So it sounds like there. Were tensions already in montreal like you said that had been brewing and then this mandatory even the rumor of a mandatory vaccination policy as opposed was enough to say that was the last straw that sparked the whole thing. So have you read about what was in particular that led addie baxter's to resist the public health laws in other words was where they were. They worried about contaminated vaccines where they worried about. Specific things or the just a general mistrust of of the government. So i think these old ways to things going on when you look at anti vaccine movements there are stated justifications and then there are the psychological social emotional underlying reasons that they're anti vaccine so i don't think you dismiss the stated reasons outright but i think we also have to understand the the other reasons so the stated reasons involve Things like questioning the science that was done on vaccines at the time. concerns that vaccines might cause injuries To people so as described this was not a very sanitary process at the time. There were concerns about secondary infections and so people would would claim that This was a burden that was being imposed. On the poor that it harmful to people there would be statistical arguments that attempted to place doubt on the effectiveness of vaccination or to point out instances where someone had been vaccinated but got smallpox anyway. So what i think is the deeper reasons. Have a lot to do with concerns about personal medical autonomy So being able to make choices for oneself about one's health concerns about who is making those medical decisions so to a degree there's mistrust of governments in mistrust of Centralized medical decision making there's also fears about polluting oneself with outside substances and fears of losing control over one's health so i think we see similar fears at played today. You know people who are choosing not to wear a mask I think likely feel that. They at least have made a choice. And so i think there's quite a bit going on in terms of justification versus actual reason you've given this a lot of thought and when you when you look at people who have various responses to public health policies today. Do you think that vaccine protesters are the same people. Poop protests curfews and mask mandates and lockdowns or. Do you think that there. it's more subtle problem. What people have so many different reasons that you just simply can't lump all those problems together well so to some degree. I think that it's a related phenomenon. So i've seen a lot of people describing it. As anti public health protests as a whole so instead of anti vaccine or anti mask they lump together and you do see anti vaccine signs at mass protests you do see combined protests. And you've seen now people who've been studying these groups finding significant overlap between people with vaccine hesitancy and anti mask loose. I think there may be people who are more concerned about one or the other. But in large part i do think there are deep similarities between those viewpoints and the the rise of anti mask sentiment and anti lockdown sentiments is given a a new source of potential converts to the anti vaccine movement. And looking internationally. Do you see any differences or similarities between while you talked about similarities but but in particularly the differences between anti vaccination groups so yes there are similarities and yes there are differences so similarities. The arguments are often very similar. The things that protesting often very similar. The differences of course are the groups and the the stated and often the underlying reasons for thirty so in the united states a few years ago about five years ago anti vaccine movement targeted the somali american community in minnesota for for a misinformation campaign and there was a drop in vaccination rates that led to a measles outbreak and in two thousand nineteen. There was a measles outbreak in an orthodox jewish community. In new york that had also been targeted by a anti vaccine movement. Those are very different communities and with very different concerns and and that need to be addressed in different ways in terms of of building trust. But what they share in common is not having the same language necessarily as the surrounding population having a different religion from the surrounding population Having a different cultural identity than the surrounding population so smaller groups are often targeted for anti vaccine campaigns And not being a part of the not having access to maybe the same materials language as broader population makes it harder to to reach them with public health messaging. Now i'd say international. And i only talked about america there but there are there are three examples do any standout So one i think is is perhaps salient from the early twentieth century. mahatma gandhi was anti vaccine And he wrote quite a bit about it. And i think reading his objections. A lot of it has to do with vaccination being seen as an imposition by the raj the british rule in india at the time to were imposing vaccination on the population and so a lot of his arguments mirrored arguments of british anti vaccination assists And anti vaccination is today but also Were framed in terms of an outside colonial rule. We also see A fair amount of anti vaccine sentiments in the middle east in part driven by a rumors of sterilization campaigns by the west and by certain actions that have been taken by western militaries that Have caused a drop in vaccine confidence. When you mentioned you know we use the term anti vaccination groups almost as if it's a distinct entity but as you're talking. I'm thinking of guessing that actually anti vaccination arguments can be used Under other umbrellas almost repackaged as part of a broader group. So so are you talking us. Use the term anti vaccination group. Do you mostly mean a group that has taken on the cause to support his larger political aims for example gandhi with colonial concerns Or are you talking about specifically dedicated groups working against vaccination so there are both there are groups that produce a lot of the anti vaccine material on the internet today that are very active in organizing protests and paying for The production of materials. I hesitate to say educational material but pamphlets and things like that. And there's actually a very small number of groups that are funded by a small number of people That are involved in that on the other. Hand those groups are often been successful in convincing social campaigners to allow anti vaccine sentiment to latch onto other social causes We saw an example of that over the summer And to date this this is in march. Twenty twenty one of last summer with the black lives matter protests. We saw some some well-known anti vaccine groups going out in framing anti vaccine protests as black lives matter protests in attempting to hijack those protests to their own ends and make them into something that would benefit their cause. Do you think in person protests have the same impact as anti vaccine efforts on social media so in-person protests reach a different audience. When you're doing a protest you essentially doing. Pr you're you're saying. This is what i believe. I want you to hear about it. And and why and in person protests tend to be covered by the media more by traditional media more they tend to get different sets of eyes on them People who are walking down the street and happened to run into them. Diff- different attention than stay online statement. You might make or or you might share. I think only twenty percent of adults. Roughly are on twitter. Probably less than that worldwide. So if you're on twitter there's only so much impact you can have. And if you're if you're in person like that protest in los angeles is your possibly reaching people. You're not reaching through your your social media bubble. Now that being said i phrased that like social media is the default and in person as this new innovation and it kind of the opposite. Historically has been true. People have done most of the protesting in person and brochures pamphlets Influence campaigns and social media is the new development. I think it gives both people interested in public health influence and anti public health influence new avenues to reach people If you're designing a public health campaign. I don't think you can ignore those online communities. And it's worth the investment in finding out where people are online and how to reach them online or one thing we do know is that a lot of our listeners are physicians and So i guess this is one way to start thinking about how to reach people in the confidence of that doctor patient relationship now as you mentioned that there will always be people who categorically refused to take vaccines but some people who fall in the vaccine hesitant group might be open to having discussions with their healthcare provider about the sars kobe vaccine or other vaccines. So i wa. This get some perspective on this How many people in north america can be described as vaccine hesitant so. I don't have like a very specific numbers for canada or the united states or mexico. For vaccine hesitancy we can get estimates. I think from other numbers so for measles vaccination about ninety percent of children get vaccinated for measles and of the remaining percentage. I think the majority are people who don't have very good access so tend to be poorer communities in the us Don't have very good health access. So actually making vaccination more widely available Would go a lot farther to increasing vaccine uptake. In that case then persuading every single anti vaccine activists in we've seen over the summer there were a number of surveys asking. Who would be ready willing today to get a coronavirus vaccine and we saw numbers in the forty percent range stain. No i wouldn't be ready to to get a coronavirus vaccine. Now we've also seen those numbers going down so we're starting to see those numbers decline into the twenty or thirty percent range Similar to what we would see with as people in various communities get vaccinated as it seen as more available as we see millions of people get vaccinated with with no or little ill effect. That's fairly persuasive Especially when you see your aunt on social media on posting her vaccine card or showing off. Hey i got vaccinated. I'm safe now or safer. Now i think the the role for a physician. And i say that not as a physician. I think the role for a physician Is going to largely be less persuasion in the sense of debate. In less in terms of argument in more in terms of gentle nudging so presenting. Good information to patients allowing them to make their own choice but but also making it clear. What the sciences. And and why you believe it and for a lot of people that will be enough. Some it won't but now it's not the physician's role to make medical decisions for their patient. We're past that age of of paternalism but it is their role to help. Guide them to what the best health decision is. That sounds incredibly sensible. Well thank you for joining me today. Thank you for having me on pleasure. I've been speaking with professor. Jonathan berman from the new york institute of technology medical school. He covers a lot of what we talked about today. In his recent book called antibac- sers how challenge a misinformed movement to read the article. He wrote for cma j. Visit cma j. dot ca. Also don't forget to subscribe to see him. Aj podcasts on soundcloud or podcast app and let us know how we're doing by leaving a rating dodger during a dish our deputy editor for seem aj. Thank you for listening.
Critical race theory in medicine
"To shingles age isn't just a number. Do you have patients fifty or older. They're at higher risk of getting shingles. Don't wait talk about shingles with your patients over fifty today. Shipwrecks is indicated for the prevention of herpes zoster shingles in adults fifty years of age or older. Consult a product monographic. Jfk dot ca slash singer slash pm for contraindications warnings and precautions adverse reactions interactions dosing and administration information a product monograph or to report an adverse event. Please call one eight hundred three eight seven seven three seven four learn more at think. Shingle dot ca. I'm dr carson. Patrick interim editor in chief for the canadian medical association journal today. I'm talking to dr. Were hells and dr mollica sharma. Who have written a medicine and society humanities article published in cma j. on the topic of critical race theory and how it can be applied in medicine. I've reached them in vancouver and toronto respectively. Rebel and malacca welcome to the age. A podcast thanks joining. Thank you for having us. Thank you so much so malika. let's start with you. Why don't you tell us out listeners. A little bit about yourself. Sure so My name is monica. Sharma and While i was born here in canada settler here took her until and i'm currently at the university of toronto For thousands of years this has been the land of the huron wendy seneca mississauga's of the credit and still home to many indigenous people from across turtle island so grateful to be speaking to you from us land. I'm an hiv infection disease. Physician in toronto and clinician teacher at saint michael's hospital clinically actually particularly focused on caring for people in communities who are often marginalized or oppressed by our healthcare system. Include people use substances and people living with hiv and as an educator. I spent a lot of time thinking about anti racist and feminist practices within medical education harm reduction and the structural determinants of health royal. Would you like to tell us a bit about what you do. My name is charles. O.'day i am currently in internal medicine resident at ub. I completed my medical school at university of toronto. And i currently serve as the president of black physicians of british columbia on. I am a black woman. Physician first generation immigrant and staedtler ellen that traditional ancestrally and unseated territorial of salish people and selena Atmos kim nations. So you've written this great article about critical race theory your understanding of it and how you use it in the work that you do. How do you understand the concept. First off. I think it's actually really important to clarify that. I don't consider myself an expert in critical race theory. And i don't think we're held either. I think both of us have found it helpful in understanding what we see around us and we both tried to learn a lot more about it through meeting works written by critical race theory scholars like kimberly crenshaw derek bell. Gloria leads and billings and richard delgado others and so ra helen. I've written this piece on. Crt but we come to it not so called experts but as learners together in this process my understanding of crt is really thinking about it both. As a theory and methodology we'd actually do something and in particular away to explore the ways in which racism is actually just woven into the very fabric of our institutions and society with medical institutions. Being no different With really the goal of not just identifying it or naming it actually challenging it in the pursuit of of justice and while crt emanated from a legal scholarship. I think there's lots of potential applications to medicine for hell. So like mallika mentioned i also came to crt as a learner and this article as someone who has learned about crt in founded quite useful in my professional enter personnel and casey work came to it through the guidance and encouragement of my mentor at milica. Sharma who here with me and says you know the commission just reading the earlier works of legal scholars and understanding where the origin of this year radical framework is coming from and how it really builds on the struggle so black and brown lawyers and reading the more relatively more recent work so scholar slight camara jones chandler forward in their discussion of crt on the public health arena while at the interpersonal level has given me another layer of understanding of crt as a framework that could be integrated into fields outside of law particularly appreciating. How this framework could be instrumental in a field like medicine. But overall in essence my understanding of crt is that this is a framework that gives me the tools to understand the structural forces that shape everyday life and as a black woman physician. It gives me a lenz to us. To examine the workings of structural racism in my interpersonal. Professional interactions so mollica. Do you remember when you first encountered critical race theory. From the very first way i came across it was actually when i was doing my masters of education here in toronto. Interestingly even though you've heard that it's sort of stems from legal. Scholarship my very first introduction to it was from a scholar. That rail mentioned cha hundred ford and collins are who apply to public health. So i think for me. That's kind of interesting pieces. That i already was seeing an applied to the healthcare field in the very first way. I am countered it. But for me i think when i first started doing some further reading into crt it really kind of just gave a language to things that i was experiencing or that i was seeing that. I didn't know how to talk about. And for me. Think that was kinda revolutionary. I finally feel like. I have words to put to the things that i'm seeing and to help understand them and help explain them. That is a useful thing with frameworks much as their theoretical constructs. They do help you to have touch points for understanding and putting words to things. So what are the key components off critical race theory as a framework for understanding. Yes so we have outlined some of the critical components of critical race theory and our article. And i think the starting place of this framework is that it recognizes that race is a social construct. it's not a biological or genetic entity So i think that's one of the most important concept of starting place of crt and then we go onto this idea of race consciousness. Which is the idea of examining the process of racialism action so how people become racialized society and how that affects interpersonal relationships and professional dynamics and how it just manifested society another important tenets of critical race theory is this idea of censoring the margins. As so voices and communities who've been pushed out to the sidelines by the mainstream or dominant society need to be centered. When we're using the rt lens so the discourse would be beginning at the marginalized group rather than At the mainstream or dominant society as it has been done in society previously and then another important element of critical race theory is deciding of contemporary orientation. So oftentimes there is a perception of racism as this avert vary is spelled out thing that happens but racism in the twenty first century is embedded into everyday life and it seemingly ordinary and on salient and it does not need to be something that is overt or something That would just stop your day and you would have to say like oh that racism just happened. Just because twenty-first racism has been integrated into the fabric of everyday life on then lastly and I would say the more importantly the idea of practice is very critical elemental. Crt so praxis. Meaning fury burned action Where examining structural races in documenting you know the disparities that result from structural racism is not sufficient but it has to be coupled by interventions that are targeted an informed from your close examination of structural racism. I think one of the other things to just add to that is that critical race theory really came out of legal scholarship. And it's been around for decades right. We're talking about it in medicine now but it's been around for a long time so it's actually a huge body of work and there are many other tenants or constructs within critical race theory including many others that have application to medicine that we don't necessarily talk about it in this article. Such as the idea of voice and counter story and listening to narratives of people who are experiencing structural racism other ideas around property in other ideas around interest convergence and how to align goals in the pursuit of social justice. And i think my hope is that there's going to be ongoing work in the field of medicine in this area. And i know the. Cmha's doing some work around that as well which is exciting but just to kind of reiterate that we explored some of the central tenets but it really isn't very rich enlarge audience work. I found it very interesting. When reading your article that you emphasize those particular tenants about censoring the margins and listening to the voices of of people who are and have historically been oppressed depends making those voices louder. I'd like to ask you. How do you apply that in the work that you do. So an example from my personal and professional in debt advocacy work is My work with the traditions of british columbia during my first year of residency. Here i noticed that i receive only black resident in a group both are hundred fifty residents But i also worked with hundreds of medical students stop. Physicians residents fellows through my first year and i did not work with a single box trainer physician until the end of the year. So i had to ask. Why is this the case. And is there a structural doors system level cost to this rather than being just a mere accident and this is just a way. Things are here at b. c. So i went into the work And formula an association opposition of british columbia to bring together are marching lives a group of black physicians and trainees in this context and then on top of the more i learned about. Crt in the importance of centering the margins. I went back to interview people who have graduated from uvc people who had previously trained at ub c extend to understand their experience to seep clarity asked to why are the way they are ultimately. I was able to a collect a qualitative data in regards to their experience as well as quantitative data in a place where don't have disaggregated data available so just learning that there has been thirty six block medical students over course of seventy years of new c. medical school which is the fifth largest medical school in north america was quite jarring and learning that there were six block medical students entering you. Bc in nineteen fifty. Eight in a cost of sixty on but having one block med students entering the cost of two hundred eight and twenty twenty in another single black medical students entering class of two hundred eight in twenty nineteen Was also important to understand what has been happening. A structural level to get here so it was. It was a very important idea of centering. The margins would allow you to understand the structural causes of Y things are the way they are But ultimately this idea of practice in the fact that we have to move in pursuit of social justice in have to mobilize towards targeted intervention was also very important to me in my understanding of crt so i worked along with the my board and the association to create targeted intervention. So we communicated a call to action to the faculty of medicine here back in october. Twenty twenty saying you know. It is not enough for us to do this. Work and document that there is marked under-representation But they'd solution also needs to implement targeted interventions. We outline specific concrete actions. That could lead to structural change on. So i think Crt has been instrumental for me in that way and has given me the tools to advocate in this space. That's a great example because you're explaining how you went about collecting the data to show the deficit to show the need for interventions to create something that is structurally difference and i think that's another thing to underscore that in the society that we have or in the medical system that we have that is set up in a certain way to privilege some over others. There's almost a a situation where we don't want to know those data. Those data are not routinely sought. We are willful ignorance and so critical race theory. It seems to me in the way that you've used. It helps us to see a better and clearer truth just to mention i know earlier in the podcast. Realm mentioned that she. You know that that we have a mentor moment. He relationship but i think as you can probably from what she's talked about like. I'm constantly inspired by her incredible. And i feel like learning so much from her in terms of how to do this work so i found that really incredible been very appreciative. For that. i guess for me. I'll i'll focus a little bit on. How your t has helped me as an educator and teacher although recognizing i'm a learner within that as well for me i feel expertise really helped me. Unlearn some of the really ingrained ways. In which i was taught about race during my medical training really this idea of race being a biological fact rather than a social construct and talking about race as a risk factor right so going through your internal medicine training and then into practice and particularly for me as an infectious disease physician you know. We talk all the time about racism. Risk factor for example as a risk factor of getting sars. Kobe too but actually we very seldom talk about racism which i think has far more explanatory power when thinking about health inequities and i think this current pandemic is a really important example of that and so crt has given me a way to actually name that and teach around that you know. I'm certainly not a researcher in that way. And so. I think it's helped me be able to teach others and to think through with others how to think about some of these issues in a way that center these experiences of the people who are who've been pushed to the margins essentially i also think for me. It's helped me identify a name. Some of the ways in which we've talked about how racism is embedded in medical practice. Well what does that really mean. Well you know there's historical examples that were still thinking about right. So for example sims speculation named after a man who built his work. Through experimentation on anesthetized enslaved black women too many of the biometrics standards norms the labeling of benign ethic neutral kenia to Lebron has a historical exploration of this barometer as a tool and plantation medicine in the management of enslaved black people. But you know we're still using some of those tools now to thinking about the ways in which indigenous and black people are treated in emergency rooms around the country. Still right and you know in our current time. There's many Anti-racism committees equity diversity and inclusion committee is happening and on some of those committees. Where i might sit. Crt has also helped me to so called. keep my eyes on the prize right. Like reminder to center in the margin so in whatever we're talking about does not serve the person who most marginalized in this setting than someone is still excluded and so whatever we're talking about is not a solution whereas you know we. We remember that if it serves the person who is the most marginalized in that setting. It's gonna serve everybody and for me partly. I'm relatively new to practice thinking through. What does that look like for me. And my clinical work in my teaching practice in my interpersonal practice. I work and how can it help age advocacy in a bigger picture way and thinking through how to do that in ways. That are thoughtful. The you talked about how you use it in teaching going back to the concept of race as a biological risk factor versus racism as a more encompassing thing. How do you teach that now too. Great question and i don't know i always succeed. I guess which is the other piece of it. But i think part of it is You know often when we talked about race risk factor before so for example when i was learning it it was kind of like a laundry list so race. They'll check onomic status housing like all. These things are listed off as the social determinants palestinian. I'll never forget. I was on a shuttle bus and at in toronto and i overheard medical students talking about a quiz that they just had and one of them said well. What was the answer to number three and the other ones had just put social determinants of health. It's always right and so to me. That was really striking right because it was like. We've been teaching this as a thing to know rather than something to take action on. Which i think is a real failure on our parts as educators and i think in particular with with talking about race. It's uncomfortable for people. Right naming white mrs uncomfortable. I find it uncomfortable to to even say that word right now sometimes right so i think it can be uncomfortable but You know there's a great james baldwin quote that says you know not everything that space can be changed but nothing can be changed until it has faced and i think my friend calling monkey ri- for introducing me to that that concept but when i'm teaching trainees or what. I'm talking among my colleagues. I may not necessarily name that what we're talking about here. Crt but when we talk about race for example. I name racism. So i don't necessarily say you know race is a risk factor for cove nineteen and. I'd also don't even say you know there's hot spots or postal. Code is a risk factor for kobe in toronto. Because that's actually that's that's a simplistic flattening of what's really going on right. Because when we look at where. Kobe is in toronto. there's an overlap. Right of certain types of professions racial is isolation income levels. All of these things intersect in ways that reflect how power flows through our societies. Actually able to name that and talk about that. And you know everyone comes to it from their own experience and comes to it from varying degrees of how much they've been thinking about these issues but often it leads to much richer discussion than if we just kind of mentioned it in passing then moved on. So i think that that's part of it. And you know some of that. Pedagogy as an educator means but maybe the teaching around that is slower. Maybe it's a conversation unless less hierarchical like i'm not the one with all the expertise and the knowledge right. So many trainees have far more expertise and knowledge in these areas. Many of them are living right now and so. I think that that for me has if it's informed not just the content of teaching but also pedagogy how you approach that teacher. I'm thinking particularly about the ways that i have been taught so for example. Somebody who's taught me a lot about racism in medicine. Is dr amish story in. Who is chair in black canadian studies in the faculty of medicine at some dow and she pointed out repeatedly that we will in research papers in semi jay talk about racists risk factors so for example like race being risk factor for sars covy to positively among people undergoing dialysis like that is actually written in the discussion of of a research paper and dr dryden pointing out that when we do that. We perpetuate this idea that it is the the thing rather than the structural issue. That is racism in your article. You talk about praxis of the tenets of crt and rahel you spoke about that s theory informed action. How do you see that working out in practice. In the way that you operate in your lives in your work one is as you and milica happened discussing. Just starting at the place of recognizing race as a social construct and particularly right now at a time where medical institutions physicians are talking a lot about racial health disparity ever mainly because of the covid nineteen pandemic. I think it is a time that racial health inequities have been discussed like never before But it would be very important to release stop and recognize that. We've had decades of to eat out and medicine that have documented racial health disparities infectious diseases ratio spiritus cardiovascular diseases etc but that hasn't always been coupled with targeted interventions. And we are where we are now. Because despite decades of documenting it and steadying racial health disparity as an institution on medicine hasn't mobilized to develop targeted interventions to reduce that racial health disparity. So i think the practice component of crt would be extremely instrumental right now to put the responsibility and the onus on our clinicians and researchers were studying this racial health disparity to say it is not sufficient to document the disparity and we have to look at targeted efforts. So it's it is racism that subjects people to poverty overcrowding limited access to care not the inherent nature of phrase instead of thinking of as modifiable risk factor on. We have to start thinking of racism as a modifiable risk factor and design interventions to reduce it and to one example that i see on -tario is our physicians. Advocating for paid state cleaves in light of significant racial disparity that they have been seeing a with covid nineteen and seeing black and brown patients who Often work as essential workers and have been subjected to add things like poverty. Overcrowding on died ended up leading to higher rates of morbidity mortality no communities and coming up ways to create solutions mobilized change is something that the practice of mental. Crt is all about. I love the way that you put it that we need to stop seeing it as a non modifiable risk factors something that which make it difference on you know. It's almost a question that we can be asking ourselves at every point. And i think that that's true for those of us who have primarily educational roles for those of us who have primarily research roles like was talking about also for those of us who haven't in leadership roles right so You know if we're planning on educational module around anti oppression. Like i was doing earlier this week. Or if we're sitting at a board table talking about Udi initiatives for a hospital as as members of the leadership team or something. Like that. i think with any action or anything that's being discussed. There has to be this question. Is this working towards justice. And i think part of the challenges is people want you know understandably people want a tool or a a solution. I think that the other thing that's really important to remember is. This is a big problem and it's not going to have an easily recovered or or comfortable solution. I think was just the piece of it And so praxis might be uncomfortable and it might be messy. It might also not look as narrow or focused as we're used to thinking that isn't it really does require us to have what delays where talks about. Is this like dialectic gays. Right where you have like one eye on your patient and one i on the concentric circles of their social context. I have brought them to you. And so i think similarly If we really are only focused within our small healthcare space In terms of thinking about how we address healthcare inequities that. I don't think gratifying going to achieve practice. I'd actually do need to look broader into society around the broader ways in which that equity is manifest whether that's housing whether that's transit justice right i think so much about was on transit coming from scarborough and brampton to do what we call a central labor but then when we don't actually protect people were doing that labor and the other concept you talk about is censoring the margins just that look like medical institutions. And i'm in -versities across the globe now are increasingly talking about equity diversity and inclusion and so i had a surface level Dismay still seem to be working. Align with this idea of censoring the margins said crt but i think it is also important to recognize when we talk about censoring the origins. It's quite different from maybe previous approaches. Where institutions wanted to quote unquote habit. Diversity checklist as we have to ask the questions of. It's not necessarily about who is in the room. It's not necessarily about who is sitting at the table. Get also who's voices are being heard in the room and who is sitting at the head of the table. And who is left in the coroner's 'cause i would like to raise that as a caution flag as we move towards doing more fdi work across medical institutions dot. We don't stop at inviting the marginalized into our discussions and we don't think we have fulfilled our diversity responsibility by virtue of having one person from each marginalized groups. Sit at the table. We have to actively work to create spaces that those voices are being heard. And those places are being centered. I think when we think about censoring the margins we really need to think about it in an intersectional way There's this tendency. I think within medical practice to somehow think that people fit into one particular know so called minorities box and not others. But you know. I'm not a woman at nine o'clock and brown at ten o'clock and this is something that i heard a colleague say once and i can't remember who decide i apologize. I can't cite them properly but I'm all of those things all of the time and so you know i think that that's the other piece of it. Is that sometimes this work when done in in ways that actually don't dismantle some of the hierarchical and supremacist ways of thinking actually create these boxes that no one really fits into right. So i think it's actually really important but we recognize that we need to think about how power and privilege actually intersect to create that marginalization. And it's not just about the identity it's not about identity actually right. It's about power and to actually engage in Work in a meaningful way involves dismantling power somehow And i can't pretend like. I have all the solutions in terms of how to do that but i think it's important that we recognize that that is actually what the call is four. Thank you so much for this. Fantastic interesting discussion. I've learned a lot from you. And i hope outrageous well to thank you very much for having us. Thank you so much. We really appreciate being here. I've been talking to dr rao. Hells they wounded. And dr malek has sharma to read the article they co authored is it. Cma j. dot ca also. Don't forget to subscribe to seem. Aj podcasts on soundcloud. Or podcast ap. I'm dr kirsten patrick. Interim editor in chief physi- meiji. Thank you for listening.
"From the ted audio collective comes a new podcast called body stuff with dr jen guenter. Dr jen guenter an obgyn and pain medicine physician as she bust. The lies were told and sold about our health. Is it possible to boost the immune system. Do we really need eight glasses of water. A day she'll unpacked some of the surprising cultural stories behind the medicine and explore. How the body actually works you can find and follow body stuff with dr. Jen gunter wherever you listen to podcasts. This is a cbc podcast. I'm pat o'brien goldman. This is white coat. Black art as the third wave of covid recedes and seen rates. Go up there's reason to hope. Canada is on the road to something approaching normal in healthcare that means coping with a huge backlog of untreated diseases especially cancer. So if you've got an iphone you can You can open voice memo and let me know when you have and when you and you can hit the red button as soon as you do just let us know when you started recording yourself l. k. And we're all set. That's karen townsend. She's fifty scientists do now practices law. She's married with an eleven year old daughter. Since kovic these virtual interviews that we do have made it harder to connect the pandemic has likewise made it harder for patients to connect with their own doctors. Canadian medical association journal study found in-person gp visits dropped eighty percent virtual visits picked up the slack. Hello my name is karen townsend. I live in london. ontario. And i was diagnosed with ovarian cancer in september of two thousand twenty for women like karen. Ovarian cancer is the most serious kind just one and five or detected early because the initial symptoms bloating. Discomfort and constipation are hard to pin down way to hear the rest of the story. Karen towns and welcome to cope lockhart. Thank you for having me. When did you first notice something was wrong with your health. I noticed something was wrong with my health. I would say the end of june of twenty twenty or early july twenty twenty. What did you notice. i started. Having intermittent stomach aches which was pretty unusual for me. So i thought i should a take care of my health and have it checked out so what happened next so i spoke with my family physician in early july. Twenty twenty At that time he was not seeing any patient's lives so we had a telephone conference and at that point. He said i think you probably have. Ibs yearbook bowel syndrome. I'm going to give you some medicine. And i i'd like you to go on a low of five map diet and then call me back if that doesn't solve your problem. So what kind of diet was that. A low fahd map diet. What's that obviously healthy eating. But it's you know she can eat certain fruits and vegetables. You can't do that other suits fruits and vegetables. It's a little bit of a weird diet. But i was willing to do anything he wanted me to do. So so i did it. So what did you think of Your doctor's diagnosis of irritable bowel syndrome. Well he said to me at the time when when we spoke on the phone he said you would not be the first middle aged woman. I've spoken to during cova. Who's called me with stomach complaints. So i said well that very well could be. You know if you think. This is the most likely scenario for my for my health Let's let's let's see where it goes. So did things get better on the diet. No they didn't get any better at all. So i was on the diet for about two weeks and the medicine should have really taken care of the problem almost immediately though i was a little bit concerned when after two weeks i still wasn't feeling any better at all now up until that point when you saw your doctor in july. How long do you think he'd been feeling unwell. Probably three weeks maybe four. So what happened next to try the diet. What happened next. I so i called him back and i said listen with all due respect. I don't think this is my problem. What are what are some next steps. We can explore did then. He said well the only next step that i can suggest is that you have an ultrasound. So we'll check things out a little bit more carefully so he said i will. I'll schedule ultrasound for you And he did that and it was scheduled for about a month later and tell me about getting that ultrasound. i actually never got that particular ultrasound. Because in the meantime i was just laying in bed one day and felt my stomach and i said this is strange. I feel something kind of hard in my stomach. I don't know what that is. And i thought well i don't really. I'm not sure what to do with that information. So i sat with it for a day or two and then i mentioned it to my husband and he was one who said you really need to go checkout immediately and so i went to urgent care here in london and they did an ultrasound on me at at the urgent care facility. And that's where. I actually learned that had a large mass in my in my stomach. What was that moment like for you. Finding you had a mass in your abdomen. It was obsolete devastating. I can't describe it to you. I'm a scientist by training and have quite a bit of training and cancer. biology. And i knew it wasn't good to be perfectly honest. So what happened next. I so i. So i i spoke with the the the emergency room physician. The urgent care physician there. And i said what do we do next. And he said karen we run as fast as we can so he immediately that day. Set me up with an appointment to be looked at by gynecologist because he said the tumor mass was apparently coming off. One of my over east. I was very lucky i. We've seen within week by gynecologist and then by gynecological surgeon with another week and within another week or ten days of that. I was in surgery having the mass removed so i was extremely lucky and was blessed with good timing in that sense. What sort of treatments have you had. So i had surgery Right away to remove my ovaries uterus. Cervix philo bean tubes And and any any little metastasis that they found in my in my pelvic area i then about a month later started around six rounds of chemotherapy and that ended in january of twenty twenty one and then i had a c t scan around that time and i was very fortunate to have a a diagnosis of no evidence of disease. Which is great. I then spoke with my medical oncologists. Who thought perhaps we would also do some radiation therapy just generally in that area to to see if there's any residual disease there that we try to get it. So i did twenty five rounds of radiation therapy in march and april of this year and that has been all of the treatment that i've had you were doing this show to talk about delays. And i wanna ask you. Do you think that you've had any delays either in the diagnosis or in your treatment brought on by the pandemic. I certainly think. I had delay in the diagnosis particularly sort of getting through the gate and getting my primary care physician to to help me through this and say oh. I wasn't successful. I had to basically go around that physician. You know kind of into my own hands. Just really unfortunate. As far as treatment goes. I have to say i feel. I felt like my treatment was was quick. I was scheduled for surgery about ten days. After i met with the The surgeon. I have to say once. I got into the cancer center here in london. I was very very well taken care of. I don't feel like there are any delays at all. Sometimes we have phone calls instead of me being seen live but to these days. But i don't feel like my my. The quality of care is has been at a disadvantage because of that whereas in the actual diagnosis part. I definitely felt that way. Karen you mentioned having to in some sense. Go around your family doctor. can you elaborate. Can you say more about why you said that sure. I felt like i wasn't being taken very seriously when i called out to discuss my health and i. I am somebody who doesn't utilize the healthcare system very often. I would before this all happened. I would say. I went to my family physician for my regular checkups and i was very very healthy and So i sort of thought when i call say. I think i'm having a problem. I think i need to be seen i was. I was disappointed that it wasn't taken more seriously. I'm sure when you know the old saying when you when you hear. Prince don't think zebra so. I'm not sure that. I can necessarily think. Blame my position for not diagnosing. My cancer straight away. But i wish i had been in to see him because he had felt if he had felt my stomach he would. He would probably felt this a lot sooner than i had. And there's a loss of confidence there now. Because i didn't get the help that i needed at the time. And it's it's very very sad. Have you had a conversation with your doctor. Since then have seen him once since then yes. I suspect. He was surprised at the diagnosis. And he's tried to be quite helpful since then To be honest. So i guess that's a good thing you came to us because we asked for four people who had stories of the possibility of delay in diagnosis or treatment. Or both during the pandemic. Why did you want to share your story with us. I think it's important to share my story with other people. Because i want people to understand that you can be very you know fit healthy. Everything's going well and yet you may discover you've got you've got a problem. That's that's the needs to be taken care of straight away and particularly during kovin very very easy to get lost in the shuffle. I wouldn't say that. I necessarily took myself out of the shuffle. But you know it's very easy to say. Well let's try this. Let's try this. It's probably this where i think. Sometimes you have to really advocate for yourself to be to be seen. Telehealth isn't always going to work for for all sorts of diseases and conditions. So i just want to recommend people that they. They do advocate for themselves. When they think it's appropriate. I can imagine that there are some people listening to us who who might not be as assertive As you were and may still be sitting at home with a mass in their abdomen or or some other symptoms like like extreme weight loss and and wondering if they should go in and seek attention. Yes if you have an inkling that something might be wrong please reach out to your healthcare provider or anybody else who who will listen to be honest. Because it's better to be safe than sorry in the sooner something can be diagnosed. The sooner the better off. You're going to be for it all well karen towns and i wanna thank you very much for telling your story to us and i hope that that you're you continue to do well and that your health is good and I want to thank you for speaking with us. Thank you dr goldman. I appreciate it karen. Townsend was diagnosed with stage two ovarian cancer which means the cancer has spread beyond the ovary with treatment. The five year survival is about seventy percent. The mainstream treatments century and chemo can cure some ovarian cancers at that stage. I hope that happens with karen. We'll be right back. Hi i'm dr. Hillary mcbride normally therapy sessions are totally confidential. But in other people's problems opened the doors to let you hear sessions with my long standing clients. This is what people sound like when they talk with someone. They trust about healing addiction. Parenting stress racist ideologies in the family. And other topics that feel so timely. Is we come through this difficult time. Other people's problems available now on. Cbc listen and everywhere. You get your podcasts. You're listening to white coat black art this week. The pandemic has caused a huge and growing backlog of canadians with undiagnosed and untreated cancers. Many don't even know they have it. We're talking about very serious. Cancers like the ovarian cancer karen towns it has catches with lung esophagus in the head and neck. Hello deja vu. That's right. I yes i'm ready. I'm going to hold my recorder in my hand. i'm i'm good. how are you not clinics. Is a back story here. This is my second interview with dr. Tony s candor is a head and neck cancer surgeon who worries about patients whose cancers haven't been diagnosed during the pandemic so okay so no. Don't hold anything and you know we're gonna do this time. I'm not what i had was. I had my papers on top of this last week. I went to sunnybrook health sciences centre in toronto one of the hospitals where he works for his take on what to do about the backlog and i discovered how easy it is to hit the pause button literally hit an accidentally hit pause and my record during the interview. That's never happened to me before. Doctor was kind enough to give me a second chance. Ohi my name. Is tony skander. Head and neck. Surgical oncologist at sunnybrook health sciences centre in the sunnybrook research institute. And i'm also a health services researcher at ics and the institute of health policy management and evaluation at the university of toronto. So we're here today. Because i did something i have never done before. I completely muffed a recording on a perfectly wonderful interview and you have kindly consented a couple of days later to repeat the interview. Why have you done that. Because i think you have an important story to tell. I think there's an important message to go out your mench. Yeah my pleasure okay. So welcome back to white coat. Black art thank you. What has it been like for you. As a head and neck. Cancer surgeon during the pandemic in one word. It's been unpredictable. The schedule has been unpredictable When we will treat our patients has been rather unpredictable. And we've been running a list of priority patients week to week. What are you noticing about. Patients patients are scared. Patients are also uncertain about when they're gonna get treated and that leads to additional anxiety for them. They often need to reach out to us more for reassurance as to what will happen with the additional weight. And what we're doing about that weight. And we try to provide them with as much information as possible. Some patients have been coming in with larger tumors or undiagnosed. Tumors i think. That's very common amongst my oncology colleagues To see these types of patients with more advanced cancers can you say more about that How much more advanced You have any japanese stories. I've got stories. I mean. I wish we had data because data would be the best. The problem with the data is the data. Takes a long time to get curated. And we won't have the data for another year year and a half to know about whether more patients are coming in with a more advanced stage there are many of patients who either have not sought medical attention because a fear of catching covid from coming to the hospital or stories of patients who have tried to to get medical attention and that medical attention was virtual or teleconference type medical attention and therefore they couldn't have a full physical examination and that has sometimes delayed their diagnosis many of these patients without getting into too many specific patient details are going and asking to be examined repeatedly but are are being treated with other treatments until they're being seen by a doctor in person sometimes they will have a family member. Many of these patients are elderly. And they're not technologically savvy and so you can imagine that a family member might come over and say oh. I haven't seen a long time. But what's that growing there. And that's when things really start moving because pictures are sent along to physicians. And ultimately their broaden and seeing quickly Several such patients in my practice. I was the first physician to see them in person. I got phone calls from physicians. Who had seen them virtually and eventually seen their pictures that were sent by younger family members. But i was the first person to biopsy their cancer and to see them in person. I've interviewed for this show. A forty nine year old woman from london ontario who ended up having ovarian cancer last july. She went to her doctor with the very typical vague symptoms. Some bloating some some digestive issues and was put on a diet seen virtually put on a diet. The diet didn't work and eventually family doctor arranged for an ultrasound and meanwhile the woman felt her own. Abdomen felt the heart area amass. What turned out to be a mass and so she went to a walking clinic and had an ultrasound done at that point. Is that surprising during the during the pandemic is is that. Is that an unusual situation. I mean i can't comment on all gynaecological malignancies because its not my expertise. But i could say it's common in my own practice to see patients who have not had their tumors physically touched or examined who present to me for the first time either having self examined or having had a family member advocate for them and say this is ridiculous. They really need to be seen in person. This problem is growing quite rapidly. I know you don't have the data. But what what are the implications for these patients and the system that you're concerned about. The implications are not really all that surprising with delays in diagnosis and delays. in treatment. We know that patients have poor curability and poorer survival outcomes from the management of their cancers. There's an excellent paper published by dr timothy hanna from queens university and ics queens site that actually and this was published in a major journal that demonstrated exactly how much two or four week delay for any given cancer would lead to worse survival outcomes so we know that it differs by cancer but we know that it matters really for all cancers so meanwhile we're building up a backlog of surgical cases. Aren't we yeah and the surgical cases aren't just for cancer. I mean i know the focus here is on cancer. But we're developing a backlog for everything orthopedic surgery important is surgery All kinds of surgery is being significantly backlogged. And that's going to impact the cancer system along a backlog are we are we looking at you. Take all surgeries. We're talking of a recovery. That's in the years. Not the weeks or months. we're talking about hundreds hundreds of thousands of delayed Surgeries dr tony. Iskander says he seeing patients with cancers of the head and neck getting diagnosed at later stages than he's used to more patients than he can count stories like this one a patient presented with what she thought was a small problem on. Her face reached out to her family doctor and was put on a series of antibiotics to see if it would get better and this small pimple became a big pimple and it grew to a larger and larger size mass until a family member came in and saw it and said wow this is growing quite rapidly am very concerned and she. She said he. Of course you know. But i am following up with my family doctor. Ultimately a picture was sent to the family doctor who directly reached out to me Which is often the case when these patients come with a slightly more enlarge tumor everyone it becomes aware at some point and then it becomes an emergency happens in my practice all the time and finally when the physician reached out to me i saw her very quickly within a few days and we buy up seeded and so on and it turns out to be turned out to be a cancer correct. And what goes through your mind when you see something like that. Well it makes me wonder how many other patients at least we found this particular patient and several others in my practice who presented that way but it makes me wonder about how many are not going to be found or at what stage the rat or if they have a family member to advocate for them it also makes me wonder about how many patients are going to progress to the point. Where we'll when they come to us. We will not be able to treat them in the usual fashion and so it has me worried Has me worried for. Our patients also has me worried for us. Because now we're going to be dealing with harder cancers to treat it's gonna take more resources and more effort on our part. How do you get through the backlog. Well i we have to find all the patients. I'm worried that many patients are yet diagnosed because to diagnose patients with cancer. They need to see physicians. They need to get tests. Like biopsies. c. T. scans ultrasounds etc. And they have to attend to their screening program. Visits colonoscopies and pap smears mammograms. And so we have a backlog of all of those things and so i think our backlog is somewhat theoretical because there are many patients that just hasn't come in yet and will be coming into a more advanced stage. So i think probably the best way to get through the backlog to first identify the backlog and have people come in before it's too late for even for them to even make it on a weightless for surgery. Maybe they don't qualify for surgery anymore. Which is one of the most important treatments. We can provide to cancer patients. But how do you discover all of the people who might have cancer and have no idea. Yeah well first of all you managed cova very aggressively and you get the numbers down. That will get us back to some form of normal but even once you get back to that normal you can't just operate at one hundred percent you've got to go into some type of one hundred ten or one hundred and twenty percent rate to bring people in more than you would usually to try to catch up on what you've missed in the past and the ideas on how to do that. I don't have any good solutions. For that problem. We can try to work on evenings and weekends But we have a very Fatigued healthcare workforce who've just managed a very long and challenging crisis. I speak almost in the past tense. Were still in the midst of it and so as much as we'd like to wrap up one hundred twenty percent. I don't know how realistic that is. One last question you obviously care about your patients a lot and by inference all of the patients who are waiting to see their own. You know your colleagues. How frustrating is this for you right now when you think about. What's out there that you don't even know about in terms of patients who are sick with in your case it's cancer other people it's other diseases. Yeah it's frustrating I think that's why i'm doing the work i'm doing. It's my way of dealing with the frustration by studying it by advocating for equitable care especially amongst those of lower socioeconomic status and those who might be more rural those who might have access issues and despite the frustrations there's no doubt there's a ton of it. I have been also proud of my colleagues and the leadership at the hospitals that i work at for the reason of that they have been able to get our patients through yes. They have been waiting slightly longer but they have been able to prioritize them in an ethical way to get them through so i have more hope than frustration. I do have some fear that i don't know where these patients are and i want the messaging to be clear that they should come into hospital and seek medical attention. Were open for business. It's quite safe. The covert numbers in the hospital are in fact quite low but even when they weren't low. We're so careful about separating those patients in about testing everyone that there are very few infections spread within the hospital if any and so if you need medical care at the right thing to do to just come in and get that care. You shouldn't question it. You shouldn't second guess it get some rest. You're going to need it. Thank you and thank you for speaking with my pleasure dr. Tony has lots of ideas for dealing with the backlog of hundreds of thousands of patients that will take years to clear things like clinics patterned after automobile collision centers for faster turnaround and directing patients to surgeons with the shortest wait lists. He thinks about the patients who have cancer and don't know it sorta. Why if you think there's something wrong. Don't wait and if you think you need to see your doctor in person say so your life may depend on. That's our show this week. Email us at white coat at. Cbc dot c. I'm on twitter at night shift. Md and the show is at cbc white coat. We're also on facebook. You can listen to white coat. Black art and the dose on the cbc. Listen app or subscribe to our podcast with your favorite podcasts provider. This week on the dose darsur lenora sack singer and infectious diseases specialist in edmonton talks. About all the things you'll be able to do once you get your second dose of covid vaccine. Here's a sample. I think a lot of restaurants have done a really good job with distancing and protocols and that they continue you keeping those structures in place that they'll be pretty safe spaces by large especially the ventilation things all that stuff you know. If you're going to a large group gathering guess what worries me about stuff like concerts is that we never went to anything like that during lockdown and so kind of you tend to fall into your previous patterns of behavior the familiar patterns which would involve really not very much distancing. I think that those were be situations where increased vigilance would happen. And i would actually expect that kind of large group. Gathering might be one of the last things to come online. And i'm okay with that. Because i think what people are really missing seeing friends and family in in you know a reasonable group for a reasonable amount of time without feeling so anxious and without coming into place over the summer especially for outdoor gatherings. Pretty much everywhere. I think that we can defer some of the large group stuff for a little while longer without really a big hit. You can hear more on the dose before we go. We need your help for season ending show. Who is your healthcare hero. Who helped you most. During the pandemic share your story with us by email at white coat at cbc dot ca on twitter at cbc white coat or at night shift md and on facebook will feature some of those stories later this month white coat black art was produced this week by ominous offer with help from rachel sanders digital producer rubies and digital writer brandy waikele our senior producers geoff goods. That's medicine from my side of the gurney. I'm brian goldman. We're in this together. See you next week for more. Cbc podcasts go to cbc dot ca slash podcasts.
Prone positioning (chest down) for COVID-19
"The scotiabank healthcare plus physician banking program was co designed with md financial management for canada's physicians by combining md's fifty year history of working exclusively with physician households and scotiabank expertise in banking were able to provide specialized advice and unique financial solutions tailored to your needs at every stage of your career. Were better together. And more committed than efforts cannabis physicians. Find out more about how we can help you and visit. Www dot md dot ca slash healthcare plus two shingles age isn't just a number. Do you have patients fifty or older. They're at higher risk of getting shingles. Don't wait talk about shipwrecks with your patients over fifty today shingles is indicated for the prevention of herpes zoster. H shingles in adults fifty years of age or older. Consult a product monograph. Gmc dot ca slash english slash pm for contraindications warnings and precautions adverse reactions interactions dosing administration information to request a product monograph or to report an adverse event. Please call one eight hundred three eight seven seven three seven four. Learn more at Dot ca Pneumonia with response to stress and talks. Yeah is it common reason for admission to hospital among patients with covert nineteen for these patients. Some conditions have tried it intervention. That's been used widely among ventilated patients with acute respond to distressing drum or a. It's not a drug or oxygen but prone positioning. This means having patients lie on the front rather than their back. I'm dr kirsten patrick. Executive editor for the canadian medical association journal. Today i'm talking to kevin. Venus general internist at university health network in toronto. He has co authored. A review article outlining what is known about propositioning for patients with hypoplastic respiratory failure related to covid nineteen the oscalus published in cmha. I've reached venus in toronto. Hi kevin welcoming bergerson. Thanks so much for having me. So let's start by having you tell me ask who you are and where you're out. Yeah sure so as you said. I may general interest That works in toronto. Unacademic academic teaching center completed my undergraduate and postgraduate training. All in toronto. And have now stuck around my in. Clinical activities include in patient general medicine on the on the medical boards and during the current pandemic states that we're living in that includes the code word from time to time. Otherwise i also attended the ambulatory clinics and on the medical consultation services which mostly deal with peri operative medicine is intervention of prone positioning or putting patients on. The front is something that used to be used in in a very discreet setting usually ventilated patients. With aids. In the icu. Can you tell me how and why things have evolved such that. Physicians are using this in non-integrated awake patients. Who were not in the icu. Yeah and so. The the supine position having patients on their back is sort of the default position. That everybody's familiar with. This is how we usually relax at home in bed or on on the coach for example. it's comfortable and in the hospital. Setting there are benefits to this beyond comfort because the patients into your chest is available for imaging studies or monitoring leads linzer easily accessible for veena puncture. Iv lines the prone position has been used a really only in the intensive care setting consistently and the recommendations or suggestions that the position might be beneficial for patients with high toxic respiratory failure from covid nineteen are really drying on the expertise of that's been gained from the population of intimated patients in issues specifically as you mentioned patients who have acute respiratory distress syndrome. There's a wealth of strong randomized evidence that has shown that patients who have severe hypoxia failure of this kind benefit from a prone position. And i think some of the excitement about propositioning being extrapolated to other patient populations and patients who aren't intimated also has to deal with Some of the understandable anxiety That healthcare workers and health systems researchers have about the potential for covid nineteen overwhelming healthcare resources and critical care beds. So i think you've touched on something very interesting there with the covid. Nineteen pandemic and overwhelm of icu and hospitals. It seems like people have been willing to innovate at a faster rate than he might usually so extrapolating this prone positioning to the non. Ar non icu setting could be classes in innovation. Yes i it could be I think that there's certainly been an appetite both from the medical scientific community and also in the population public population at large to look for innovations. That may up see will help patients who have this new disease that we're still understand think we've seen this play out a number of times especially during the early months of the pandemic with Many potential drug therapies being used very quickly made me without The same amount of oversight or randomized trial evidence that We usually try to ascribe to And so i think it's certainly could be viewed as an innovation but we also have to exercise. I think some restraints as researchers and medical professionals To make sure that we're not adopting something without giving it the scrutiny at deserves. That's your article is great because it really delves into into what is the state of the evidence that we have for. it even versus yard. Yes and how will we try lightness And what happened in susan verging walked on the prone position. I mean if you think of going to visit a patient you expect to find them reclining on a back in And having someone lie on that front. It's not something that you expect to see. If i think about if i were to lie on the couch on my front to try and watch. Tv that would seem like it would be really uncomfortable. So how does prone positioning effect lung function in such a way that it would make lung function better. Yeah so this is a interesting topic. And there's some really complex physiology that goes into understanding the benefits of propositioning for those who have hypoc respiratory failure and it even made more complex in intensive care settings when patients are receiving positive pressure ventilation so for patients who are spontaneously breathing. And not intimated there are a few sort of key physiologic up principles that are important to understand to understand a benefit. Really the first is the gravity. And so if you're supine lying on your back then The heart and the media tunnel structures will follow. Gravity in fall are shifts slightly posterior early back onto the lungs which adds a compressive pressure to the lungs as well while supine liver and domino organs can also shift securely to compress mostly some of the post earier zones in the lower ropes If you're prone than gravity doesn't reverse but the effect on your interest rasa can adopt reversed and so in that position the heart media steinem shift interior early instead towards the chest wall and there's a decrease in the shift of the domino organs overall this results in less lung compression and less alveoli collapse in alexis when there is this compression and alveoli collapse. What can be accentuated is a ventilation perfusion mismatch and increasing rates of hypoxia. The pulmonary perfusion is mostly directed towards the posterior lung zones regardless of which position patients lying in. And so if you're able to better oxygen eight the post earier lung zones while prone then you decrease the amount of ventilation perfusion mismatch another consideration relates to the expansion of the chest wall. And when you're lying on your back or in the supine position than The expansion is somewhat more limited because The lateral and post your chest wall is against the bed or gurney however when you're prone The anterior chest wall movement is restricted. And since most of the lungs are positioned posterior early having increased movement of the poster. Lateral chest wall allows for expansion or greater expansion Of these larger lung zones. So those are some of the main considerations from a physiologic perspective that can explain how prone positioning can improve oxygenation. So considering this potential for improving ventilation and reducing ventilation perfusion mismatch in the lung. At what point should we be thinking about placing patients in the prone position. Early on in their hypoc sat or later on. And how should we do it is sad continuous or episodic yeah so this is one of the great unknowns our current unknowns unfortunately in terms of when we should position patients into the prone position we really don't know for those who are not intimated what we do know from a large wealth of randomized robust data for patients who are interested in the icu with severe aids These patients benefit from prone positioning of twelve or more hours per day. And this is now standard of practice in intensive care units all over the world however for debate patients as we're talking about it's really unclear at what time to what time is best to initiate positioning. It make intuitive sense. That patients who may be aren't yet hypoc less likely to benefit but there's simply no data to that regard yet Data has suggested that prone positioning can decrease patients respiratory rates in work of breathing which may be able to decrease the risk of developing something known as patient self self-induced lung injury which is another concept born out of the rds literature and this essentially means that with increased work of breathing. There can be an increase in the negative intra thrust pressures in actually a pressure related injury to the lungs which may worsen their course as they get more sick but whether or not this means that prone positioning should be adopted earlier later in one's disease course if they're not intimated is known and then i think the second thing that you mentioned. Kirsten was you know. How long should people be in the position and certify for what duration And again as i mentioned we know that for patients with severe air yes there have been randomized studies and meta analyses that have shown that people benefit if it's greater than twelve hours per day however for those who are not intimated we just don't know and so a lot of the observational studies right now have very heterogeneous prone positioning protocols Some us total number of hours per day. a target. Some use different episodes of prone positioning of certain durations in in their studies and so there's not a lot of consensus right now. I suppose it's important to emphasize that that a patient. That's not into beta days awake and therefore tolerating being on their fronts and possibly with you know hemmings Head from one site to another can be difficult so that may limit how long they can stay on runtime edging yes definitely In the icu. In the critical care setting you know these intimated patients are usually heavily sedated and maybe receiving neuromuscular blockade and be effectively paralyzed as well and so There's not the same level of conscious discomfort that patients who are not intimated may experience and this discomfort which is usually musculoskeletal in nature relates to shoulder discomfort neck discomforts Back discomfort is been consistently seen as a potential limitation to implementing this intervention on medical words per se so to delve a little bit more into this this positioning shared. Is it something that has to be quite carefully done. And and how do you mitigate against the difficulties or our hardens of putting a patient in a position so again i think there's A lot of experience being drawn from the intensive care units and critical care settings You can imagine that placing somebody in the prone position If they have enter tracheal to end props central venous catheters and other devices while they are sedated and paralyzed is significant. Logistical feat in requires many people to to complete safely special training for patients who are conscious not intimated breathing spontaneously Ideally they're also going to be able to do most of the maneuvering and change in position himself in bed and so the staff were looking after them should be aware of you. Know maybe a safe sequence of events about how to instruct them to turn in bed for example But also to be mindful of things like fully catheters or iv lines or monitoring leads So that they don't become tangled up In the patient's bed and then the other Important piece is as we're talking about. Comfort or mitigating discomfort is for appropriate padding with pillows roles or extra sheets for example under the pelvis chest other pressure points to try to make it as comfortable for the patient patients possible. I think you mentioned the article that that positioning couple of towel rolls under the pelvis actually has the added benefit of elevating the abdomen. So that you have less compression of the donald contents into the chest. Yeah that's right And so it of has to benefits. It increases comfort for the patient and then also by decreasing Direct pressure on the abdomen as we're talking before is another way to decrease that shift of intra abdominal organs up towards the cavity which will decrease the amount of lung compression That's going on. I think the other thing that's important to mention is that Especially after the first episode of chrome positioning the staff were looking after the patient should monitor them to ensure that there's no worsening of the respiratory status for probably the first ten to fifteen minutes although there's not a clear guideline about that yet and this is one area where remote monitoring systems can be useful. If there's efforts being made to conserve personal protective equipment or infection control concerns. I had any patients for whom prone positioning is not recommended. Yes so there's there's a few Specific patient populations where This may be should be avoided and again a lot of this is being drawn from intensive care experience so patients who have been traumatic injuries to their anterior chest or face should avoid the prone position If there's been a recent anterior thoracic surgery or abdominal surgery should also be avoided or if there are concerns for able spines stable pelvic fracture than the sort of movement manipulation should should be avoided as well practically What we're also seeing. Is that a lot of groups who are conducting. These studies are also choosing not to involve patients who are on continuous cardiac monitoring for example as the the leads are less accessible when somebody's in the prone position And then the other important consideration is Patients who have a decreased level of consciousness. Or maybe aren't able to shift independently and sort of shift around in bed so may get stuck in uncomfortable or unsafe position. without assistance. Finally i think those patients who are spontaneously breathing but have signs of severe respiratory distress and may require imminent emergence into tracheal integration should not be placed in the prone position just for concern of the worsening their other work of breathing and also in a previous life. I was in neath aside and we think if somebody looks like they might imminently need education. You're gonna want them on the back. Exactly and i remember in your article. You also mentioned pregnant patients. So i think that's not necessarily a contra indication because you point to a couple of case reports that say that that prone positioning has been used successfully and pregnant patients folks with covid nineteen and not so. That would be something that you would think about being more logistically difficult but not necessarily a contra indication yeah that's exactly right the it's It's not just in this area. But in many areas of medical research pregnant patients have not been routinely included in trials or or studies in. So there's a there's even less Data available for this patient population however again in intensive care experience prone positioning has been used successfully In in patients who are pregnant including a late in pregnancy and there are case reports coming out now a related to covid nineteen where prone positioning has been successfully used in both intimated in non intimated patients. Who who were pregnant as well so there are. There are some other ways to logistically. Make it a a easier. Might need some more staff on hand for example or something modified mattresses or padding to make it more comfortable for the patients but But from a medical perspective. It's something to consider what evidence exists about the effectiveness of prompt positioning in patients. Who are hypoc sec. In general in general as as we talked about before so for patients who are in the icu. and our intimated with moderate to severe air diaz Prone positioning has been consistently shown through a high quality randomized control trials and also met analyses that to be beneficial to reduce mortality if it's completed for at least twelve hours a day and this has now been widely adopted as standard of care practice for For these patients internationally shifting to you know the patients that were focusing on today. Those were not intimated. Were not critically ill before. The covid nineteen pandemic. This was not a question that many people were looking at There i should say that. All of the data both before and now during the covid. Nineteen pandemic is optional. nature We don't have any randomized data yet. And it really is comprised of case studies case series and mostly coked observational cohort studies. The observational studies at tend to look at a few different parameters. One is the question of whether or not prone positioning improves. Oxygenation for for these patients and Appears to do so again. With the caveat that this is not randomized data there is still conflicting evidence coming out. Not all studies. Do show an improvement in either the oxygen saturation or the pdf a ratio. If it's being calculated and not all studies are showing a sustained benefit in oxygenation either While people are then reverted to the supine position or after Longer durations of trump positioning another area. That's being looked at is whether or not The prone position will actually decrease the need for tracheal intimation. And we're really lacking a lot of data in this area. I think some of that is due to the fact that the decision to intubate a patient is not solely based on their current oxygenation status. But you know other. Medical context is comes into play as well But we don't have a good sense yet about whether or not Prompt positioning will will help decrease intimation rates for these patients. So you've been talking about observational evidence that's available and saying it's not randomized trial evidence at this stage for covid nineteen however there are a number of randomized trials underway. As i understand from your article. Are you involved in one of those. Yes i am involved in one called the covid prone study and as being led by one of my co authors. Dr michael froehlich. This is a pragmatic randomized control. Trial which started in toronto and is now expanding to other sites a hostile sites as well as some international sites trying to answer some of these questions about whether or not prone positioning for not intimated patients. is beneficial in terms of reducing rates of hypoxia and also a patient symptoms and to clarify. You're enrolling only patients who unaudited Spontaneously breathing and awake and What outcomes like looking at so we're looking at a number of outcomes including patient centered outcomes such as Comforter discomforts We're looking at oxygenation. Data does this actually improve patient's oxygenation or not and also looking at rates of complications Either at potentially related to pro positioning or Trying to understand whether or not this will delay or avoid patients needing admission to a critical care unit at this point with with trials ongoing and onate observational evidence available. What are some of the unknowns that really need to be answered yes so there are far more unknowns than knowns at this point and so i think they've fall into a few major categories. One is really the question of how to best identify which patients are most likely to improve from this intervention. We don't really know you know how best to select patients to prone yet. How should they be. How high toxic to see a benefit When should we initiate prone positioning Depending on some of these variables how long should we Administer prone positioning either in terms of total daily dose or perhaps in discrete throughout the day. We also don't understand what the benefit of positioning is compared to other interventions like a noninvasive ventilation options including c-pap or high flow nasal kenya oxygen delivery systems. There's been some studies that have shown that prone positioning has been beneficial only in conjunction with one of these other adjuncts and so we need to try to tease that apart as well We don't understand if approved positioning is going to actually delay or avoid intimation for these patients in. That's sort of the The biggest question that i think is on everybody's mind as we get concerned about the strain that this is placing on our our healthcare resources and as well in terms of healthcare resources. How does or how would propositioning affect healthcare costs if it does actually delay or avoid peoples admissions to intensive care units at than there could be considerable cost savings associated with that however if maybe there are increased use of personal protective equipment for staff to help patients maneuver in out of the prone position than that could be competing Competing factor so. There's lots of unknowns at this time. Luckily there are a lots of randomized studies underway which are hopefully going to address these questions and and give us some of these answers you know at the beginning of the pandemic there were actually youtube videos telling people how to put themselves into breath at home if they got code nineteen and they had a stay at home. So is this something that patients could try if they were ill at hope but not necessarily needing hospitalization. It's a really interesting question because This this out there in the public sphere. Now right i think it was the new york times who published a a month or two ago in one of their their weekend editions. I think a sort of Summary of the at that time. Currently available therapies and potential therapies for kobe nineteen including drug interventions and non drug interventions and prone positioning was listed as something That basically they said people should try right and so there's a lot of public knowledge already out there about this sort of to two thoughts about this as a as a member of the public and as a physician who knows a little bit about physiology for a non hospitalized patient. Who's not hypoc sec. There's probably very little downside to try this at home safely right. Many of us choose to sleep on our fronts overnight every day of the week and so there may be some benefit in terms of symptoms are feeling Feelings of disney. That are mitigated a little bit but from a perspective of a medical researcher You know could we. Should we be officially recommending this. I really don't think that there's enough data to To sort of give that recommendation yet. Kevin this has been a really interesting discussion. Thank you for joining me today. Thanks very much. Kristin the pleasures mind. I've been speaking with. Dr kevin venus to read the article. He co-authored is it. Syria j. dot ca also. Don't forget to subscribe to salvage podcasts on soundcloud or a podcast app and let us know how we're doing by leading rating. I'm dr patrick executive editor. Thank you for listening.
Misinformation in medicine during the COVID-19 pandemic
"The scotiabank healthcare plus physician banking program was co designed with md financial management for canada's physicians by combining md's fifty year history of working exclusively with physician households and scotiabank expertise in banking were able to provide specialized advice and unique financial solutions tailored to your needs at every stage of your career. Were better together. And more committed than efforts cannabis physicians. Find out more about how we can help you and visit. Www dot md dot ca slash healthcare plus two shingles age isn't just a number. Do you have patients fifty or older. They're at higher risk of getting shingles. Don't wait talk about shipwrecks with your patients over fifty today shingles is indicated for the prevention of herpes zoster shingles in adults fifty years of age or older. Consult product monographic. Gsk dot ca slash english slash pm for contraindications warnings and precautions adverse reactions interactions dosing administration information to request a product monograph or to report an adverse event. Please call one eight hundred three eight seven seven three seven four learn more at Dot ca Cope in nineteen is the biggest pandemic on earth since the age of the internet smartphones and social media this intersection has created an epidemic of misinformation. That is spreading faster than we've seen before making it difficult for both doctors and patients. We might think it's an information technology problem but historical perspective suggests this is an overly simplistic way of labeling. The problem i'm dr during de shower. Deputy editor for the canadian medical association journal today. I'm talking to dr nancy. Tom's distinguished professor of history at stony brook university in stony brook. New york dr. Tom's is well known for her. Extensive work at the intersection of expert and popular understandings of disease. She's written a fascinating article unpacking the modern info dynamic by approaching it with a historical lens. Her article is published in c. j. I've reached turn in stony brook. Welcome nancy thanks for having me here to beautiful day on long island so could you tell us a bit about your work and your area of study. Which as i know. And i think our readers should know is is huge. It spans everything from infectious diseases. Mental illness to marketing of disease. So this moment in time really has has me thinking about my work in relation to the different phases over time Particularly a a book. I wrote in nineteen ninety eight. Call the gospel of germs. That was about the public health efforts to make people aware of and frightened of the power of the invisible microorganism. It's a fascinating historical subject that turns out to be eerily useful in twenty twenty as we combat the kofoed pandemic the basics of social distancing that we're using in this flattening the curve moment are the same as sour developed a century ago so it's a good example of how history continues to be useful in understanding our present moment when i was working on the gospel of germs. I was fascinated by that intersect. You mentioned between experts and the public. I've always been interested in media. And how media works to spread scientific information. And that's the kind of background for what caught me interested in this concept of an info gimmick the term info demonic combines information and pandemic It's a term that describes the overwhelming amount of information. We have access to but the word was first used during the stars epidemic. Can you tell me a bit about how the word info democ was used back then so. The usefulness of the term for me is that it really does target the internet and after you talked to any historian who studied pandemics in the past. What we're seeing now. The conspiracy theories st calling out of specific groups to be harassed or even the attempt to make a quick buck out of people's fears these are ancient phenomena. You can see them in a mediaeval. Vanek plag- you can see them in nineteenth century epidemics. What is really i think. Captured by that word info generic is the concept of mission technology and how it has speeded up processes that One hundred years ago. Same things might have happened but they would have happened slower and they wouldn't have reached so many people so fast certainly misinformation news. I'm not sure when that term. I came out fake news but fake news exists in the media and on social media especially surrounded by this confused by the current political climate. But as you describe in your article the rise of misinformation during epidemics has has a strong residents to the past and you just mentioned medieval times bubonic plague Can you tell us a little bit more in detail about how that information or misinformation moved around back. Then so i think one of the fundamental continuities that we struggle with us. Historians is that because people didn't have the internet doesn't mean that they didn't have ways to communicate if you look at the plague in in the fourteenth century oral communication people talk to each other. Of course they still do that. there are far fewer print avenues simply because papers more expensive. People's ability to read is is less widely disseminated So ideas moved around more through oral transmission through people talking to each other rumor spreading when Folks are down at the end of the street. Gossiping over there. You know morning cleaning out the sewer or whatever So that there was that kind of of connection. and spreading of ideas and information. It was just a lot More diffuse and so the big. I think the direction have changed. We go from the fourteenth centuries fate of the nineteenth century when you began to get print media involved in this. You have newspapers reporting. You have a more health information that gets put into paper form like a broadside posted during the cholera epidemic in nineteen century new york for example. So it's It's it's circulating. We have more paper. And i think we have a different conception of expertise by the time we get to the nineteenth century Each sharpening of sense that there is this professional elite that is generating new knowledge and sharing that knowledge. So that's kind of the scientific. Modern scientific medicine in a nutshell is is. It changes a lot quicker and that interface between here experts trying to figure out what the problem is and then share that information with the public to help them not die To help them vade the disease. I remember this brings me back to your book. Gospel of germs. I think there was quite quite a bit of Searching into the cholera epidemic. As you mentioned. And if you bring this concept of certainty. Because i think that's a theme in your in your cmag article and a theme as well as how experts handle that uncertainty as opposed to say the way the way knowledge was presented to the public if we can if we can say is such a thing as a single public but if there is then how does that come out of newspapers as opposed to what was going on behind closed doors in medical schools among experts that Scientific churn where you have different physicians from different professional backgrounds. Trying to figure out what causes cholera. They don't agree and that lack of agreement certainly comes across in terms of medical writings How much of that gets picked up in an amplified in the popular press. It's it's less I there's a difference in what was considered newsworthy until the late nineteenth early twentieth century that the notion of what was the new say in eighteen. Thirty two as it's it's news about what's going on in the business world. What's going on the political parties. You have a lot less space in in the modern media for All the the kind of were personal social or even public health aspects of of life so one factor that changes from say the early nineteen th century to the late nineteenth century When the gospel of germs really gets rolling is is a different conception of what is newsworthy and the degree to which newspapers cover public health events. And what is their coverage and and really even into the twentieth century the coverage is more about. Here's what's in the paper. Here's what's happening. And we are going to reproduce the latest advice from your local public health department about how to cope with problem x y and z. There's not a huge attempt to try to explain the basics of what's going on to the public in the midst of of a crisis there is an attempt to help people understand that it's much more diffuse sits more willing to be school training. What children are being taught about how to how to take care of themselves. A lot of Health handbooks lots and lots of how to stay healthy by keeping your home. Germ-free is a lot of the kind of literature but it's again it's Not as broadly disseminated. I mean we use the word mass media It's kind of problematic term in a lot of ways but it does indicate a shift in the twentieth century of where you have a much broader reach Say newspapers then. Are there in in the eighteen seventies if we fast forward to the early twentieth century the greater interest of the media in covering scientific discussions and educating people about those discussions that increases dramatically over the course of of the twentieth century. I would say there's There's a lot more control that the these the american medical profession had over. What went into newspapers magazines from about world war one through maybe the nineteen sixties so that that there was more professional control over. What got out there. And i think partly what we're living with through now is that those controls have been shredded. Mean they started shredding in the nineteen sixties and seventies But one of the problems we face today is that there is no control over. What gets out there And there are now attempts to try to rein in what's being shared on social media but only after a lot of resistance on the part of those media platforms they didn't want to police the content and that's part of what we're living with now is struggling with with the that free speech elements and not wanting to tell people what they can say or think. We're reluctant to do that And yet a sense that this circulation has amped up so much and the there's no controlling force anymore that material. That is just clearly false. Totally unscientific i mean maybe you can find one renegade. Scientists were Physician to say yes. This is true this what i would consider. Fake news is true. But we're the ability to hush. That person up. There isn't so can i ask you. You've studied and be able to trace this relationship between experts and popular knowledge over centuries and so are you seeing than a profound shift in the rule of experts and particularly medical experts in society and in in the flow of information I wanted to touch on this question of experts of the changing role of experts in society. That's a really key issue and one that we have to think of both continuity and change in this current moment and that's kind of standard historian Position when i see what's going on now I can trace the roots of that loss of control over what gets into the media. Well back before twenty twenty or two thousand and three when the term info democ was was. I put out there. I i see a major shift in the reporting i'm going back to the nineteen sixties and seventies and. It's part of a larger shift in thinking about the democratization of knowledge in general and medical knowledge and healthcare in particular. So we now believe in. Patient centered medicine We believe in activated patients or patients who take charge of their health and their medical treatment. Well that that implies a collaboration with the expert that a sharing of knowledge and understanding of what's happening securing the patient's willingness to Abide by the treatment and into cooperate with the physician. So that i mean. That's just a cornerstone of late twentieth century. Healthcare thinking that's very hard category but let's say nations like the united states that are affluent have relatively high rates of of literacy Excetera and i'd say it's also that idea of educating patients was really critical in the ability to expand the assertiveness of medical treatment. You have to get informed consent before you do surgery. Give somebody chemotherapy etc. So there's that assumption that that information needs to change hands but one of the most problematic areas of post world war. Two biomedicine is that communication process What's see you know. Sometimes we call it. Health communication science communication. Whoa that that has been one of the most contested areas and i'm said say it also has reportedly little standing in saint academic medical center. How many people are actually concerned about health communication. They're usually at the fringes of importance and yet that ability to communicate what you now either from the bedside or From the laboratory bench to bedside. If if you can't communicate the information share the information but also put it into a larger framework that that's that information versus knowledge to to kinda skillfully parks the information. You can end up with all kinds of the tensions and in fact we do. I mean that kind of brings us to one of the points that you were talking about this distinguishing between interpretation and knowledge of facts or data to can you kind of help for listeners to parse out what exactly you mean by knowledge so i think the default option in modern biomedicine is to dump data dump the information in statistical forms may be you know somewhat curated but basically to make this vast array of statistics and results outcomes available and then expect a patient to be able to make sense of those now again i'm I'm not a physician. But i have lots of friends who are in fact that leap from here's the data to if i were you what i would do with that information is is huge and so that's the piece where the knowledge and experience Comes in i know. One of the aspects of the internet that many physicians resent the most is the person who google their condition and comes in with lots of ideas about what's wrong with them and which should be done with them And i can imagine that's really annoying. If if you spent years in medical school understanding a problem to have some somebody think well they can spend an hour on the internet and come up with the same wisdom no On the other hand scientists very complicated. There's disagreements and some of what those laypeople going out and looking carefully at the scientific evidence about a particular problem they sometimes see things that There in fact bring back to their physicians. That is Useful to know. And i'll just give one example of of the growing awareness that many physicians did not know symptoms of heart disease in women. If women activists had not spent time doing their homework that issue might not have gotten the needed attention. It did so. There's this balance. I think that kind of generalizing that all all patient input is irrational or unuseful. Clearly we don't wanna go there. We also don't want to go to the extreme of saying someone who's read about the plan democ is one that you as a physician after listening to trying to find that kind of middle ground It's very difficult Sort of when when is When is an informed patient. Someone worth listening to so that. That was a huge issue. Starting in the nineteen seventies and up until twenty twenty. Now try to layer on top of that you have a new viral disease. The scientists themselves have to figure this out its new. They don't know everything. Right off. The bat i if they can't so that kind of slow process of we we need some time to figure it out. What is it whether it's symptoms. How did the fact different people differently. What all treatments can we recycle. How can we get new vaccines. That's a lot of very complicated stuff. That i think then very quickly to a degree that i. I don't know that we've seen in in the modern internet age. Got kind of blocked out In into the public sphere not just in mainstream sort of traditional news media but then onto the social media platforms. It's just a really Complex and hard to control. So if if you already have confusion about how much information patients can use turn us. And what is the the relationship between information and interpretation or knowledge already. Had that problem put this on top of it and it's no wonder that were struggling as you're talking. I'm thinking from training. You can understand this as sort of a almost like a selection bias in a personal bias. If you're looking for a particular thing you'll look until you find it in this ocean of information and then flip that around and look at the medical profession as a whole and and. I think that i mean this is the canadian. Medical association journal where most of our listeners are physicians. So what can the medical profession do to combat this at the individual level to combat covid misinformation s. I argue in the article. I think there is a real service that physicians can play at in this current moment even though it may seem almost hopeless to try to combat this on a person by person level. I would say now that that in fact having that access to your patients your family members to be able to present a rational moderate view of what's going on is enormously important An part of the reason. I wanted to write. That article was to encourage your your readers to see that as important and to put them into in a in a very simple way to to include including the footnote some of the resources and an i mean they are they are considerable and they're growing every day of Curator's of covid knowledge that are trying to put it into usable form. So you yourself. Don't have to the wheel. You can send people to trusted sites A think using The that the trust and the knowledge that you have of of your patients to target the message to try to nip some if it's possible to nip some of the craziness In the bud. I think would be again. I'm concerned that probably when people who deeply into conspiracy theories go to see their doctor they may not share freely that they're taking their cues from q. On but i'm not sure that that that level of dilution you can combat by the the kind of more Muddled and confused yes. There's an opportunity there so. Let me play devil's advocate then and say well. What if a physician is thinking. It's actually not their job and that they think well let's just leave it to the politicians or the it experts at to combat misinformation. What do you say to that. Well i i'd say i entirely understand that impulse. This seems like such a horrible mess. You have enough trouble. can you can't go and solve the problems of the world. you certainly Trying to Heal the current political partisan disaster. That's too much to ask of anyone on the other hand. I'll play devil's advocate. I think there's a long tradition At least in the us medical profession of wanting not to be political To try to stay out on a partisan politics especially at the individual level. But i think sometimes the moment may calm in a crisis where accepting that. The there is an important political role that the profession could play. I wouldn't say that to individual physicians. But i'd say in terms of your medical societies even editorial board to be thinking. About what responsibility does the medical profession have at this present moment to join in the effort to pressure the big social media platforms to take down the really really dangerous stuff. That to me is a would be a good thing For the medical profession to do to join in that. And i'm seeing things happen. That i never thought would happen in terms of breaking through that distaste forgetting political or partisan i mean the new england journal of medicine editorial is just mind blowing But i you know. This is all hands on deck. This is a crisis of unprecedented proportions. So i think maybe getting more assertive in terms of again not trying to close down free speech but looking at the the dangerous words that fire in a in a in a movie theater that might be worth thinking about as a professional strategy in in the next year when of the lessons i am taking away in the big picture from this covid. Pandemic is very much. what What i think we all knew ahead of time in that is that Pandemics expose all the weaknesses in in a in a society. It's culture and we are getting really a up close and personal sense of of the failings About what do we do about it i. I'm totally in favor of vaccines and funny in new vaccine. But i think sometimes the default option is to try to find a easy techno solution. Just go find the new vaccine in this. All these problems will go away. They won't why history is useful in the middle of a pandemic is that it helps us focus on the big picture on the continuity and and the changes every epidemic. That i've ever studied has thrown the spotlight on whatever it is that the dominant culture is ignoring. And we are certainly getting that Reawakening again a search searchlight on areas of neglect in areas of inequality that have to be addressed if if we are to avoid this disaster with the next pandemic that can feel really daunting to take on. But it's really essential to do it and in just try to end on a more optimistic note. We actually had a lot of understanding of what those problems are. What we have lacked as the political momentum and the the will to act on that knowledge so maybe in this moment that political will will appear. I can only hope I go to bed at night. Praying that that we're going to have real a weakening out of this that will lead to changes in in the future. That's certainly a lot to think about. Thank you nancy. This has been a great conversation at thank you for having me. I've enjoyed it as well. I've been speaking with professor nancy. Tom's to read her article visit. Cma aj dot ca also. Don't forget to subscribe to see him. Aj podcasts on soundcloud or podcast app and let us know how we're doing by leaving rating. I'm dr dish our deputy editor for c. j. Thank you for listening.
Painful periods in adolescents
"To shingles age isn't just a number. Do you have patients fifty or older. They're at higher risk of getting shingles. Don't wait talk about shingles with your patients over fifty today. Shipwrecks is indicated for the prevention of herpes zoster shingles in adults fifty years of age earlier. Consult a product monographic. Jfk dot ca slash singer slash pm for contraindications warnings and precautions adverse reactions interactions dosing and administration information jerk cuesta product monograph or to report an adverse event. Please call one eight hundred three eight seven. Seven three seven four learn more at thanks shingle dot. Ca this episode is brought to you by audi canada. The canadian medical association has partnered with out candidate to offer. Cma members preferred incentive on select vehicle models purchased any new qualifying audi model receive additional cash incentive based on the purchase tight. Details of the incentive program can be found at audi professional dot ca explore the full line of vehicles available to suit your lifestyle. The audi driving experience is like no other many teenagers with pain. During their periods it can disrupt attended school sports or social commitments and is generally uncomfortable to live with and sometimes the pain or dismiss. Maria has another more serious caused that warrants further investigation by a specialist. I'm dr shannon charlotte blah editorial fellow for the canadian medical association journal. today i'm talking to dr olga chuck and dr sarah kivus there joining me today to talk about dismantle and adolescence had the pain and had a diagnosis. They co-authored practice article published in cmha. I reached him in toronto. Welcome hello hi. Thank you so much for having us. You tell me a bit about who you are starting with you olga. My name is olga kachuck. I'm a fourth year resident in obstetrics and gynecology at the university of toronto. And i have a special interest in working with children and teens around gynecologic and reproductive health and my name is sarah keys and i'm a gynecologist n toronto. Both at the hospital for sick children and michael's hospital and i have a special interest in pediatric and adolescent gynecology. You both for coming. How common is pain or just menorah during periods and teens so disciplinary as we know refers to pain with menstruation and the prevalence in adolescence is high estimates range as high as fifty to ninety percent importantly we know from the literature that this can have a significant functional impact on teens. It is the most common cause of absenteeism from school for teens. Who menstruate but it's also associated with what's known as president. He is where young people are there at school or activities what they feel their concentration or their performance are worse because of period pain in fact in a recent survey more than one third of adolescents. Reported that they missed at least one day of school in the last three menstrual cycles because of period pain and the rates for missing physical activity or sports were even higher at almost fifty percent. This just goes to show that painful periods are not just a nuisance not just inevitable but can really interfere with academic and social functioning during what we know is a very formative time in the article you introduce the concept of primary versus secondary dismissed area. Could you take us through. What primary dispensary is and whether it's causes. Primary does menorah refers to menstrual pain. In the absence of pelvic pathology and this makes up the vast majority of cases of dismantle ria among adolescents very typically occurs with osceola tori cycles. So usually within six to twelve months of men are key and when you look at the pathophysiology at mediated by an excess of inflammatory markers so prostate. Glendon are leukotrienes within the endometrial tissue of the uterus. What are some of the disorders are pathologies. That could cause pain in the form of secondary you so when we think about secondary disciplinary of this refers to menstrual pain associated. With some form of pelvic pathology for the adolescent the most common cause of secondary dismantle is endometriosis but other conditions can also lead to pain with menstruation. Include malaria anomaly. Such as a non-community uterine horn or congenital obstructive malformations such as the micro per frit hyman but other things that you need to keep in your differential include the possibility of infection or even ovarian cysts. What steps in determining if a patient has primary or secondary area so obtaining a detailed history is a key first step there are certain features on history that should raise a flag for care providers to consider further workup for secondary dismiss area. These features would include things like onset. Immediately with men are key progressively worsening dismantle rea- irregular bleeding with pain family or personal history of renal or other congenital abnormalities mid cycle or a. Cyclic pain disparate. Nia or a family history of dimitrios and these features are all listed in our sammy j but an important point that's both broadly applicable but also especially helpful in providing virtual care is that impure treatment with kids and hormonal. Medication can be started before. Any specific diagnosis is made and in fact in a situation where no secondary disciplinary of features are present starting treatment and assessing response can provide clues as to whether further work is needed as a gp. If any of these flags are raised. And i suspect secondary dismantle. It may be the issue. What are the next steps in my workout wayne. You're suspecting secondary dismay at this point. Physical exam should be considered. I know in the time code. We've been doing a lot of virtual care and doing a lot of prescriptions over the phone. But at this point i think that the adolescent should be assessed and this may include a pelvic exam if the patient is amenable to this or even abdominal erectile exam can be helpful assess the anatomy however i believe that liberal use of the ultrasound should be ordered to assess the anatomy of the reproductive structures particularly if they are not comfortable with a pelvic exam as a gp. If you're suspecting seconds mentor mia and you've completed a physical exam and you still are uncertain referral. Call just to be considered at this point when investigating a teenager do ultrasounds have to be ordered. Trans-nationally that's a really good question. In fact for most adolescents. We perform the sound transit normally and do pain good information in toronto. Were very lucky to work at At the hospital for sick children where they're very comfortable doing ultrasounds on adolescence. So sometimes if you're having difficulty getting an ultrasound in analysis and patient you may consider referral to the children's hospital where they're more comfortable getting good images on the adolescent or teen. Let's talk about pain management. What are the different options. Are there any that are recommended over others so first line treatment of disciplinary up is the use of non steroidal anti inflammatory medications. Your highly effective. They have a number needed to treat of only three when used appropriately for primary dismantle rea- now appropriate use means using them on a short term prophylactic basis cyclically in order to decrease the excess prostaglandin levels that we talked about earlier. This means using full strength and said doses on a regular schedule with no skipped administrations and starting them one to two days before menzies onset if that's predictable or at the first sign of bleeding or pain and continuing these medications for the first two to three days of leading the strategy. We tend to recommend to our patients not to wait until the pain is unbearable until they're curled up in bed already but to try to get ahead of the pain with this prophylactic dosing schedule between naproxin ibuprofen and other assets. All are equally effective for menstrual pain. And we do always reminder that end said should be taken with food in order to minimize gastrointestinal side effects. If the vision is having breakthrough pain adding c can also be a good option. Interchanging regularly dosed and sides with acetaminophen. Is there a role here for oral contraceptive pills or hormonal intrauterine devices to help manage the pain definitely so if in fact the incense that you prescribed have not worked. You may change over to hormonal medication. But hormonal medication can also be considered as first line treatment particularly if the team has a need for contraception for teens who have no contraindications to estrogen the combined oral contraceptive pill. Patch a ring or an option with number needed to treat of only five primary dismantle rea- when choosing a combined or a contraceptive for an adolescent patient. I believe that all pills are really created. Equal however more recently formulations with ethanol westerdale doses above thirty micrograms are ideally chosen the maintenance of bone health. When i'm starting a combined or a contraceptive pill traditionally started. Cyclically for the first month however using the combined or contraceptive pill continuously or in an extended. Fashion has been shown to provide better relief of dismantling than standard cyclic. Dosing lunch term. Other hormonal options would be progestin based treatment for example. The lebron just are ud or the e-e-e-e-no just throw implant which was newly improved. Encana as two thousand and twenty. Both of these treatments were also associated with decreased rates of disarray and are safe and effective for the teams. Were looking for a long acting option and effective contraception. This is wonderful information to have available for. Gp's if any teenagers are listening what would you want us to say to them. What we would hope that you've gained from today's discussion and from our article. Is that teams. Don't have to suffer with period pain. There are a lot of effective medication options to help. Avoid pain during periods and avoid missing school missing social activities. Because of it. Don't hesitate to talk to your family doctor. Thank you very much for joining us today. Thank you for having us. Thank you very much. For having that i've been speaking with dr olga kachuck and dr ceri kiva to read the article they co authored. Visit j. dot ca. Also don't forget to subscribe to see him. Aj podcast on soundcloud or a podcast up and let us know how we're doing by leaving a rating. I'm dr shannon shiloh wa editorial fellow for cmha. Thank you for listening.
Button battery ingestion in children
"But button batteries are small round batteries that power various electronic devices such as watches remote controls and even children's toys they're small and shiny which is why young children most sometimes grab them and put them in their mouth but they can cause severe injury. If a child swallows the button battery and it becomes lodged in the digestive tract. I'm dr shannon charlotte blah medical editor for the canadian medical association journal. Today i'm talking to doctors to be three retina pollen one of the authors of the j. practice article about button battery suggestions in children dr ratna. Pollen is a pediatric emergency physician at the hospital for sick children in toronto. It's time to take yourself and your practice. Further with advice. Sue tour unique financial needs with the combined expertise of md financial management and scotiabank healthcare. Plus you get access to a full suite of specialized financial planning services tailored to you and every stage of your career. It's the expertise that meets your complex needs today and tomorrow you've come a long way. Take your finances. Further with md financial management and scotiabank healthcare plus. Many adults may not be aware that simply being over fifty puts them at increased risk for shingles help prevent shingles and patients over fifty wishing greeks shingles is indicated for the prevention of disaster h that are shingles in adults fifty years of age earlier consulted product monograph gnk dot ca slash english slash pm for contraindications warnings and precautions adverse reactions interactions dosing administration information to request a product monograph or to report adverse event. Please call one eight hundred three eight seven seven three seven four learn more at things. Shingle dot ca. This episode is brought to you by dr bill. Bill makes building on the go. Easy and pain free at a patient in as little as three seconds and submit a claim with just a few taps. Start your forty five day free trial today. Visit dr bill. Dot aps last jay. That's dr b. i. l. l. dot app slash c. J. to get started dr nepal. And welcome thank you for joining us and combating. My doctor shot both by inviting me. I am very passionate about baton. Battery patients should not happen So thank you again for this chance. We are so excited to have you because this has been an absolutely shocking article for me personally. Both as a gp in the community and as a mother of three small children. Why did you write this article so we have been talking about. Button battery injections in regular around. There have been a couple of presentations every time. We have a bad outcome. A child who have significant mobility with abadan battery ingestion and at some point dump discipline skiing. I thought that we should write this up. Because it's not good enough that we talking little circle. This has to be prevented pennants and practitioners. Shouldn't everybody should know about this. Absolutely can you tell us exactly what you mean by battery. Batteries are batteries that looked like coins of batons as opposed to slightly along the three and two batteries that we are all familiar with so these batteries are really really tiny and very very useful in many electronic devices so previously used just the watchers. Now we have them in musical cards candles the key-fobs it's pretty much everywhere. Even in children's toys and their shoes that light up when they walk so they're they're out in the open and being used exclusively in many smart electronic devices. The reason for this is they have a long shelf life. They're smart and it's very easy to get them into smaller devices now. These button batteries are usually made of different metals. They have the civil ones and more recently. We have lithium ones so the lithium ones are supposed to be worse however the button battery shape itself is the problem so it's not always lithium button batteries that you get and most of them have the lettuce. Seon them to save their commun- because regardless of what medalist used this chromium in it. So that's why sia in they come in different sizes and different voltages retrievable. So how frequently do children's follow button batteries and is this becoming an increasingly common problem. It past become an increasingly common problem at least from the us data but more than how common it is. It's how bad it is that matters year so if a child saw knows about battery ending doesn't get remote within a couple of us it just burst through the tissues and erodes into major arteries and other important organs so that can cause liberty and they have been separated bits so sadly what we see is a child dying independents going on social media and the media picks up and you have a a newspaper article or tv program on it and they just die down until the other child dies and this has to stop. Yes how is button battery. Ingestion managed so traction only when we have any indications where you have to go to the operating room to get railroad v. Say don't give anything by mouth now. That's different in baton battery so if it cannot prevent and we know that the child has ingested battling batteries panton calculus can give honey at all if they have tiny so they get put teaspoons of honey up to six those every ten minutes. They can keep doing bad just to coat. The button batteries. So that it doesn't erode into the esophagus because the bobby batteries plaque and both the positive and negative so close to each other rendez stuck in the throat of the esophagus. what happens. Is this connection so as an electrical connection this atrocities and you get academic formation which actually burned through the tissue and it goes in and if you look at some of these youtube videos you will see people doing experiments with button batteries on a ham of loonies and showing how quickly they erode through tissues. So that's one of the things i want to get across. The there is trusted Until they get to the hospital. That's one of my favorite parts about this article. One of the only thing that really relieves my terror and thinking about all of this. Because i did watch one of these videos you mentioned on the bbc and you see how much damage one of these can do tissue. How quickly But it's great for Public knowledge that the parents can give something as simple as honey while they're on their way to the hospital. So the second thing is we hospital do they go through right. So i really. They should get to a hospital where this battery can be removed as quickly as possible so you could call your family doctor. But the family doctors should make sure that the child doesn't come to their office gonna reference if they go to the emergency department. It should be im- identity department where you will have a pediatric surgeon who would take it out. So that's the second thing we had to go. And the third thing is depending on rod this child lance before they get the definitely treatment so in case you have this child coming to your local emergency department you can stop giving them sucre plate which would also quote the button battery and reduced tissue damage and then send them as quickly as possible protective treatment. So that's one aspect of treatment. The second thing is you take x rays and you pay to us to make sure that you know that the battery is and then we have an algorithm that says you know age of the child type of battery size of the battery at rides lodge. If it's anywhere in the survey of it casted to come out as quickly as possible cities your prior to give one to the operating room and then there are other considerations depending on read the batteries. What the sizes and then began goes to that atlanta. But anything in the east vegas on in the north has to come up as quickly as possible. All in the knows. That's a good point. I hadn't considered that might be a good place. A child would think to stick one. So that's one aspect of management. This second one is menu. Do not know that a child has ingested back battery so people go to the cottage The child is a little tired. they're throwing up a couple of times and you'd think it's probably nothing probably about the child card but if any suspicious that it could be a baton wbap even they reach your imagine department. Get an extreme to see what's going on because without the next day you won't see. Sometimes the parents say or that. My child swallow the coin on this day. No one hundred percent. It's a coin. Get the next fan. Get to us. Because on the xrays visas for physicians. You could see a tiny halo in the ap viewer and then you see the slightly different Scientists on both sides of the battery on the latter view so x ray. Not just to confirm that it's a baton battery but also deceived the size and the The we add dislodged and then to management from there. What sort of long term complications are you seeing in these patients so long term complications can be two kinds number. One you know that is a button battery And you know that. I guess it'll add. So you expect these complications like isa figure trade share and strip kids in difficulty swallowing and whatnot. If they have eroded further into the main us than this so much more surgical complications that happen because of other said today. This child had to undergo to manage the damage caused by the backing. That's one lock. The second is when you have successfully removed the battery anything. Everything is fine. And it's not because these batteries dookie electrolysis 'cause aptly formation. Which reacts with the tissue and there's what's caused sepanek vacation with which is like so commission any erode through the athletes worse than acid so even all the remove you could have continued to should damage. So that's another thing that parents and practitioners have to be avera. The fuss sign anything anew shut. These children should be seen as quickly as possible to assess what else is going on. In these cases obviously prevention is worth by the bets. What steps can parents take to prevent this their children. The first step is to be avia that that did a button batteries in many electronic devices and to make sure these devices that not actually for the toddler age. Surprisingly many children are not surprising. Many children can get through the time locks and open things. They did a study to show. That thirty percent of children can actually open these things with the child. Lock antidepressant adults cannot sometimes so make sure that these are out of reach especially for toddlers with a little fingers. They tried to poke and prod on everything number. Two if you had removing the button batteries put them away safely in trash. Don't keep them for recycling or any other noble purposes because stalling or baton batteries. Which you think spent is a nightmare waiting to happen when a child finds it because even batteries that are completely empty and not punching as you think would cause damage if swallowed. The thing is be suspicious. If is an indigent or if your child is acting. A little unusual specially in circumstances where they could have had access to a backward. Patrick get them seeing. Get an x ray and the combo. So is this only a problem in pediatrics. Not really because you know. Pecs casale but more than that The elderly population sometimes mystic. This for pills an have swallowed this to the older population have a habit off saving everything in making sure that things are not wasted so if you have a device via you're not using the batteries everyday they've picked the batteries often keep it separate so the backyard doesn't drink. I know a quite a few people who do that. And then you have your pills then you have. These battery baden batteries. That looked like pills in the same draw and they have been at burton. Swelling the or the population are the elderly population. We had they have caught. It was the pill and swallow it. So i've been absolutely shocked by how these are in children's toys. I almost just bought my son. A little robotic dinosaur for his finger for christmas dot was recommended by a major Magazine in the states as a great toy for children Is what's the situation on. Controlling or trying to legislate the use of these. At least in children's toys in in canada has been a not talk about but nothing has happened. as far as legislation goals as to. I you cannot cannot rotate. The manufacturers have stopped at covering the negative pole which is the smallest side of the button battery the plastic cover so that you know that's kind of addicted but the educate the cover many put it into a toy so as soon as it goes into a tie a debt disaster waiting to happen so it's very useful and i personally as an adult life is button batteries because they are so useful there so come back and they paula a whole lot of electronics I think safer locks And then also you know not being able to remove them up you. Predicting a children's star may be another way to go so you completely see the battery compartment so you use it at the battery last and you throw it which is one hundred pints better amitai ingesting it absolutely. Thank you so much for joining me today. Dr adam pollen. Thank you very much for having me any and really hope. This message gets across to everybody carrying with children. I've been speaking with dr severe. Three ratna pollen. You can find the article. She co-authored at cnn may j. dot ca or by clicking on the link the show notes. I'm dr shannon shiloh baugh medical editor for cna. Jay thank you for listening.
Diagnosis and treatment of adenomyosis
"To shingles age isn't just a number. Do you have patients fifty or older. They're at higher risk of getting shingles. Don't wait talk about shingles with your patients over fifty today. Shipwrecks is indicated for the prevention of herpes zoster shingles in adults. Fifty years of age or older consulted product monographic. Gsk dot ca slash singer slash pm for contraindications warnings and precautions adverse reactions interactions dosing and administration information jerk cuesta a product monograph or to report an adverse event. Please call one eight hundred three eight seven seven three seven four learn more at think. Shingle dot ca dead. Oh my oh so. This is a common cause. Heavy painful menstrual periods it bothersome at times debilitating for people. But how is it best diagnosed. And how's it managed. I'm dr shannon sharla editorial fellow for the canadian medical association journal today. I'm talking to doctors. Sharon dyson and marae sobel two of the authors of cma. J. practice article called five things to know about diagnosis and treatments of myocarditis. They co-authored the article with dr crystal chan. I reached them in toronto to discuss what they know about identify. Ossis welcome gangster hunting. Hi thanks for being with us. Can you tell our listeners. A bit about who you are. i'm mara sobel. I practice general gynecology with a specialization in minimally invasive surgery at mount sinai hospital and at women's college hospital. I'm sure indecent Last year of residency at the university of toronto and ongoing entering infertility fellowship at mount sinai fertility. i've been very lucky. Throughout my residency actually to work with mara sobel and crystal chan on a number of projects related to adenoma adenomas. And what i found through my reading and through our projects is that. I don't know my us. This is something that affects a lot of women. It's quite common. And we feel that it's really important to talk about the diagnosis and management of this kind of new. Clinical entity shred. Demayo says what characterizes it. So i don't know my assists is actually a benign condition where we find that lesions of the and dmitri on which is the inner lining of the. Us's found within the meiomi trim which is muscular lining of the uterus. And we see that they're inflammatory. Changes around these lesions classically. This was actually diagnosed on histology. And we're now seeing that with advancements in imaging like specific criterion and transformational ultrasound We're able to make a clinical diagnosis We've seen that. It's really associated with clinical symptoms. Such as heavy. Menstrual bleeding pelvic pain which includes dismay nria disparue neon chronic pelvic pain sub fertility recurrent miscarriages and even adverse pregnancy outcomes. Sharon you say in your article that osas often coexists with other conditions. What can you tell us about that. So i think it's interesting. Actually that on its own. Adenoma analysis is the only condition that can cause both heavy menstrual bleeding and pelvic pain what we do find in the literature from studies that were done on imaging and in surgical studies. I dunno my has been found to coexist with two other conditions and dimitrios and fibro. His you know wide range of patients. We've seen studies sets a twenty percent. We've seen studies that seventy percent. Basically we know that they coexist. What's important is that. Their clinical symptoms can also overlapped so should actually be suspected when the typical symptoms or whatever. A patient is presenting with aren't present for example of patients presenting with endometriosis pelvic pain if they're also experiencing heavy menstrual bleeding. We should actually be considering a confident. Diagnosis of adenomas similarly if a patient is presenting the fibroids that causes heavy menstrual bleeding. It doesn't typically cause pain if a patient has pelvic pain in addition to the heavy menstrual bleeding. And we know that they have fibroids than you should also be considering something like whistles sharon who gets a dental my office. And what is known about why certain people get it and others not so shannon and as i mentioned adenomas typically be found on histology after hysterectomy. So if you think about the population underwent hysterectomy. There were classically in their forties. To fiske's we thought that cynical risk factors like prior cesarean section multiple parody previous. You'd ryan surgery important in order to disrupt the endometrial meiomi trail junction in. That might have been the reason. The endometrial implants were found. However now that we've actually seen that on imaging like transformational ultrasound and mri performed in young women even in their adolescents are finding signs of adenoma. Llosa's we actually think that it could be accounting for a lot of symptoms before women actually reached the typical age group of a hysterectomy so the clinical diagnosis and the landscape of diagnosis has really changed. And were no longer really sure. What risk factors contribute to this diagnosis. We do also know that. It's actually found up to thirty percent of women. Under the age of forty which is a really high prevalence mara. What are the steps in diagnosing. That'll mouses starting with a patient going in to see her family doctor so probably. Most cases of adenoma assist can be detected on the history alone. A history of heavy and painful periods is the hallmark of adenoma asus and should be really high on your differential diagnosis when a patient presents with these two symptoms together next on physical exam with adenoma assists. The uterus is often diffusely enlarged and soft and it is mobile and can be tender on palpitation. And this is really different. From the other causes of similar symptoms so with a fiber address this is usually very irregularly enlarged and you can often help eight. The firm fibroids and with endometriosis uterus is usually very immobile and fixed and there's often tenderness or nachos along the sacred ligaments. Of course trans. Vaginal ultrasound can make the diagnosis now. In is the first line imaging modality for any individual with heavy and painful periods both to assess for adenoma but also to exclude other causes of the symptoms such as fibroids or polyps. Now that ultrasound. Signs of adenomas is better characterized. We no longer need to rely on. Ameri either. Make the diagnosis richard. Confirm a diagnosis of adenoma. Sis that yunan ultrasound as the ability to diagnose at enormous ultrasound is relatively new it may be important to use an imaging center that has experienced with reporting on ad assist or to communicate on your requisition the symptoms of adenomas or that. You're looking to see if adenoma assistance present. How is it in this managed. What are the different auctions. Symptom management is the main goal for adenoma asus so up to thirty percent of patients may have adenoma asus findings on imaging. But if you're patient is asymptomatic. They actually require no treatment. And it's really important to remember that it's also important to recognize that adenomas typically doesn't cause symptoms menopause. So as we have more ultrasounds that are reporting on how to is if you see this in a patient who's in menopause typically. No therapy is required. For patients with symptoms of adenoma llosa's it's important to recognize that this is a chronic treatment and Lifelong management will be required depending on what the patient is presenting with. Whether it's heavy bleeding or pelvic pain care. Providers should feel comfortable using the common pathways for management of these symptoms so for example patients. That aren't interested in hormonal. Therapy can try inch. Inflammatories as well as tran- examined acid with good success in addition both combined hormonal contraceptives as well as projections alone are Effective for symptoms of adenoma asus in there are several small studies in expert. Consensus suggesting that all of these therapies are beneficial for adenoma asus. The best studied therapies. include the. Leave oedema jetro. Intrauterine device and dine adjust and there are several studies on. Leave own adjustable that shows that this is a very effective therapy for both hain and heavy menstrual bleeding associated with adenoma. In addition dine adjusts which most of us are more comfortable using for endometriosis. May also be effective for pelvic pain. However i'm can cause some bothersome spotting which may not be ideal For patients whose main presentation is heavy bleeding in general. If first line therapies fail after about three to six months referral to a gynecologist is recommended. A gynecologist may choose other medical management options such as gen rh agonised or antagonised or may refer a patient on for urine artery. Embolism which is another effective therapy for adenomas. But ultimately hysterectomy is the gold standard and common reason for patients to undergo hysterectomy it considering woman with a heavy or abnormal uterine bleeding. When should we be thinking about doing an enemy trail biopsy as a really important point. Any woman over the age of forty with abnormal. You'd rhyme bleeding as well as any woman. Underage forty with abnormal bleeding. Who has other risk factors for endometrial. Cancer endometrial hyperplasia for example Polycystic ovarian syndrome or elevated. bmi Should undergo an endometrial. Biopsy is part of the workup for abnormal uterine bleeding. So a lot of women who ultimately you're diagnosed with adenomas would have an endometrial biopsy as part of their workup because this classically presents as a change in their menstrual bleeding chareh gun of my osas effect facility. So i think we're seeing now. That emerging evidence does actually suggest that autonomous may have an impact on fertility and this is important to realize that even if patients only have ultrasound evidence about this and not clinical evidence like heavy menstrual bleeding pain. They may still have trouble getting pregnant We're seeing that. There are higher rates of ultrasound. Evidence about analysis found in women presenting with just infertility and patients with adenomas may actually have less success with fertility treatments like in vitro fertilization. It's important to realize that this is very new evidence and there's a lot of research coming out and family. Physicians now should really just follow the usual referral guidelines for patient presenting with sub fertility or even recurrent pregnancy loss. Ambition something that's highlighted on the requisition for an ultrasound in patients presenting with these concerns Or in the referral guideline in real requisition to a fertility provider. What do you want physicians term member. Keep in mind regarding into my office so we really want care providers to recognize that adenoma assist is a common condition in. It should be considered an all patients in all age groups. That present with headache pain as well as heavy menstrual bleeding. Adenoma llosa can now be well seen on ultrasound but it's important to remember that thirty percent of patients will have findings about anoma assist on imaging but remain ason dramatic and these patients. Do not require therapy. Finally adenomas is a relatively new clinical diagnosis. And we want to empower care providers to both diagnose and feel comfortable treating symptoms of adenoma haussas care providers should feel confident and starting first line medical management for symptoms of adenoma asus and can use the same pathways that they are familiar with for the treatment of heavy bleeding and painful periods that they're used to using inclosing. Do you have any summary remarks. i just like to say that. Adenoma assist is a common gynecological condition. That really affects a lot of patients throughout their reproductive lifetime. I think it's really important to recognize it. In order to empower patients to recognize that they have this condition and to give them options for treatment. Me are really expanding. The research in this area and we will continue to find out more treatments and more management options for patients with this condition. That can really affect their quality of life. Thank you both for joining me today. Thank you so much for having a thank you. I've been speaking with. Dr morris will dr sharon davison to read the article that co-authored visit cma j. c. I also don't forget to subscribe to the podcast on soundcloud or a podcast app and let us know our doing by leaving rating. I'm dr shannon sharla editorial fellow for c. j. Thank you for listening.
"This is kirsten. Patrick interim editor in chief. Cj i'm jumping in here before this episode starts because we have. Some exciting news will soon be launching a new podcast series. And we're putting a call out for a new host. The ideal person will be a canadian physician. Someone who's dynamic and curious and someone who's excited to have a great conversation with experts about diverse topics that are relevant to family physicians and generalists. So if you think that's you or if you know someone who might be interested these. Check our website for full details or click on the link in the show notes. Okay back to today's episode. Many options exist nowadays for teenagers. choosing to be on. Hormonal contraceptives recently approved. Long acting option. Which may soon become. The most popular auction is designed to be implanted in the upper arm. It's effective up to three years and doesn't require pelvic examination prior to insertion yet barriers to accessing contraception. Still exist for adolescence. I'm dr kirsten patrick. Interim editor in chief of the canadian medical association journal today. i'm talking to dr margot rosenthal. Who is a pg five resident in obstetrics and gynecology at the university of manitoba is joining me today to expand on an article that she co authored with dr sarah mcquillan in sammy j about adolescent contraception will discuss the different options available which choices best and what side effects to watch out for right after this break. Many adults may not be aware that simply being over fifty puts them at increased risk for shingles help prevent shingles and patients over fifty wishing greeks shingles is indicated for the prevention of disaster h that or shingles in adults fifty years of age earlier. Consult a product monograph. Gmc dot ca slash english slash pm for contraindications warnings and precautions adverse reactions interactions dosing administration information to request a product monograph or to report an adverse event. Please call one eight hundred three eight seven seven three seven four learn more at things. Shingle dot ca. This episode is brought to you by dr bill. Dr bill makes building onto go easy and pain free at a patient in as little as three seconds and submit a claim with just a few taps. Start your forty five day free trial today. Visit dr bill dot aps last. Cmha that's dr b. i. l. l. dot ap slash cmha to get started. Well camargo hi preston. Thank you for having me today. It is a pleasure to be here and to speak a little bit more about this topics that i'm really passionate about so i'm interested to hear you say you're really passionate about this. What makes you passionate about contraception and adolescence. I think contraception in general is just such a huge topic about bringing power back to the patient and really allowing people to decide when and if they choose to be parents and i think a possibility of people making opposition on their own terms is incredibly important. Which su who should be on contraceptives so really if we're speaking about adolescents. Any you who is desiring prevention pregnancy should be considering contraception and it's important to remember that this is not only What we traditionally think of as i'm girls or young women but really anybody who is engaging in sexual activities that put them at risk pregnancy and so this does include transgender or non binary individuals who have a uterus and of a china that may put them at risk when engaging with harness that may have a penis could put them at risk for pregnancy talking about teenagers who are at risk of becoming pregnant. What sort of barriers might they face to accessing contraception. There are several barriers. And i think it's important to to really break these various down. One of the first varies we think about is really accessing quality information there's been studies looking at where adolescents are getting information and they raided school friends and television as their top three most valuable sources of information. Ideally these adolescents should be getting high quality. Reliable information from their physicians are their healthcare practitioners another barriers access to the canadian geography is extremely unique and we have many people living in cities and also keep living in small rural and remote communities where adolescents. Who may not be driving and may be living somewhere. With access to public transport accessing confidential contraceptive care and without involving the parents have very challenging and the final barrier. We think about Is about cost. Many of the contraceptives us on our prescription medications so that means the cost for most canadians without a pocket. I'm the some groups may have third party insurance that this can also be a limitation as the parents are often the primary policyholder for Indigenous youth they may have access through non insured health benefits that the are limitations to coverage on certain methods. There's also a fair amount of youth clinics or nonprofits which may have a limited selection of no cost contraceptives but this is again very limited. So you were talking about adolescence being able to access confidential medical practitioner advice on this topic. What is the practitioners duty in terms of confidentiality with an adolescent to seeking contraception at three am encounter with an adolescence. Should include a one on one time with with the team and that comes down to practically routinely asking parents to step out at every visit in making a part of a routine visits after that. It's really clearly stated boundaries of with the adolescent that there are boundaries the importance of disclosing risk to sell for others or any activities that are taking place in a position of vulnerability that that you are really on their side at out to help them and really opening up opening affect eight so moving onto different hormonal contraceptive options. What are we looking at options for teenagers. in terms of contraception probably simplest way to break hormonal contraceptive option. And it's what we call sark and lark so would be short acting. Reversible contraceptives and lark would be longer acting reversible contraceptives. There is a very excellent position. Statement on the. Kate had pediatric variety in two thousand eighteen about contraceptive care in canadian news. Where they're really recommending. Bark methods as i live and so lark methods are commonly. Iud's intrauterine devices which are available in both copper non-hormonal version and beefing adjust eulogies. Failure rates. For both of these devices are less than one percents on the hormonal. Iud's have the additional benefit of providing menstrual control new to the canadian market is term adjustable subcutaneous implants known as next on recently approved in canada in twenty twenty but has been used international for many years the implants insert into the upper arm and provides excellent contraception for three years with the failure. Rate are zero point zero five percent making it the best contraceptive we have a market. Moving down in order to the efficacy is deputy rivera which is intramuscular injection every twelve weeks. That's a failure rate of about six percent with typical use and is quite common choice in adolescence than up. To twenty percent of adolescence. Tried it and then. If more efficacy are the starkness and these are what we more commonly are comfortable with so the combined hormonal contraceptive pill the progestin only pill vaginal rings or the contraceptive patch and these have higher failure rates up to nine percent with typical use. And i think it's also really important to remember that emergency. Contraception is hormonal option. And very important to be discussing with patients. And there's some that does require prescription in such as not right. So when we're talking about starks and you talk about a nine percent. Failure rates does that factor in the fact that they are short acting in the people can forget to take them at the light so which perfect use failure rates are point. Three percents habit. The typically use of failure rate of nine percent takes into account missiles and the position statement from The canadian pediatric society. I'm guessing is coming from replace solve long acting contraceptive devices being more reliable. Yes and let the the lark methods should be i at. They're very high efficacy. They have high continuation rates. And there's a high ease of use. I'm so he's very effective devices. That providing contraception and other important pieces the are routine some reversible method. Nobody is ever using these devices with the intention of leaving them in place forever they could easily be reversed. It's genuine intolerance or a side effect or applying of a pregnancy in your experience to teenagers. Ask about the possibility of Non reversal of the contraception. Are they ever worried about being on a long term contraceptive and then you know wanting to get pregnancy in six years or something. That is definitely a question that some youth asking many youth who tried deputy rivera have found a long time of return to nancy. Think that a amen not be quite concerning for some patients there are quite communist conceptions about the injury device devices. Fit may be affected fertility in the long run. There's good evidence to see. The fat is not the case. And that really dispelling. Some of these myths is very important in this especially the high risk adolescents. Let's talk a little bit about side. Effects of these contraceptives and things that you need to think about when prescribing them accurately a another nice piece of the large methods. The cop raggedy for example has been hormonal component. So there's very few contraindications on to a property but some of the side effects can be heavier at mencia. Some patients might have increased crapping with emergencies in terms of the suggestion. Iud's blends available at this. Time are the kind leaner which is a slightly smaller device and the marina which has a slightly larger device with a higher dose adjust. Shell drawback for some patients for these insertion of these devices. That it does require a pelvic exam and that the insertion can be quite uncomfortable are certainly many pediatric and adolescent gynecologists. Who have access to an operating room can place these devices under sedation. A summit lessons actually do very very well in a clinic setting that brings us to the next one on. Which is the newest Piece on the canadian market and to be quite an attractive option. Adolescence as they do not need station. They do not need a pelvic exam. On the and the insertion process. It's been very much streamlined. By the factors simple insertion under Aesthetic in the office one of the side effects to next plan on to be unpredictable. Menstrual bleeding about twenty percent of patients are amen. React and another about thirty percent. Have lighter regular metro bleeding bleeding patterns to be very difficult to predict. I'll be the biggest drawback to the next one on circling back to what you were saying about. Where at get their information in the beginning of our talk if there are side effects like irregular menzies and teens talk to each other. Do you ever find that you'll have you in clinic saying my friends said that she was constantly on her period after she had the implants. What should i expect a week. Definitely half those type of conversations with dapple the implant is so new that i think there's not quite that experience upon us. I'm with the next amount of ice that there are many patients who will come in saying. My friend has a marina at ud and she doesn't get her period anymore. And i think. I want that that conversation actually can go both ways and people can see at a menorah as a wanted side effects and we see implanted lasts for up to three years if it is causing unbearable side effects is. It's easily removable correctly. Placed implant is very superficial under the skin and has actually palpable under the skin and should have a quite simple removal process. The levels of tom'll gesture in the bloodstream. Paul very very quickly and within days will be out of the patients system which is important to remind patients that unlike differ where they may have and affects a longer returned to a matter via if their next one on is rebuked their body could start cycling immediately in your article. You talk a bit about spohn mineral density and concerns around the the socks in that area. Could you talk to me a little bit about. That's absolutely so traditional birth control pills had significantly higher doses of ethanol astra dial and the doses for us today so every birth control pill on the market. Today should be considered a low dose pill. There's a bit of a misconception among certain providers that if the adolescent younger that she should on a very low dose pill but there's actually growing evidence that because forty percent of bone mineralisation occurs in the adolescent years that providers should be choosing an oral contraceptive pill with over thirty micrograms of beth nostra dial. Charlie maximize bone density in these patients. And what is the effect on bone mineral density of other contraceptive options. So you know that dep. Rivera can have a decreased bone mineral density dragons use that in most studies appears that it does rebound after cessation use the contraceptive implants are does not appear to have an impact on bone density and with the intrauterine devices. The effect is mostly local with a lot. Lower systemic levels. So there's very minimal effect on foreign aid with achieved onto faces for adolescence. Who choose long acting options are they as safest they can be. Oh do they soon lead to consider a vary methods question. We also talked about that in the article so there is some canadian. Data showing natural one in twenty teams have actually been diagnosed with a sexually transmitted infection in that same. Study about seventy five percent of you reported these condoms their last sexual couch. There's evidence specifically in adolescent using methods that they're up to sixty percent less likely than their peers were not in saying at lark methods cheese carbons fifth maybe driven by combination after from potentially less fear of pregnancy but this group of teens is also more likely to have more sexual partners. So i think it's really really important to remind adolescence. The importance of barrier contraceptives had to decrease the risk of sti as and when we were talking about information sharing between physicians and patients. It's important to remind these patients of some of the long term effects of some of these actually transcendent infections. As she watch at the supply can be if they are. Undiagnosed are treated and one more piece dot commonly sexually transmitted infection. Testing is only either your interest small testing for gonorrhea and committee. I think the plug that we need to be doing full testing which include serology for hiv. Hepatitis b. on hepatitis c. n. rates in certain areas of the country. Are there any particular teens who should not take hormonal. Contraceptives the main limitation to contraceptives of. Actually the estrogen college. I'm so that the f. alestra dial amac's actually mostly contained in So the pill the patch the ring all have estrogen in them. The estrogen is contraindicated in any patient have migraine with aura. Any patients who are within six weeks of delivery and he patients with hypertension or diabetes complications. At anybody who has been a struggle embolism or proper genetization and as well as patients with liver tumors or severe supposes. He's patients who cannot have. Estrogen still have very excellent contraceptive options including gesture. Ud's copper ud's next on depot Which are very effective methods which do not carry the same risk because they do not have any F molester dial so we'll talk about contraception. Are we winning against adolescent pregnancy in canada. So i think we are winning internationally. Adolescent pregnancies represent up to ten percent of lifer but there's been dropping rates over the past several years in canada who five point eight percent while breath such thousand down to one point seven percent of all lifer twenty nineteen word a mother's younger than nine years old and so i do think that we are making progress toward decreasing adolescent pregnancy rates. I think we still have a long way to go. In terms of optimizing contraceptives. That are arguing. And i think the biggest take home for this is for providers to really consider using like methods. Whether that be intrigued by the bicester implant in adolescence central. Really reframe our thoughts to make that truly a first line methods and for providers to become more comfortable with these methods. I think you make the point very well. In the article that even though rates pregnancy among teens are decreasing in canada eighty percents of teen pregnancies is still unwanted pregnancies in some end in termination and so there's still a good reason to be really concerned about getting kids the best contraception that they can and there are significant long-term effects on his patients physical emotional and socioeconomic health detrimental effects really from unplanned pregnancies and even within the pregnancies themselves and they're higher risk for pregnancy complications include increase from birth entry by growth restrictions. So it's really important to focus on the highest quality contraceptives that we cannot participation. When it's been great talking to you about this this topic today. Thank you margaux. Thanks for joining me today. Okay so much. For for taking the time. I've been speaking with dr margot rosenthal and obstetrics and gynecology resident based in winnipeg manitoba. You can read the article. She co-authored on our website or by clicking the link in the show notes. I'm dr kirsten patrick. Interim editor in chief of c. j. Thank you for listening. Surgeries both are and a science. We dissect out both on cold steel. The official podcast. The canadian journalist surgery. I'm chad ball. The co editor in chief of the canadian journal surgery. And i'm a mere for associate digital editor for the canadian journal. Surgery each episode. We're joined by amazing guests ranging from iconic students around the world as well as leaders and other fields such coaching counting law. And more as we try to understand how to become better surgeons physicians and human being listened to cold steel. Wherever you get your podcasts.
COVID-19 in patients on long-term dialysis
"To shingles age isn't just a number. Do you have patients fifty or older. They're at higher risk of getting shingles. Don't wait talk about shingles with your patients over fifty today. Shipwrecks is indicated for the prevention of herpes zoster shingles in adults. Fifty years of age or older consulted product monographic. Gsk dot ca slash singer slash pm for contraindications warnings and precautions adverse reactions interactions dosing and administration information jerk cuesta a product monograph or to report an adverse event. Please call one eight hundred three eight seven seven. Three seven four learn more at think. Shingle dot ca dr andrea Pockets the editor in chief for the canadian medical association journal today. I'm talking to peter. Blake and rebecca cooper who are to the authors of a research article published today in. Cma j. about covid. Nineteen patients on long term dialysis. Non -tario rebecca's director clinical programs in peter and the provincial medical director of the terrier arenal network which is part of interior health. I've reached peter in london ontario and rebecca in toronto. Welcome to both thank you. General internal stuff cared for quite a number of people on dialysis and dances units. Honestly just strike me is almost non ideal place for to spread You know we have lots of people coming into the dialysis unit in the hospital at the same time many of them are elderly with co morbidity there dialyzers pretty close together. Nurses look after more than one patient so just wondering just how during the year or since colder does come to canada. How impatient dialysis units have changed. How they operate so dialysis. Unit certainly are a high risk environment for the spread of kobe and many changes have been put in place to reduce the likelihood of transmission to start with patients or screen for symptoms by phone prior to treatment at the hospital entrance and at the entrance of the dialysis unit. And then once. They're in their dialysis chair by nurse. There are new patient transport protocols. There are changes in waiting room practices in the physical configurations. Where where there can be patients or masked which is a practice. That started early on in dialysis units in really before it caught on more widely. There's more hand washing staffer n. P. p. e. including droplet contact precautions for confirmed and suspected cases is a very low threshold for swabbing patients and during outbreaks or suspected outbreaks. There is a wide surveillance. Swabbing in the dialysis unit covid positive or suspected patients. And also those that are at higher risk like patients who come in from congregants setting long-term care home or cohort isolated in dedicated rooms or pods or even whole dedicated units. There's been increased spacing of patient treatment stations. Where that's possible and education of patients specifically about their heightened risk by virtue of being a dialysis patient. There's about a hundred dialysis units in ontario. So there's some variation in practices in units reflect local situations but the ontario arena network has had a platform the leadership of these dialysis units across the province to come together frequently and rapidly share practices and put them in place. Another feature of dialysis units. That you would notice if you went into one now compared to a year ago when if you stayed around for a while is not such a nice one. It's the high level of anxiety in dialysis units. Which have had significant amount of cove infection the level of stress on the level of anxiety among the staff some extent among the patients as well. Of course it's very high. Some of the nurses in dialysis have children at home of elderly parents at home. Whatever they're at risk and there are very conscious of this and there has been an element of burn out. I don't think it's anything like what you see in an icu setting. But it's a little bit of that going on as well can be very difficult. We wondered about the interaction between nurses and patients. Observation would be that you know nurses to Have been caring for the same person on dialysis three times a week for ten years. Just get an old really well. And and spend some time chatting with some beside whether getting dialysis and i could imagine if everybody's all gowned up and and kind of concerned that some of that interpersonal react interaction might have been affected as well. It's not true absolutely spot on. I mean a mosque alone is enough. Many of his know recognize each other. Especially if we have a a cap on a mask on and maybe glosses on anyway for whatever reason and so. It is difficult sometimes. I recognize the dialysis patient that i've known for years uncertainty. the nurses icon recognize. It's the same for the patients. And i decide that from the patient. Experience dialysis in center is a treatment that you get three times a week. Typically for for half your day so you you you know you know the other patients as well and there is a there is a bit of social interaction and that's really limited and out of necessity for safety reasons so it is a very different experience. Patients say you're screening patients. I would imagine. Many dialysis patients have a lot of symptoms. That kind of goes with being on dialysis and having end stage. Kidney disease cannot get a lot of false positives from those screening questions. That's very true. We did a questionnaire. Study across the province using one of these screening questionnaires and more than twenty percent of the dialysis patients answered positively to something so being unusually fatigued having a coughing a bit short of breath. All these things are standard for dialysis patients. So there is limits to the effectiveness. You're quite correct. So we sat sort of background in the changes. You've made I mean clearly. I would say necessary even though it has some sort of negative impact health briefly about the study. And what you learned well. Right from the beginning of the pandemic. We realized that Dialysis units going to be a potential problem potential risk setting for patients. We knew this because of stories that come out of italy and of course from wuhan in china so we decided early on to follow very closely. The numbers of dialysis patients and what happened. What their clinical course was what happened to them and we set up a weekly calls them. We developed a collection tool at the ontario networked. Collect this data. Normally when we tried to collect more data we get a bit of a negative feedback from the programs often but this one there was a lot of willingness people realize quickly we were in a very new and serious unsew week after week. It took us a few weeks to get fully set up. We did it informally initially. And then we had a full blown spreadsheet that was filled in every week by the data clark each adele and appointed data person at each site We were able to follow this through the course of the pandemic indeed right up to the present time it's still operating the data that's in the publication is basically the data from wave one of covert. We wrote started writing the paper at the end of august because we thought things had settled out and by that stage we had one hundred eighty seven patients who had developed covert and. We realized we'd quite a special database here because it was comprehensive for the whole province. Unas near perfect as we thought we could make it We talked to all the programs regularly and they are very aware of other patients doing so. We collected all this data. We asked lots of questions. We wanted to know what happened to these patients. The mortality the hospitalization. Rate the icu. Rate and we found these were. These were very high. We've found that over sixty percent of these patients. Were getting hospitalized and twenty percents of them. We're going to icu. On a significant proportion of those were going on a ventilator sadly in the range of just over twenty eight percent in wave one died. This was a very high horrific mortality rates and it became apparent from other parts of the world on single center studies that this was not unique so we then looked at the risk factors for which style patients were getting this and that was interesting. We found some things. Were very predictable. We found the people who lived in long term care homes and miranda dials. That was a pretty pretty lethal combination and they at a very high rate of getting this seven times the rate of people who didn't live in long term care homes. We also found that lived in the toronto area. Where at much greater risk of getting this in the range of three times the risk but then we also found the ethnicity was associated with a higher risk and in particular being black was associated with three times the risk of getting a covid compared to being black for people south asian ethnicity. It was about two times just under two times and for all other non caucasian ethnicities put together. It was twice the risk. So we see these big big ethnic variations. There was also an income effect where people in lower two quintiles of income based on neighborhood income. Were twice as likely approximately to get code and then something the spur of particular interest the renal community andreas. We found People who were on in center hemodialysis were two and a half times more likely than those on home dialysis to catch cove it so there was a lot of information there. Some perhaps predictable some not maybe so predictable on the strength of these correlations quite quite striking even though our numbers were not huge these were all significant and an independent each of the other summary. Peter and i was when i was looking at the paper. I thought you know a lot of the risk factors that you described are the ones that we would expect if you live in crowded home if you live in long term care. I think it's been well shown in the states in the uk that maybe not into asas patients People black s methodology saturday's method a much more likely to get covid likely to do badly. How has this information if any change the way you provide aosta sir screen patients for dialysis or manage them. Rebecca has already outlined the course ten twelve different ways that standard practices in dialysis units of changed the observation. That long term care home residents were at particularly high risk. As you say no surprise and quickly we recognize that another dialysis units and these people were given particular attention they were sequestered in a particular area of the unit typically kept well apart from each other. The nurses observed full. Pp droplet precautions with them. And in many of the dialysis units were outbreaks. Were in long. Term care. Homes nearby had been well recognized. There was surveillance testing. That's an actual swab done. Once a week once every two weeks at varied and on the lowest threshold of symptoms for doing it so these residents not only of long term care. Homes that have retirement homes any other form of congregate. Living were considered to be a very high risk population. That was difficult for those people To be sort of separated out and given this extra attention which sometimes was you know on pleasant having repeated swabs but it was felt to be the right thing to do and they largely consented to do this so that was an example of Response to this these observations. We also took the opportunity to push home dialysis as an alternative especially for people. Just starting dialysis quite an interest in that. The role was at some but a lot of the patients were very Optical into the in center units if they hadn't started has already or even to get out of them and go to home dialysis if that was on the menu that had been if it had been already a part of the plan. Maybe i'm we did actually see in the first three or four months of the pandemic. A sudden spike in numbers doing dialysis. I would add that Certainly the finding that in center patients versus home dialysis patients were more likely to be infected with covid. It wasn't a big surprise being able to quantify that the risk is two point five times greater for in center patients with very very stark. And end to dr blake's plane. I think we have seen that. There has been an increase in hump dialysis and and this is something that The ontario wants to continue to promote. And i think this could actually prove to be a positive outcome of the pandemic in a way since home. Dialysis offers patients A higher quality of life in equivalent outcomes not to mention that it's more cost effective for the system in the context of covid. We now know that. Home dialysis safer to my senators. Unfortunately there's a number of people onto also suggest. I guess are sick enough that they're not going to be able to to have home dialysis treatments. They wanted to. Am i right about that. It's not a treatment for everyone. Yeah certainly for those who can and we're seeing more interest in it now on during covid than than In the past it very good option in some long term care homes. Are they large enough that they have enough people on dialysis that you could actually put a dialysis machine in the long term. Care home. dialyzers them there. It's a great great question in fact this is where we're going to increase availability of dialysis inside long-term care homes. It's not a common today in ontario but certainly a huge opportunity To provide dialysis to long term. Care home residents right there in their home as a as a form of home dialysis and avoid the transportation back and forth to the hospital or or other unit the particular issue limiting factor in some parts of the province. The there isn't a density. There isn't a number of long term home patients in any one nursing home to justify it but in the greater toronto area where there is a great density of population. There there are some Some dialysis units within nursing homes under now a whole lot more being planned number of the very large hospitals have put in locations to proceed. Exactly with what you're saying given the experience in covid on. I think that's another thing that may be good. That comes out of this. This is a form of home dialysis where these people saved them from. All the traveling on the risk that goes with it and indeed save the expense and what about vaccines. Yeah i would imagine that these folks should be fairly high on the list of getting a vaccine. No well absolutely. We are advocating very strongly that group with mortality in the first wave of twenty eight percent. Almost such a group of people should be candidates for highest priority status for vaccination. Let me maybe step forward a little bit and say the second wave has come and more people are now getting infected into despite all our efforts. The mortality has come down a bit since the first way. But it's still very high. The overall mortality is twenty percent approximately at this stage. The mortality rates are very similar to those for long term care home residents who get covert running in that same range in the twenty percent to twenty seven percent in the first wave range. So we think there's a real indication to give this group high parties at this stage as many as four percent of caught the virus and they also are patients who have a high rate. As i've mentioned already of getting into hospital getting into icu's they're getting ventilated. They bring a brick load of healthcare onto the shoulders of the hospital. Furthermore think that there a population will be relatively easy to toback sonate in the. They're all in their three times a week. In the the hemodialysis ones are in their three times a week in the unit sitting in their chairs easily accessible to us to vaccinate so we we think this would be a group that really deserve parties. Ation i realize lots of people feel they deserve prioritization but we think the data in this paper and from elsewhere suggests that a very good argument. And you think you'd be listening to. I think people are listening. And i think they here. It's a good argument. But i think they're under enormous pressure from lots of people on a is a shortage of vaccine as we know at the moment and long-term care is where most of the debts or recurring. And so they see not unreasonably as the immediate priority. But i we suggest to them that. This population are very similar story. And there's easier access to vaccinate when you talk to patients as i'm sure you have. Are you getting a sense that there's general you're going to be vaccinated or is it or any vaccine hesitant or yes does general eagerness but yes there's vaccine hesitancy and just in the last few weeks we've listened to people in some of the toronto units who have noted that vaccines hesitancy is more common in certain ethnic groups and this is consistent with findings that have been in the newspapers in the general community at there are various ethnic groups including black patients in salvation patients who have often a degree of distrust of medical systems and are unsure about in because of understandable reasons are unsure about vaccination and this is something that i think it's very important for the renal community to address in the dialysis population. We've been talking a lot about that But yes it is an issue. You might say unbelievably with mortality. That's going on but yes. It is an issue in a a minority but very important minority and other plans to address that or connecting with community leaders. I would say you know. One of the things that the ontario renal network is poised to do very shortly is to do data gathering specifically on vaccination rates. Ontario's dialysis population is we have done About cove infection in the same population. And i think really have some data that helps to Very specifically speak to the point about certain ethnic groups who may be more hesitant about vaccination than other than from there with the data in hand be creative and apply some ingenuity working together with the local dialysis units now programs to be targeted and addressing vaccine hesitancy in specific groups and and help get the message to them about vaccination in a way that's most effective for them to hear. It allowed a couple of anecdotes that i think important. A number of an frolics in the front line in who are really in the front line in the worst affected units. Tell me on. This won't be surprising. But when the trust is an issue but there is trust because sometimes with the staff in the dialysis unit or within a frolic. So if you've been seeing an apologist for a couple years or something in a relationship is developed. There's much more likely to be some trust so an individual approach to hesitant patient by a somebody who whether it's a nurse are in a physician frolic who has a good relationship a trusting relationship with that can make all the difference hundred prepared to answer the question. Doc did you get vaccinated. Are for the nearest uptown. So that question. 'cause you don't have a whole lot of credibility view. Didn't soap approach also seeing other patients receiving a vaccination. Someone you know in the union of new comes back. Two days later for the next dialysis and looked just fine These sort of things are very important to establish a bit of confidence and trust. That's anecdotes but it's it fits in with what one. Here's another context on healthcare. Guess maybe just From my point of view coming close to wrapping up. i mean. We're recording this on the twenty six january and we're hearing more and more that the new variants that have arisen in the uk or south. Africa are probably in the canadian ontario. Must concern you a lot. Must i guess probably make you even more enthusiastic about Often vaccination to all of your patients and presumably the nurses and also the The people with whom you are a dialysis patients live at home without adapt. I mean we spoke about the long list of safety measures. That are in place and you know. I think as we face new variants vigilance of all the staff. Working in units is going to be required. I mean they're incredibly committed but short of a continued vigilance and vaccination. It's really a reduction in community spread. Because you can't disassociate numbers of cova cases in dialysis units from what's happening in the broader community in wave two. We've seen very few examples of in unit transmission but where are the numbers are high Really corresponds to where Community spread is high. So docs nation can't come soon enough really well. You know hama. Half of all gases patients and people interrogation thanks to the to view all people cross the problems on the country are caring for people on dialysis. Obviously i sort of imagine what it would be like to be someone on possible to send the you know the that you mentioned Peter and and i really do hope that people get vaccinated Sooner rather than later Any last comments from your point of view. Yeah andreas i would like to you. You've alluded to this. But i'd like to emphasize it. Also and maybe rebecca could comment on this to the renal community. We've always felt in ontario that we have renal community and the ontario renal network is. It's a government agency and is in a leadership position that community and has greatly helped to strengthen the community by improving the communication between the all the various centers so they can share the concerns they raise on the issues that They all have to deal with. But i would like to acknowledge What exactly as you did. What the stuff in these units are going through what the patients in these units are going through. And also i would like tack knowledge that in the middle of all this horror show that they collected the sort of data here with great care that was provided that made this paper possible. This is really been a great effort by all of them to collect this data and to record what's happening so the story gets out there and his understood widely. I would really acco those points in really what i would say. Is you know to be honest. We initiated the collection of this data to share it really amongst ourselves within ontario. The people who are working directly with patients on the front line to understand what the risk was to to them into other parts of the province in n You know that was that was sort of job one and then from there. We did the further analysis and right up of the paper to share the findings. More broadly because it is such a large group of patients. Twelve thousand dialysis patients in ontario credit to all those working in dialysis units in regional renal programs in ontario and credit credit to the patients too. Because it is. It is a community as i think. We've alluded to in this discussion. And you know. I think everybody involved has a tremendous commitment to keep their heads down into keep working get through this for not note. I'll thank Both of you. Rebecca cooper pure blake if any listeners. Wanna read the research can be seen on Cma j. dot ca also. Please don't forget to subscribe to see a major ed podcasts on soundcloud or podcast app and let us know how you think we're doing by leaving a rating i'm dr under pockets editor in chief for c. j. Thanks very much for listening.
Healing with music in the COVID-19 pandemic
"I'm dr curson patrick. Executive editor for the canadian medical association journal today. You'll be listening to a humanities encounters obstacle published in sierra j. cold virtual bedside concerts patients with covid nineteen a trio of perspectives in this essay. A musician a nurse and a doctor come together to provide a virtual bedside concept for some of their sickest patients with cope. Nineteen melanie ambler. Cellist and aspiring physician was inspired after hearing others during the same. the obstacle is reg by its officers first. Melanie ambler the musician. Then laura would decky nurse manager at rhode island hospital and ending with dr timothy intensive care physician in denver colorado. The challenge this patient with kovin has been sick for several weeks and is not doing well. He's paralyzed and sedated. On the venta leader. His son has been having a hard time with this and likes the idea of you playing music for his dad. I feel the weight of this opportunity and dial into his room. Silence the were of a machine an occasional russell but mostly silence. Before i begin playing sunup. I asked him to picture the sun ruling over a calm lake. I want him to know that this is an entirely personalized concert. Even though he cannot respond his silence is not emptiness. It's quite the opposite. I lift my bow. Inhale and let the first notes sing with warm abroad. The sound carries from my home to his hospital bed thousands of miles away. A conductor once told me that rests are the loudest parts of a composition. They must be present for the music to carry. Wait to have contrast to breathe while playing for this patient. I value that extra space every time i take a rest. I'm not alone. Two weeks later. I sign onto zoom call to play for the same patient. He's off the ventilator but still has a surgical airway much to my surprise. Sixteen other squares. Populate the screen family friends. Doctors and nurses surround the patient online. We discover a special moment of congregation and shared humanity albeit virtual. I delve deeper into my cello than i ever have before smile. And find all the joy and positivity and luck that i have in being healthy i converse through my music and interact with an entirely present yet mute audience. This intimate opportunity to play for strangers at their most vulnerable moves me beyond any other performance. I share pieces that are near and dear to my own heart. It's different than playing recording. We connect to the music. We breached together the nurse. Let's review the unit which patients might benefit from the gift of life music the choices to so many patients ventilated and sedated. Many are not waking up like other cushion to be cared for in the past one. He's been with us for ventilated completely. Isolated from her family and friends can soothing music. Penetrate of sedation. I call the chalice. She smiles eager to play. I know you're busy. You can leave the tablet in the patient's roof you buy and i will disconnect name done played. You have so much to do. I enter the cacophonous room with cellist. Really on the tapa sit down by the patients better holter. I have held so many instrument past few months my mind drifts. To all the families that have watched their loved ones take their last breath he had the scene tavern either in all too frequent firms for ic- kobe the challenge planes for beautiful instrument. Nice start to bring my and ninety thousand dollars off closed find solace in the museum. The patient's primary nurse listens with me chelsea thing. She's providing only the patient with the gift of music. The during this time of unimaginable lawson stress. It gives us a glimmer of hope. We are grateful. We stare at the patient. Hooping is will. She needs to get the patient is the doctor. The patient is breathing at forty. And you slowly waking from seven weeks of intensive care on a ventilator. Most of it sedated now with a surgical airway in profound weakness between moments of lucidity and stability and others of confusion and inside when the cellist. Thousands of miles away plays her. I knew is moved to the screen. Respiratory rate drops to twenty is focused and using their cell phones to dial into the concert. Team that has been working tirelessly for this patient so many others gathered with pint of ice cream outside. They asked me to join inspired by the patients relaxed breathing. I joined the team breathe for a few minutes myself as the music plays resident spontaneously says this job is so hard job is to see people at the most vulnerable to witness the joy and sadness that come with the journey of each patient who arrives in the edison now during the covid nineteen to know the only ones who can stand with them forest moments of there. There's no way to prepare the experience of the family. Overall videoconferences people the tablets so they can stick by sharing. In the joy of libaridian other person from the soundtrack of each other's our team explores the pains of the lights. Being a doctor use it crescendo. 's curious our emotions up to the surface calming phrase arrives. We discover the bandwidth to reflect on what we bear witness to on a daily basis tears moments silence and we discussed what has been around rarely acknowledged. We wonder if name although i do not know the question And that was the cmha cold virtual bedside concerts for patients with covid nineteen the trio of perspectives which you can find on our website. Cmha dot ca. If you'd like to contact melanie to request a live virtual concert at your hospital you can find her e mail in the podcast description. Also don't forget to subscribe to see him podcast on soundcloud or a podcast app and let us know how we're doing by leaving racing. I'm dr patrick. Executive editor c. j. Thank you listening.
What is The Best Thing You Can Do For Your Health? Sleep!! - 742
"Before we jump into today's topic allow me to take just a moment to think. Today's show sponsor which is organic you guys know. Feel about organic. It is might go to in fact this is refreshing. I have a glass of ice. Freshwater mixed with pure an immunity is got just enough citrus. That's two of their products mixed together. I don't know if everybody likes the taste of that. I do. I love it. It's like an orange flavor the immunity kind of tastes like orange. And then the pure to has a lemony taste and i mixed two of them. And that way i get everything i need for my immunity. My antiviral antifungal. It's just a great way to support your immune system every single day. And then i mix that with my organic by pure. Which is it's basically all the superfoods that your brain needs to help reach maximum mental performance in other words. It's what i drink to help me. Think better to help memory to increase neurogenesis and get this. The reason why i drink it. Their product is clinically proven to boost be brain derived neurotrophic factor by up to one hundred and forty two percent. Anyways they've got tons of great products. Whatever your nutritional needs might be lacking or your palate might be craving. Organic fi is definitely the company to check out our guys. The cool news twenty percent off all of their products. When you use coach lean again. It's organic and i'm going to spell it. O r g n i f. I dot com for slash lean. That's organic fi. Dot com boy slash. Lean and you get twenty percents off. Welcome today we're talking about the very most important thing that you can do for your health and it doesn't matter whether we're talking about your mental health physical health sexual health your brain health gut health. All of it starts with sleep and we're learning this more and more every single day you wanna live a better life. You want to be an optimal human listen. We're also focused on exercise and what we're putting in our malls and all these other crazy things that you know sometimes can cost a lot of money and take a lot of time but the absolute best thing. The most important thing you can do for your health is sleep so today. What i'm bringing to you are the best expert. The best advice and the best tips my own practical tips and what exactly it is. I've done to help reset my sleep because ladies and gentlemen sleep is crazy important. The first thing you have to understand is that sleep is is not something that's nice to have. It's necessary is critical to your health. You can live without food for quite a period of time. You can live without water for quite a period of time. You're not gonna die if you don't go to the gym you're not gonna die if you live or sustain yourself on a diet of soda and cookies but y'all if you're sleep deprived you are shortening your life and in fact if you go without sleep for too long you'll die. Sleep is necessary. Everyone knows they need this. You're fighting the good fight. Why don't we think it's important enough. This answers so simple. And i spent time contemplating this for a long time. Actually and the simplicity is where the beauty is at with this. We don't really value sleep because we don't have to do anything right so sleep has been really interesting phenomenon recently. Will we having issues with the word our jeans. Just expect us to do this thing. And today in our society really taught. Like if you're not hustling if you're not doing twenty-seven things and while having the kids and drop everybody like if you're not just overwhelmed you're not showing up doing the best that you can and so having that type of paradigm that we're living in to value something that you actually don't do anything it doesn't make sense to us. And so that's really worth starts and digging deeper digging into research. Start to find out that all the stuff that you're actually doing is not effective. You know there's a difference between doing things and being effective. You're losing so much of you're all of the things that we keep ourselves awake. Yeah all the things. We're like well. I need to get this project done. Sacrifice the public large doesn't even know why sleep matters and that's another thing it's just that disconnections because if you got ten things at doing sleep is one of them would x-nate asleep. She's i think that people do not why they need sleep fringe level. It's very outer level. It's not that deep visceral leg. I gotta have my sleep. Okay no because it's like. I know i'll feel better. I know you know that kind of thing. How do you feel about that concept in kind of the trend that to be successful you gotta go go. Go sleep less hustle more my whole career. I've been practicing for seventeen years and my whole career. I've had people come up to me especially entrepreneurs and business owners and ceo's corporate executives. Because i have a whole side practice. Where i just worked with them yet and they asked me one of two things. They oftentimes say well. How important sleep could sleep really be. Because i'll sleep. Went on dead the same phrase that you use the my my response is usually exactly the same. Which is well. That's going to happen a lot sooner than you might badgen if you keep up the pace that you're going because we know that sleep deprivation affects immune function. We know that there is not an organ system or a disease state that is not affected by poor sleep. We know that your decision making is greatly affected by your amount sleep. We know that you're moutainous and emotional. Reactivity is affected by your sleep. We know that your reaction time is affected by your sleep. I mean they're literally isn't a thing that you do that you can't do better with a good night's sleep. My nighttime routine looked like kind of getting the kids to sleep. Whatever time i could do that by and then maybe doing a little bit to prepare myself for the next day like maybe like okay whereas the kids homework like let's set that out by the door. Let's get backpacks. Let's i don't know maybe do some quick laundry like mainly. Just do all the things that i didn't get a chance to do while the kids were awake and then i would put kids to bed and then i would do those things like a maniac and then i'd be like oh my gosh. There's so much work that i couldn't do because there was so much going on during the day so i would sit down at my computer and i would work for a couple of hours be stimulated. Sometimes they would also use my phone. But usually i was using my laptop and i would work until i realized like okay grow. You need to go to bed then. What i would do to kind of unwind is try to do something mindless like watching. Tv will i. I would enjoy some time with my husband like. that's you know. Hello we've been married for twenty five years. That's one of the secrets to our success. San like even. When i was like really tired even if he had gone up to bed before me i would like wake him up. And you know what i mean. And that's not a good thing like you should be going to bed at the same time together. I'm telling you i'm telling you the more in sync you can get with your partner including in sync with their bedtime and bed routine the closer you're going to become just letting your partner go off to bed and then you saying and doing your own thing like that just you don't realize it but it creates distance. It creates a message for your children. It's not a good thing if you can avoid it of course you can. Of course you can avoid it so try to do a better job if you can of trying to go to bed at the same time this might mean both of you creating some compromise anyway. So that's what we did and then after whatever after watching some tv et cetera. Then now it's like. I don't know eleven o'clock or midnight sometimes and then i might be like So a lot of things. I'm thinking i need to get off my brain right now. So let me. Just grab my phone. And i'll add to my to do list on my phone and hala see what else okay so. I'm still kind of a wake so we do other things on my phone. Now the thing is in my mind. I was in bed by ten or ten thirty but i wasn't going to sleep but i could tell myself that li- like when people would say what time you go to bed to wake up every day to teach a five thirty am class which meant i had to wake up at four forty five wartime. You go to bed at night. And i was like oh. I go to bed at ten thirty which was true. I was in the bed. But i certainly wasn't going to sleep. So it's what time are you falling asleep. I would sometimes even get back up out of bed and go work on my laptop because i wanted to connect with my husband right like i wanted to have him fall asleep next to me and then i would feel like gosh. I'm so overwhelmed by everything to do. Tomorrow i'm going to get up and work a little bit more on my laptop and the next thing you know it's like twelve thirty one. Am and i'm trying to get myself to go to sleep. But i'm having such a hard time now falling asleep. Because i would think myself like. Oh my god you really messed up. You need to go to sleep earlier tomorrow. Shalini johnson what are you doing like. Why can't i fall asleep. Why can't shut my brain off. Why he's my brain thinking about all these things go to sleep. Oh no now. You're only going to get three hours asleep ono ono now. It's only two hours and forty five minutes and you start doing that countdown. And then you're just like trae even sleep or wake up. You know what i could do. I'm not going to get any sleep tonight. Anyways actually just get up out of bed. And i should just go clean the kitchen. That's what i should do. I should just like get ahead. And then that way tomorrow. I'll be able to go to sleep much earlier. So there were literally nights where i was so poor about this negative loop that i would literally just get up and go. Oh well i'm just gonna you know screw it. I'm only going to get two hours of sleep. I'm going to even more tired. I might as well just not sleep. And then you know what i'll do. I'll go teach class. And i'll come home and i will nap. Yes i'm gonna take like a four or five hour nap tomorrow in. I think you probably can guess how often that happened. Approximately zero point zero times. I never did that. And that's how i lived my life for gosh. I don't know fifteen sixteen seventeen years a long time a long time way too long. If we determine how much sleep you really need and by the way not everybody needs the same amount. You know let. Let's just talk about the myth right here in that. Eight hours is a myth. Good i was going to ask one of the reasons why i wasn't motivated to get more sleep. Even though i knew it couldn't be good for me to be getting like four and a half hours sleep. Which is what i functioned on for. I can't even tell you. How many years was i didn't feel bad. I didn't wake up tired true. That if i stop moving kind of like a shark you like if there was any inactivity or just sitting down i would follow asleep immediately. I could fall asleep in my car. But i always felt like well. I'll just keep going going going in. I feel energetic. i didn't have negative side effects. So i would tell myself this little white lie that i must be special. I'm plus not need a normal amount of sleep. Will you are special however it probably has nothing to do with the amount of sleep that you need your what. We call an adrenalin junkie. So what happens. Is that the end. You you outlined it perfectly when you're moving your moving and you have a level of adrenaline and a level of attention and a level of focus. That is very unique that a lot of people out there don't have the problem is is that you don't have enough fuel in the tank meaning sleep in order to keep that pace for as long as you might like and you may or may not know that you probably were making some mistakes. Some that might not be critical but certainly ones that add up over time now. Ours happening with a lot of my business owners. Ceos entrepreneurs and it's pretty amazing the pace that a lot of people have to keep. And i get that part. But what i don't like is ten years down the road when these. Ceo's have kept that pace for that long period of time. And they've got high blood pressure more gave atrial fibrillation or some of these pretty devastating cardiac in cardio physical aspects. That can have a major major effect on their sleep. And so when you look at how much sleep does somebody need. There's a few factors to think about. Okay so all. The average sleep cycle is approximately ninety minutes long and the average person has five of those sleep cycles. So if you take your socially determined wakeup time and everybody has one of those by the way in our house at six thirty. Because i have to get the kids up because if they get into the shower and get ready for school. 'cause i take him to school no mornings. Everybody gets up during the week at six thirty so if we know that the average person has five of these ninety minutes cycles and since ninety minutes cycles five of them is four hundred and fifty minutes. Divide that by sixty to get the number of hours that seven and a half hours so if you count backwards from six thirty seven and a half hours you now know that your bedtime should be eleven o'clock Because most people don't know what their bedtime should be and so a lot of people don't realize that there is a bedtime that's good for people now. We just disproved the myth of eight hours because ninety times five is four hundred and fifty which is seven and a half hour so we already know. Eight hours doesn't work. And then here's the kicker is some people don't have a ninety minute cycle. They have an eighty minute cycle or a seventy five minutes like me personally. I'm a six and a half hour sleeper. I have been almost my whole life. My body will naturally wake up around six thirty in the morning. So i don't really go to bed before midnight because i just don't need that kind of sleep now. My wife doesn't necessarily love that because she likes to get in bed a little bit earlier. So what we'll do. Is i might do a little bit of work or catch up on a few things and then get in bed and watch. Tv or read with her. Let her fall asleep. And then do some more quiet things like meditation. Relaxation kind of daily reflection. Journaling things like that. And then i go to bed by midnight so everybody out there can do this experiment themselves. Just count backwards from your socially determined wakeup time and then see if that works for you and then start to figure it out if you wake up an hour before your alarm clock. Guess what you went to bed hour too early. Wow that number back discipline means doing the smart thing so waking up at the same time every day notice. I didn't say going to bed. Yeah you can go to bed when you want. Wake up at the same time every single day. I'm if you do one thing if you heard one piece of advice from this entire conversation if you just wake up at the same time every day you will absolutely positively improve your sleep. That's where the discipline comes in. Okay the other two things to be disciplined about our caffeine and alcohol. Stop caffeine by two pm. Just stop right. Caffeine has a half-life of between six and eight hours right if you stop it to half of his out of your system by ten. You should have a reasonable chance of getting to sleep. Okay now if you want to be better at. It stopped your caffeine much earlier in the day to be clear. Caffeine has no nutritional value whatsoever. It is a stimulant now. There's got be about ten percent of your population that listens to this. And here's what they're thinking right now. Dr bruce sleep guy. he doesn't know what he's talking about. I can have an espresso and go right to sell easily argue. Really absorbing the caffeine. So i have a patient who has an espresso every night before she falls asleep she sleeps for nine hours and when i track her sleep. It's perfect so we did a genomic study on her and we discovered that her body doesn't process caffeine well and so she can take this dose of caffeine and the it actually takes a very small amount of it so she can drink caffeine all day and it has almost no effect on her there people that actually have caffeine sensitivities so some people need a chocolate kissed and be up for two days to other people can drink a pot of coffee and go right to sleep. Yeah this could have something to do with this genomics research. That i was talking about just a moment ago. Caffeine's a stimulant and you stuck it in your head. So guess what it's going to affect the quality of your sleep. You might still be able to fall asleep just as you so doggone tire but it will affect the quality of that sleep and that's really the thing to be observant about with alcohol. It's very simple when you drink drink of alcohol you stop time you drink that drink and your whole circadian rhythm slows down because now you've put alcohol in the picture right the reason that people wake up at three o'clock in the morning after having passed out instead of going to bed hidden is because they literally put an iv in their arm right and then it finally came out and their brain is like holy crap which has happened to me. You wake up at three o'clock in the morning you're sweating you have to p and you don't know what time it is and you're very disoriented. Simple rule drink one glass of wine. Drink one glass of water. Wait one hour okay. Two glasses of wine two glasses of water two hours yet. Gotta stop at two. Here's why y you get more than two alcoholic beverages in your brain. Your brain says oh crap. There's a toxin in here. I need to jack up my cortisol. 'cause i don't know what's going on now. You're an energetic drunk. Trying to go to sleep doesn't work. Well that's the big three things that you've got from. A disciplined standpoint is wake up at the same time every day. Stop caffeine by to stop all alcohol limit to two drinks. Stop all alcohol within three hours of bedtime. Let's talk about the relationship to sleep and our hormones sleep because when we talk about hormones and we are talking about weight and often times for many women it is the additional weight that becomes the motivating factor. It's like oh yeah. I've got brain fog but i can deal with that. I can deal with the brain fog. I can deal with a dry skin. I can deal with the hair loss. But i can't deal with the extra ten pounds i put on so sometimes. Yeah that's what motivates people to really take control of their hormones. So let's talk about sleep for a second. I recently got an aura ring and to my guests to my surprise maybe not. I'm realizing that. Even though i'm in bed for eight hours i'm not getting eight hours worth asleep. So when we're talking about like the amount of sleep you need. It's not just being in bed for that number of hours. It's how effective you're able to use that sleep and how effective use that sleep has a lot to do with how managing our stress during the day. Tell me about the relationship between sleep and our hormones and sleep and waking. Yes so much the same way. That stress activates cortisol and cortisol makes us pack on weight lack of sleep so even just getting under seven hours of sleep a night or even skating under seven hours. Asleep occasionally can activate your cortisol. So it's the exact same. It's just a different form of that same stress. Pathway getting activated literally the same hormones but the other thing is that when we're getting good sleep. Our brain is producing. Something called melatonin. Melatonin is an antidote to some of the stress impact that cortisol has on our brain and body also as women especially before menopause. Our ovaries are really important. For producing our monthly cycles and melatonin is also really important for ovarian health. So getting enough sleep is not just good for our brain and our mood and our blood sugar cravings in our weight but it's also good for reproductive health so it's kind of all tied together we can talk about the weight loss. Things study done by the canadian medical association journal. This load motivate people right. Tell us why lack of sleep makes us fat okay. So this was published in the journal and they took two groups of exercisers in dieters same exact exercise program same exact diet and one group got a plus hours of sleep a night. The other group is sleep deprived on purpose. So they're getting round five hours sleep a night or less at the end of the study. The group that was sleep deprived loss far less weight and far less body fat. The only was asleep. Everything else is exactly the same. So what's going on. There is my question where i dig around and your body physiologically changes from the exercise that you do and the food that you're eating a lot of the assimilation happens while you're asleep so we're missing that part. Now here's a big part with the whole weight gain issue. You know when you're up with living in goblin down everything. Is that just twenty four hours deprivation number. One is gonna make you as insulin resistant as a type two diabetic twenty four hours for anybody. Okay but when you say what is twenty four hours sleep deprivation in my mind. Are you telling me. I'm up for twenty four hours so this is and of course. This is looking at extreme levels to this so just if we stayed up from today to tomorrow both of us can go get some blood work done like. Hey while you've got prediabetes just because your body's doing a lot of processes when you're asleep to repair you know here's the thing with weight gain so when you're sleep deprived you're going to get a reduction of about six percent glucose reaching your brain. Okay so what does this mean. Mesa can make decisions. And here's what was so crazy as that twelve to fourteen percent of that was from your prefrontal cortex this the more human part of your brain. So that part of your brain basically starts to starve translation. You get dumber so this is the part of your brain responsible for decision making for distinguishing between right and wrong for social control for your so called willpower. Right and now. If you've ever had a cookie in your life if you've ever had ice cream in your life your brain in your body's going to compel you to get that glucose back to your brain because this is evolutionary biology. You know two hundred years ago three years ago. If you're not sharp you might lose your life. You're not might be able to not procure your food and take care of your family. You need to be a sharp as possible. Your body's just going to compel you to eat more and i don't know about you and you've had experience doing this. I haven't heard of one person in the history of humanity. That was up two o'clock in the morning. Like you know what. I wanna salad. Sounds sounds good right now. I stayed up all day all night. Sounds good. I'm going to soothe my feeling. Sorry for myself with some kale. No that does not. It doesn't happen you next thing you know you've got the orange fingers crossed the badge or you're looking down the barrel of empty car criminal to to us all and we don't know then the guilt sets in. Because like you're telling yourself. I'm going to make sure i'm working out and you're getting into a battle of your willpower versus your biology. Your body's going gonna win. Yeah recently partnered with seoul. Cbd i fell in love with the company when i started researching cbd products. And then they've helped me to develop a sleep. Gummy that is like ben a true game. Changer it was really fascinating to go through that process of formulation testing and trying to figure out the right amount of melatonin. And cbd mixing those two things and then how do you get the right taste. Profile without putting in additives and preservatives and other ingredients and make things taste good but then it takes away the fact that it's a natural ingredient. How do we find the right mixture of what other ingredients. Could we add to it. Like cana bunol to help really increase the amount of remm sleep in deep sleep that people are able to have by taking one of these companies. And i'm a big fan of gumy's because unlike capsule a capsule you just have to take a whole capsule if one capsules enough then you have take two capsules. Maybe that's too much. But with a gummy you can really customize and micro dose the amount. That's perfect for you because you can just bite off a little extra so you can take one gummy then. Bite off a little quarter of another one by the way you can check out your new nighttime best. He the sleepy gummy by going to my soul. Cbd dot com slash. Lean when you enter the coach. Lean you're gonna get fifteen percent off and a lot of our in d. went into the development of this product it tastes delicious but really truthfully more importantly it works. I assume that from the time we were pretty young. Parents are telling us you need to get adequate sleep. And that's just a message. We tend to believe because you can feel it. But i think the correlation between weight and sleep is something. That's relatively new. So i wanna come right out of the gates and have you explain to why and how in the world asleep affect our weight. So it's fairly interesting. The data has really started to come into its own within the last ten or so years but There's four ways that we know that sleep deprivation affects our ability to lose weight or to maintain a healthy weight. And just give everybody an idea of what i mean by sleep deprivation it while it does partially mean the number of minutes or hours of sleep that you get it also has to do with the quality of the sleep. Did you get so. It's not just a quantity issue but it's a quality issue of as well and there's lots of reasons why you might have poor quality sleep. I can't count the number of patients who showed up in my office. And said dr bruce on sleeping seven seven eight eight and a half hours and i can't lose weight and i feel terrible. You know what the heck is going. On and it turns out that they have an underlying sleep disorders like sleep apnea or they have a thyroid issue like Hashimoto's hypothyroidism or something like that. So anything that deprives you. A quality or quantity sleep is what. I'm calling sleep deprivation now. Once we understand that definition the thing you have to realize is there's four different areas that have affected us in terms of weight so first of all when we're sleep deprived our metabolism slows down. Han actually doesn't expend the energy that we normally would would have happened. Why is that. Well you know i. Here's the theory. And i think this is true. Is i think this holds true with the research that's been done is in fact your body wants to hold onto resources because it doesn't know why it still awake Your body's like holy cow. I don't wanna go down. You know in my gas tank to fumes. I wanna keep that. So i'm gonna. I'm gonna put the engine on idol right now if you will as an analogy in order to not use up all my fuel and so your metabolism slows down. So you're not burning calories as fast as you normally would when you're well slept when you're sleep deprived so that's number one number two. Is we know that when you're sleep deprived your fight or flight response. Kicks in and your cortisol levels ray. So more is one of those stress. Hormones that not only can burn out journal glands and caused you lots of fatigue but it also increases your appetite and the reason we think that happens is because you don't have enough resources in your body and your brain is saying cortisol high bringing food bringing in the food so already we've seen two things that have a dramatic effect. We see a lowering of metabolism. An increase of appetite. Right there even if we stopped right there that recipe would be weight gain right. Yeah absolutely but it doesn't stop there. It gets even worse so we know that hormonally things have tendency to change as well there to hormones in particular that we have to educate ourselves. One is called guerrillan. Net spelled g. H. r. e. l. i. n. And the reason i spell it out is because it starts with the g. So i call it the go hormone and it's the thing that makes you hungry now. Believe it or not. There's a difference between being hungry and having an appetite at least metabolic speaking and you have twenty percent goal or twenty percent more guerrillan. When you're sleep deprived the other one is something called leptin and leptin is a hormone that makes you want to stop eating. Makes you think that your full are what's called the hormone and we have fifteen percent less leptin so let me go over this one more time. You've got high cortisol which equals high appetite you have high guerrilla means it makes you want to eat and high hunger. You have low leptin which tells you that you fall and you have low metabolism. That weren't enough. There's even more now though there's a great study at the university of chicago where they took people who were sleep deprived and they put him in front of two tables of food healthy alternatives on one side cakes and cookies and pies on the other and they all went for the cakes. The cookies and the pies now. That wasn't as obvious to everybody as as what the previous research had been but recently they've discovered that when you eat those high fat high carbohydrate foods it causes a release of serotonin in your brain which is the calming hormone. And we think that with those high levels of cortisol. The brain doesn't like that so it makes you crave food to help. Calm the brain down. That's what we helped them. Comfort food is because it actually makes us feel comfortable now. Let me tell you what my routine looks like. An i have to start by saying i had to change all of my triggers. I did change my schedule. I had to change my mindset around all of this. And i had to focus on my family. I just think about like really truly what is most important here aside from just my health like i've gotta get on. The same rhythm is them. I was on a completely different rhythm and there are certainly times where you don't have a choice. Maybe but if you do have a choice like get your act together. Get on the same rhythm as your family take da. You don't be selfish about this. I was being selfish about this. So i can say that to you when i was living my life that way. I was always tired yet wired and because of that. I never admitted to myself that i was truly sleep deprived. I thought somehow. I was made differently than other people. But i woke up every single day behind the abe ball. I woke up every day. Feeling tired groggy. Mentally confused and completely disorganized and i always felt like i was like running running running trying to catch up and i always kept waiting for the sun to go down so that i would have time to catch up on everything so horrible way to be. Let me share with you. Now my new nighttime routine so i had to reorganize everything that meant. I needed to put myself in kind of a sleepy or state hours before my bedtime i started using an app called relax melodies. Would i do like about it is it includes bedtime meditations. It includes relaxing music. It includes special mixes that you can make that sound like the ocean or the waves etcetera. So i can play that sound machine at night. I also love that you can program into it a daily reminder that is sent to your phone as a notification that reminds you to start getting ready for bed so my notification comes in at eight thirty pm so at eight thirty pm. I get a reminder. That no matter what. I'm doing to start my bedtime routine and i do so i put my phone aside and or i will put on a meditation or something. That's very relaxing to listen to. It might even be a podcast but something. That's really relaxing. I put my ear buds. In and then i do. This is already like this. Is all my nighttime routine. I start by creating everything that i need for the very next day. So i i feel three water bottles twenty five ounce bottles of water and i make sure that a little bit of ice in there. I do that the night before. I set out my supplements that are gonna take in the morning. And i put those on the kitchen counter. I prepare my coffee. I set the programmer on my coffee machine. So that it coffee's ready by the time i wake up. I get the dog food for the next morning. Ready to go. I set my workout clothes for the next morning. I picked them out the night before. Everything socks shoes pants. Top my cover up. I also set out my contacts. I said at my makeup. I said oh my lashes. I select what. It isn't going to listen to the next morning when i wake up as i'm getting ready because that's my time for personal development usually. I'll pick an audio lesson from some course that i'm going through or maybe an audible book or maybe even a podcast. Okay not only that. I also use this time to select or pick out. What i'm gonna wear later in the day after my workout. I take my a planner which is as push journal. And i write out what my schedule looks like for the next day okay. That really really helps me. That helps me go to sleep. Also in mice push journal. There's a little place on every day where you can just write general notes like just any random thing that's in your head. I get all of that ish outta my head before i go to bed. Allow your head before you go to bed. And so i just write it down i might. I don't try to solve it. I just write it down and the sheer act of writing it down puts it in your subconscious and half the time by the time i wake up already. It's weird like these things. I already have like quick solutions for them. First thing when. I wake up in the morning. You what this does. It allows me to start feeling calm before i go to bed and feeling confident not overwhelmed. It's crazy what this has done for me. I just feel so much more relaxed. Because i know who my gosh. My entire day is all laid out for me right now and it's not even nine thirty. All of this takes me less than an hour and it just creates a routine for me that begins to induce melatonin. Like melatonin is a hormone. The body produces that tells you okay. It's time to get in sleepy mode. I would love to know if there is for people that are listening. Who have they've done everything like they've read the books they've listened to the podcast and they also are completely in agreement that i've got to get better sleep but they just for whatever reason they've got insomnia or their shift worker or they have small humans. That don't seem to care much about mom and dad sleep but for that person who was like listen. I'm doing all the things. I'm shutting off my screens. i'm meditating. I'm not having caffeine after a certain hour doing all of the things but i still can't get good sleep. Is there any suggestion or benefit to them. Doing asleep aid. Or what other suggestions do you have for. that person. says. I've done all the lifestyle stuff. And i'm still not getting sleep louis so number one. Let's get something incredibly clear. There are some people who need a pills sleep. That's how it works for some people. I like it a bit too. High blood pressure right. So if i've got a patient who comes in who exercises eats right all the things right but still has high blood pressure. We stick them on a pill to lower their blood pressure. They're not addicted to that pill. There's nothing wrong with them for being on that hill and they're actually following their doctor's orders and are actually safer and healthier by being on said nil. I would argue that. There is definitely a group of people out there. Were this would hold true for sleeping pills now. Look i'm not saying everybody needs to be honest sleeping bill. I am saying that. I think sleeping bills are over prescribed. I think too many doctors use this as a very simple band aid because what we usually call insomnia is what we call a door handle. Diagnosis is ask. The doctors got their hand on the door. And they're just about to walk out. The patient says oh by the way doc. I don't sleep so well. And so they don't have the time. They bought the prescription pad. They write a script. They take this for thirty days and come back and see me. The problem isn't that they give them sleeping pill. The problem is that they don't give them the tools to use to know how to use the sleeping bill and how to come off the sleeping pill safely and effectively. That seems to be the biggest issues. There are some things about over the counter sleep aids that i wanted to address quickly as well not prescription ones and not herbal ones but one that we can grab in the grocery or the drugstore. I really want people to understand that. There's now data to suggest that these are linked to and dementia. There have been multiple studies showing that frequent use of the quote. Pm medications out there. That is actually benadryl and long term. Use of benadryl is not. There's been at least three studies to show that it is highly correlated with alzheimer's and dementia. So if you're taking one of those more than let's say once or twice a week you want to have a conversation with your doctor to learn. Hey number one. Is there something better that i could be on prescription or not number two. Are there any other methods or things like cognitive behavioral therapy that i can do that would be much more not only safe but long term. Actually give me a better skillset. Would you believe that the data shows that if you put somebody on ambien for thirty days and you put them on cognitive behavioral therapy for thirty days that the therapy wins every single time. When be surprised at all by that pinellas nellis talked to those of you who are moms cruise. You're like okay. How does this work for me. If i'm a mom ladies if you have babies god bless ya but all bets are off like it's just not the same and then to put pressure on yourself to get perfect sleep. It's just not realistic. I'm sure that god has. I mean there haven't been any studies on this to my knowledge but i'm sure that god has designed us in such a way that there's this chunk of time when we're raising small humans that you get a pass because as much as you wanna make sleep a priority in your life. Yeah that nursing. Six month old has different plans like they're living off of you. There's a standing life off of you and you just sleep so lightly. When you're you can hear the baby on the monitor and you've got a four year old who's wandering into your bedroom at three a m and your potty training and and night's and like all these things like it was so hard to sleep and get good sleep when you are a mom so i just want to say i love you and you're not gonna believe me right now 'cause you're in the thick of it but girl there's gonna come a day. Where are you going to be like. Oh my gosh. That was amazing. I just got the best sleep. It's going to happen. I promise but mom's it is so important for you to listen to what i'm about to tell you. This is so key because remember. I started making these changes when my kids were still at home and you know in school so depending on the age of your kids the earlier you start this the better now. My friend monica who has triplets. You know. Monica crazy. Monica with the triplets. She started doing these things with her triplets out of necessity because lord knows having triplets. You have to be so organized and things have got to run like clockwork. Or you're you're gonna drive yourself crazy. I mean i remember at gosh. When her kids were like three and four years old she would involve them in this process and have them get themselves ready for bed. Have them know exactly what they were going to do in the morning. Moms this part is for you and earlier. You start this the better. Because you're trying to be superman like do all of these things for your kids is. You're not going to do them any favors. You're going to create children who lack confidence and who are lacking in self sufficiency because mom has always done it for them. Stop picking out there. Close the moment. Your kids are old enough to know that they need a shirt and a pair of pants which is probably around three. You need to let them pick those out like teach them these evening routines. Teach them these habits early. Why would you wait until they're in high school. The teachers sings at night. Okay guys it's get ready for bed which isn't just brush my teeth and go get my pajamas on or take a bath. Teach your children to pick out their clothes for the next day and ps. Let them wear this. My opinion aright. And i've raised to. That makes me an expert but i gotta tell ya we let our kids. They picked other closer night before and we told them make whatever they wanted whatever they wanted. You should've seen the things that are awarded school. Holy cow oh. Mg so funny and that was part of what helped her to become an individual brock to just let them wear whatever they wanted if they want to wear pajamas school. So be it now. Of course i would explain to them. What consequences they might have to endure like. If you wear that you might get teased today. But if that's your choice that's your choice. Make it your kids responsibility to get their backpacks loaded up with everything they need for the next day. You can double check and make sure everything's in there but that's their responsibility like come on now stab doing your kids work. Stop making their beds stop. Picking their clothes start teaching them how to be self sufficient adults. Teach them how to be self sufficient. Young humans they will be more confident than their counterparts. They'll have more respect for you and more respect for themselves. Teach him what they have to do the night before. Say i want you to pretend right now that we have to walk out the door for school in a few hours so get everything ready and teach them everything. Like a checklist critic checklist for them. And then when you start getting your bedtime routine down and they know that that starts at whatever time you set that for they will do the same and we keep energy low and we set a new tone and we talked to them about why this is going to help them rather than telling your kids like what to do. Help them to understand how this benefits them. Your bedtime routine is one of the most important things you can. Teach your children in order to have your very most productive. Well rested healthy day. You need to start the night before. It's doable in you can do it to sleep. Is really energy transfer right so we've got energy during the day and then we're going to transfer that energy to an unconscious state during that unconscious state. Our body is going to be needing to do a whole host of things with that extra energy that we've closed our eyes and stopped moving our body around because it needs to repair it needs to process and do all these different things. Sometimes our body wakes up in the middle of the night usually. It's between two and three o'clock in the morning. Okay first of all. Let's talk about why that happens at that time. When you fall asleep at night your core body temperature rises rises rises. When it hits ten thirty at night it hits a peak and begins to fall when starts to fall. It hits a trough. Okay when it hits that bottom level it has to rise again for you to wake up. Yes what time it starts to rise between two or three in the morning so your body is getting warmer than which makes it easier for you to wake up. So that's the reason number one. Why most people wake up during that time. So what we see happen. Which is interesting is if people can wake up number one. Don't look at the clock which is pretty much impossible. Almost every single person in the wake up middle of the night looks at the clock. They instantly do the mental math and then they're pissed off then they're like. Oh are you kidding me. It's two thirty in the morning. I gotta be up at six sleep sleep. Even they try really hard to sleep. Trying to sleep is about the worst idea there is. I always say sleep is a lot like love. The less you look for it. The more it shows up interest right so remember when you were out there just trying to find that person and you could never find them and then the second you stop looking that person wandered into your life. That's exactly how sleep is in the middle of the night. You must accept the fact that your body knows what it's doing. There's a reason you woke up. You may not be aware of it. That's o k relax. Your body has woken up for reason. Do you need to go to the bathroom. Go to the bathroom if you do not need to go to the bathroom. Don't yell allow k- okay. Okay slow your heart rate down. Because in order to re enter into a state of unconsciousness your heart rate must be at sixty or below What's the easiest way to drop your heart weight or seven eight breathing gonna teach everybody a technique right now that you can use in the middle of the night and it's exactly what it sounds like. Breathe in for count of four. Hold it for a count of seven. Read out for a count of eight. This is not something i developed. A navy seals developed this for their snipers in order to make sure that their heart rate would drop significantly before. They fired their weapon. It works incredibly well and it's an easy thing to do in the middle of the night. Say it's okay. My body knows what it's doing. I'm now going to relax and do some four seven eight breathing and see if the natural sleep process will allow me to fall back asleep. Remember just lying. There is actually recuperative by an hour's worth of lying. There is worth about fifteen minutes asleep. And so i tell people all the time. Just chill out trust in the process. I promise you if you need to fall back asleep you will all right. I hope you enjoyed this. I love you. I mean it. We'll talk to you soon.
Shawn Stevenson on Caffeine and Screen Curfews to Get Better Sleep
"Yeah hello and welcome back to another episode of beyond the to do list. I'm your host eric fisher. And this is the show where we talked to the people behind the productivity. This week my guest is shawn stevenson from the model health podcast. I really hope you're going to enjoy this episode with shawn stevenson. We're going to talk all about how to not just get more sleep but better sleep. Enjoy this conversation with shawn stevenson. This week is my privilege to welcome shawn stevenson to the show. Sean welcome to the show. Thank you so much eric. I'm excited so this is a topic that we've only covered kind of peripherally once before which is sleep and this is not the only thing you do however you have written a book specifically about it. So you're you're uniquely qualified. And i need more sleep. I need better sleep actually as more probably more accurate and so we're going to get to the bottom of that but why asleep so important. Oh my goodness this is like the jeopardy like double jeopardy question man this is. This is so powerful. You know you just said i'm actually a clinical nutritionist and have been focused on hormones. Nutrigenomics all this stuff for many years. But i wrote this international bestselling book now by the way which is crazy. Even say this because it's much needed. This was like the achilles heel of our results whether it's got to do with weight loss reversing insulin sensitivity brain function and productivity crazy enough. And i'm big and this is why i'm excited to be here. I'm a big student in fan of productivity. And i'm always looking to find ways to streamline especially my work life and one of the things that i cited in a ton of studies on very analytical human being scientists but one of the things that are really focused on in the book was there was a study published by the american academy of sleep medicine that found that poor. Sleep quality was equal to marijuana use and binge-drinking in determining academic performance. You you know and this is. The thing is many people listening. They might not be students any longer but we really are. That's what this whole game is about. It's about being a continuous student. Continue its learned being in being able to execute and sleep deprivation literally cripples our brains to be able to function properly and also in the study reported that the college students were sleepers. Were also more likely to earn worse grades and even to drop out of classes than the people who were healthy sleepers and so. How often are we dropping out in our goals in our work life. And one of the things that's being brought to the forefront when things. I'm talking about a lot in media and things like that is this new term called cyber loafing are. He's called cyber loafing in what this is basically. Is that when you're supposed to be working on. That project is supposedly working on that landing page or whatever the case may be and you're just like in fighting that you find yourself opening up twitter for a few minutes or you find yourself opening up facebook or instagram for just a few minutes and the next thing you know you get sucked into the internet black hole in his like thirty minutes later. An hour later like what was wrong with me. You know in cyber loafing. What they found was that basically every hour of poor sleep quality correlated with twenty percent greater incidence of cyber loafing so each each of those segments of time loss Resulted in more. And more of you getting off track and doing the things that you're supposed to be doing in by big big amounts and you know this you know in those days when you're not really feeling rested you're much easier to just kind of daydream drift off and do other stuff. That's not as important. So that's one thing i want to share one other study This one i. I like to bring up as much as possible. Because it's important for many areas of life but there was a study published in the lancet and this was looking at a group of physicians. This was actually done on physicians. Who need to be incredibly productive for lives right and so they took physicians and they had them to complete a task right so they had them to do a task. Didn't they sleep deprived them all right so they sleep deprived them for just twenty four hours. They had them to come back and do the same exact thing and what happened was pretty incredible. They actually made twenty percent more mistakes doing the same exact thing and it took them fourteen percent longer to complete the tasks do the same exact thing and so a lot of us thinking we're productive. We're thinking that we're plugging away. Were doing more work. Not understand that we're sacrificing the quality of our work. There's a difference between doing work and actually being effective. And that's what. I want people to really realise because a lot of times creating problems for ourselves like they may twenty percent more mistakes. We're talking about especially in. The realm of physicians are healthcare providers or our public safety individuals. You know who are doing that kind of work. If you make a mistake this could be. Somebody's life at stake. You know so for you. It might not be your life at stake. It might be a sacrifice in your business but this can influence your bottom line in a big way you know and so i really want to get people tuned in to the fact that this whole concept out there and i've talked to these people i've hung out with gary vena jug of hung out with eric thomas. The world's top motivational speaker. Who's flying all over the world and all this stuff. I'm telling you now. The story that you're getting from them isn't the full story. And they know this Gary's made a big shift over to focusing more on his health and getting better sleep. Making sure as nutrition is right. Exercising all this stuff because he's playing the long game now. Now use and same thing with eric. Thomas you know he make sure he accidentally was getting sleeping. What we call the money zone. Which is pacific hours of sleep that you can That are based on kind of our chronological evolutionary biology. He was getting that sleep and he's just crushing it when he was awake. So there's just a couple of things to get people to lean in and listen a little bit closer and understand. Just how much your sleep quality impacts your productivity. Well i know more than just for myself but also for my audience. We've never heard that term. What was it against cyber loafing. But we've definitely done it yet and we've and and i know that we did. We had no idea that. Because i know that's one of the things that comes up as i've asked people like okay. How do you block out those facebook and twitter. In the social media distractions from your work and you know just browsing hours on end not hours on end but like chunks of time that that get eaten away. I had no idea sleep. Lack of sleep or poor sleep contributed to that. Yeah it's it's kind of mind blowing but then it's just if we are able to zoom out and look at this rationally. We know this. You know we know how we feel when we're not well rested and this when we start to lean on other behaviors like really leaning heavily on caffeine stimulants in energy drinks and things like that that are only exacerbating the problem. You know so One of the things that i talk about and i. I'm a fan of caffeine full disclosure. Clear a love caffeine. I love the goodies packaged in whether it's chocolate or or rt or whatever the case might be for thousands of thousands of years. Humans have had a great resonance and caffeine is interesting resonance with the human body and how it impacts These specific receptor. Which i'm not going to get into all the the dirty stuff unless you went to. But here's the bottom line. Is that caffeine in this particular. Study outside in the book. It has a half-life life about eight hours all right so what that means is if you have a three hundred milligram coffee which is kinda common if you just go and get like the general cup of coffee at starbucks or something like that eight hours later so by having a half life eight hours later half of it is still active in your system so one hundred and fifty milligrams that is enough to light your system up like light your nervous system up like a christmas tree and if you're trying to get some sleep you might be so exhausted that you physically pass out in your unconscious but that amplitude of your nervous system firing is going to prevent you from going into proper your proper stages of sleep so this is what i really want to focus on for. People is. it's not necessarily about sleeping more. it's about sleeping better. it's about getting high quality sleep sleeping smarter. Make sure that your brain your nervous system. Your endocrine system are all online doing their proper job so that you can wake up and actually feel great rather than waking up feeling like a like a dirty holy sweaty musty sock right and so that's what the real goal is in almost. It's almost in a sense if you go reverse metaphor here like if you were wanting to lose weight which i know it's that physical activity is also a key part in this but if somebody was just going to go on a diet and eat less calories in the same way that someone wants to get more sleep. It's not just about getting less calories. It's about getting the right food. You know yeah so. It's about getting the right sleep. Oh my goodness you just said it so perfectly because today in. I love this and i love that. You're even saying that in our culture today we're really it's coming to the forefront that it's not about calories right calories do matter but it's really the quality of those calories and what the real bottom line is and i've been teaching this for almost fifteen years now is that it's really boils down to what those calories are doing to your hormones your hormones or these kind of chemical messengers that communicate information between all the cells in your body and so your hormones are literally telling all of your cells what to do and if your hormones get thrown off your whole system gets thrown off and so two hundred calories of broccoli impacts your hormones radically different than two hundred calories of twinkies right. It's totally different. What happens with insulin with leptin with grell in with cortisol all this stuff in all of those things are influenced by everything that you eat in the same vein so many people today are getting low. Quality twinkie sleep right. They think that they're getting enough calories and our time on the mattress but the quality of their sleep sucks because melatonin is suppressed. Cortisol levels are too high. And we talk about some of those things today and how to reverse those things of course but we've mistaken again this cookie cutter idea that these experts over the years have been saying you just need to get seven eight hours asleep. That's not true it's not true. You know many first of all depends on you and your lifestyle. It can literally change next week. How much sleep you need could be less. It could be more depending on your lifestyle but also what tends to happen is that people is the longer that they spend on the mattress the more time they can accidentally hit those cycles. Basically so a great example of this in regards to body transformation weight loss. Because that's a real visceral thing for people we can kind of grab so the university of chicago did a study and it was so good such a great study and what they did. Was they what you said earlier. This calorie restricted diet. They put the individuals in the study on a calorie restricted diet like i was taught in a traditional university to do for clients for patients. Which isn't the right way to go about it. The majority of the time but this is what they did to monitor their fat loss and the space of the study. They allow them to get eight and a half hours asleep. They monitor this another phase of the study. They had them on the same exact diet. they didn't cut any more calories. They didn't have them exercise more but they sleep deprived them now. They're getting five and a half hours asleep. At the end of the study. They found that the individuals who are well rested getting eight and a half hours sleep loss fifty five percent more body fat fifty five percent that you cannot get this kind of results by kicking. You're like kicking your butt in the gym. All the time or being yourself down counting calories all the time. It is absolutely mind blowing for people to find out. Just how much sleep. Influences your body composition because it impacts your body composition in your appearance more so than diet and exercise combined. How is that even possible. Well this is when your body actually changes from all that stuff. Your body changes from the workout. When you're asleep. Your body changes. From all that great nutritionist simulates nutrients and get ra- gets rid of metabolic waste products. While you're asleep this is when the real transformation happens but if you're not getting that High quality sleep. You're missing out on the huge leverage point. You know so. I just wanted to share that as well. Because if it isn't productivity then everybody wants to look good and feel good and you deserve that and really if you can focus in on optimizing your sleep again not necessarily sleeping more but just making sure you're getting higher quality sleep it can change the game for you. Yeah isn't there some other study. I'm trying to think of if this is true or not. There was some study where they were exercising properly. And they were eating properly but then of the two groups they. They sleep deprived one of them and the other they didn't and even with those two other factors which you'd think are like the bigger factors. It still made a huge difference in the sleep was the main factor exactly. There was a study that was published in the canadian medical association journal. That was just like that. That diet and exercise combined same exact diet same exact exercise program. One group sleep deprived one. Wasn't they sleep deprived group loss far less weight and far less body fat. It just kind of right there in black and white. Yeah so do you think in terms of somebody's really want. I mean i know this the productivity show but even if somebody's wanting to go at productivity but say their productivity is lacking and they know that probably they should be getting maybe more sleep. I first of all because there may be getting three or four five hours a night at most but but then on top of that they know they need to be getting better sleep. Would you say that it's more important to really start here than with like diet and exercise although those play a part in probably would cascade into that really quick. That's the thing you just said it right there. You know many people when they're working to get to that place they're using willpower loan really dragging themselves to eat healthy to work out because they're tired you know. And what's so crazy. Is that when you sleep. Well you actually feel well and you feel much more inclined to do those other things. I've got the research to back that up. One of those things specifically Stanford university found that sleep deprived. Individuals had far less production of our tidy. Hormone called leptin right so when you're sleep deprived you're not producing that. Society hormone is much that keeps you from like crushing. Their bag of doritos or those cupcakes. Or whatever it is the donuts at office when you feel satisfied when leptin is produced. Probably your system is just not a big deal. You know. that's really where. I want people to be in what i've done to be successful in my practice is make it. So it's not a big deal. You know to not eat halloween candy. All right. yeah you know. It's not a big deal but you can. if you want to. You can enjoy it or choose to. Do you know these small things whenever you want to you. Choose to rather than governing and driving you to do it. so yeah. that's the big thing is really helping people to stack conditions in their favor so that this is more on automatic and not a big struggle. Because that's really at the end of the day. Nobody wants to constantly try to think about what they're going to eat. And try to exercise and all those things but really yeah like you said sleep at the end of the day. This is an so crazy i would've. I would not said these things. Ten years ago in my practice. I just wasn't thinking about it. Even though my sleep quality was so poor. When i was going through my own health issues back when in my early twenties and because i got my sleep to be so great i just forgot about it. And that's what i want people to be able to experience as well that because once your sleep is great you just feel great and you don't think about it anymore when you truly healed from from something you no longer you no longer think about in pine over it but when you don't feel well it's on your mind all the time you know and for so many people people don't do well because they don't feel well and we all have the opportunity in the in the right to feel are best in it's just structuring our life a little bit differently with more intention because we all have the same twenty four hours is just how we structure thing i have kids i have three kids i know all the stories man i also have books i have a show i travel all over the place speaking i have website What else do i do. I do so much stuff man. I had a clinic for ten years. You know like on and on and on we all have the same twenty four and it's just utilizing some of these strategies. 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So let's talk about that. These strategies i see them as kind of falling into two different categories. Here one is stuff that you do or setup about yourself your your own Your internal self in terms of how you prepare your mind your body and even your heart you know emotionally all that kind of stuff and then there's the environment where you do the sleeping and you prepare that environment. So let's let's start with ourselves first and then let's move into the environment while yes i love that so you just said it. Starting with ourselves there are certain things that we can do with their own activities in our own approach things that can radically improve sleep quality and this is the big headline for today. Is that a great night of sleep. Starts the moment that you wake up in the morning k. A great night's sleep starts the moment that you wake up in the morning so everything you do specifically in those those early morning hours sets the template literally sets your circadian rhythm your cortisol rhythm for the rest of the day in how you're going to sleep that night and this is going to be a little bit. A little bit counterintuitive for some of us so number one the getting sun exposure at a certain time has been clinically proven to enhance improve your sleep quality at night. So let me share specifically so Innovations in neuroscience journal innovations in neuroscience found that when you get sun exposure in early morning between six. Am and eight thirty am. I just tend to twenty minutes. What they discovered was that your cortisol rates which cortisol is the most anti sleep hormone that we can talk about but your cortisol levels drop even lower in the evening when you get sun exposure in the morning all right so cortisol and melatonin. The sleep hormone. Everybody knows about today. They have an inverse relationship. So that means when cortisol is elevated melatonin is like in the ground floor. They kind of battle for position in your body and so if your cortisol is too high melatonins not getting produced in his greatest capacity and so again you can go to sleep and be physically passed out but melatonin is in raising to the police needs to be your your sleep quality. Basically your sleep cycle. So this is like the different brainwave frequencies that are going to tell you which hormones produce enzymatic repair enzymes things like that. That whole game is gonna get thrown off so getting some sun exposure early morning a lot of entrepreneurs a lot of people working in the office. They don't think about this and they're not doing it. Because especially entrepreneurs who worked for home just not thinking about it just kind of get. It plugged in wake up. Get on our phone start doing emails and eventually get some coffee. We go pee. I don't know like we're just kind of dragging away through and trying to be productive. Get into our day instead of doing the things going to sexual set you up for even more success now. So how do we do this. Well i've got a bunch. I mean we could just do the whole show talking about this one thing. But they're a bunch of strategies on how to leverage this. But i'll just tell you this. I mentioned earlier ten to twenty minutes. It can be a little bit more challenging like right. Now we're in the mid west. You know so it's The temperatures change is getting a bit cooler. Even getting light in nye cited some studies in in the book on office workers exposed to natural light from windows even getting some natural light coming through windows getting through your optical receptors can help a lot best thing. Best case scenario is getting the sunlight directly on your skin in the darker your complexion the more sunlight. You're actually going to need because melanin is built in sunscreen. All right so you might need twenty to thirty minutes all right. So we want to start to structure our life to make sure we get at least ten minutes of sun exposure because it number one reduces cortisol at night number two. It increases your cortisol in the morning. Why is that a good thing. Cortisol is not a bad guy. It's just when it gets produced at the wrong time or in wrong a mouse that it can be a problem in so by getting your cortisol elevated in the morning if we look at evolutionary biology. Your cortisol should be peaked. Super high at its highest point between the hours of six. Am in about eight. Thirty am finding enough and gradually it declines and drops in bottoms out in the evening. That's how that's how it's designed to be how your designed to be clinically. I would see people. Who are we call them. Tired and wired where their cortisol was too low in the morning thus they had a horrible time trying to get out of bed and of course all is too high at night and so even though they know that i i should be getting into bed with. They're just wired and so they just keep are doing more and more stuff and so sun. Exposure helps to reset that cortisol rhythm. Last thing is it increases your body's Serotonin levels that's you. You can buy stuff that can do the same thing but you might get arrested. All right you might. You could buy some illegal stuff that could do some of these same benefits at sunlight exposure can do. But this will increase your body's production of serotonin. Why does this matter. Serotonin is a precursor for melatonin. So eventually will get converted into the sleep hormone that you need to get sleep all from getting a little bit of sun exposure all right so that's number one to throw in one more morning activity here and there's guinness twenty-one strategies that i talk about with sleep smarter but this is so simple that the super low hanging fruit but appalachian state university did a study and they had exercises to train at three different times to see the impact that has on sleep quality. All right one phase of the study they had them exclusively workout at seven. Am in the morning which is in that kind of cortisol sweet spot. We talked about they. Another phase of the study exclusively. They had them workout at one. Pm n- afternoon in other phases study exclusively. They worked at seven pm at night. They discovered that the morning exercisers spend more time in the deepest most anabolic stages of sleep. Some people up to seventy five percent more time at seventy five percent more time in the stage asleep where you're producing more growth hormone. You know this youth hormone. That makes you stronger more energetic. They also found that they had more efficient sleep cycles and morning. Exercisers had twenty five percent greater. Drop in blood pressure at night which is that's correlated with something called your para sympathetic nervous system. Where your quote. It's called the quote rest and digest nervous system activation in turning off the fight or flight so super powerful stuff if we can leverage and get just five to ten minutes of exercise in the morning and i didn't experiment before the book came out and worked out exclusively in the afternoon which i hadn't done i've been working on the morning for maybe ten years prior to that to see the impact that it would have if i worked on afternoon instill did five ten minutes of exercise in the morning because a lot of people worried about their schedule in a lot of people also worried about their performance in their games with the workouts. Everything's still improved for me. That little five to ten minutes in the morning then impact my workouts later so i just wanna throw that out there. People like well this time. I have to get to the gym. you don't have to go to. the gym. Does do five to ten minutes of exercise in the morning at home if this is in your gym time and you know this could be rebounding with using a little mini trampoline. I love that. It's something i keep in my office. Do takada which is twenty seconds. Twenty seconds of exercise and twenty seconds of rest repeated back to back for about four minutes and then do some stretching You can go for power. Walk listen to a podcast like this one. All learning burn Just do something to get that cortisol elevated in the morning get your heart rate elevated in. It's going to pay off dividends when you go to bed at night full disclaimer for this last piece. Really quickly for for ten seconds series. These things work is clinically proven to work. But if you do these things and then one o'clock in the morning you're watching daredevil. It's not going to have an impact like that's going to cancel things out significantly. So it's this overarching strategy. Having these things in place and doing a few other things with your environment in your activities later in the evening that can really set you up for that amazing sleep. that's awesome yeah totally so okay. So let's go into this watch and daredevil thing because i would assume that if you did get up at the right time and got out there and got that sunlight and you got that even brief workout in that. You're going to feel tired way before that one o'clock and so if you hit that window right you will go down and you'll stay down. Yes more likely. Yes absolutely this is. Here's the thing though. We can easily be stimulated as human zurich. We're very resilient yes and things can turn us on what happens. Is something called the energy second wind. Right where you are tired and it's like you know you're driving home. Seven o'clock at night yawn. You're like i'm going to get to bed early on exhausted and then eleven o'clock rolls around you're up. You're on the computer. Maybe you're watching youtube videos. You're watching tv or doing work. And all of a sudden you feel why wide awake again you know and so this is called the energy second win and actually break that down. This is a. It's a response from your from your metabolism and these enzymes are released in the evening for the purpose of repairing your body and your brain while you're sleeping now. They're being used to keep you awake. Are you dipped into the supply that is now keeping you awake so and also when we talked about earlier with melatonin and cortisol so exposure night to again daredevil is awesome. It's like the best show. Whatever it is. You're into house of cards. I don't know if that's the lawn or scandal. Whatever you're doing all right we could still enjoy those things. We just have to put them in their proper perspective. Proper place and i'm going to share some hacks with you but would harvard. Researchers have confirmed that exposure specifically to blue light from our devices which that is the strongest light coming from your television coming from your laptop coming from your cell phone so what they could find was number one it suppresses melatonin for basically what they found was that every hour. You're on your device at night every hour. Suppresses your melatonin for thirty minutes all right so if you're on your device for three at night as one and a half hours or melatonin is not kicking in all right and again. We're going to bed and we're thinking oh i'm just going to get i'm gonna get my seven hours. Sleep knits not so. You're not actually getting that quality. Sleep that you think you're getting because you're not producing melatonin. They found that all light is in created equal in this though that blue light was twice as suppressive melatonin and disrupted to your sleep cycle than green light and they found that red light was negligible. Didn't really impact your melatonin that much at all. So that's a it's something that gives us a hint to what kind of light exposure we can use an evening. And so eric you know a lot of people don't really think about this but we've only had these devices like computers like readily available for like a couple of decades like for you know like i remember time. That computers weren't even like thing right. It was like something you see on star trek or something. Then there's a bunch of fake buttons like on on on Darth vader's chess computer sicklets glued. On right it's not even real you know so but it's only been a couple of decades but period even with television. It's only been like within. You know our our grandparents lifetime you know that these things have been around if he throughout human humanity like the evolution of humanity. We've only got like a blink of an eye that we've been able to manufacture a second daytime and we're not getting that natural day or are light dark cycle and our bodies are craving darkness in the evening but if we were to have light exposure in the evening it was what color fire that color. So that reddish orange is yellowish. And so what we can do. Is we can utilize some hacks here. And so are encouraged everybody to do this. Like right now. Are you can pause it by gas or you know you could do this after pockets either way but we'll be here when you get back. But here's the thing number one apple on all of their new devices their iphones ipads dave included a blue light blocking device in the tool section of all their devices. And even if you have older phone got iphone five. Whatever it is i phoned one. Whoever is out there got the dinosaur. I dunno you the latest update. You now have that tool on your phone that pulls out the most troublesome melatonin crushing light from your screen. Why would a multibillion dollar company like apple do that. They don't do it for no reason. I mean everything they do is have has a specific purpose and what it is. There's so much more data coming out showing that this blue light exposure at night is number. One is wrecking honestly quality. Leading to higher rates of cancer. Heart rates apart disease diabetes metabolic syndrome. Obesity crazy stuff that they're again. They're doing this for purpose. They don't want to be the ones to blame really. That's what we're looking at here. Because world health organization has come out and said that sleep deprivation specifically being up in the evening working is a class. Two a carcinogen right. It's a cancer causing agent to be up at night. People don't hear that you don't hear that in the in the in the media right what's going on. Why is that will melatonin. Not only is it a powerful sleep hormone but it's also a powerful anti-cancer hormone and if you're not producing it because you're exposed to light at night we've got a serious problem you know. So the nurses study that. I cited in the book Found thirty percent greater incidence of breast cancer for for the nurses who work the night shift. So wow back to back to the point. So bottom line to wrap this point up us Hacks like the is called. Nightshift on your iphone in your apple device for your desktop and laptops right. Now go to doctor. Google go to doctor. Google tight been f. dot l. u. x. flux f. dot low flux i love flocks i bet man like the home a link in the show notes trust me so many people over over the years i've been using flex for probably three years but even people who are dealing with migraines and things like that would just message me and say that flexes helped so much with their sleep quality reducing headaches things like that the eye strain so it cools off your screen same thing pulls most troublesome spectrum of light out of your desktop laptops automatically super easy to install if you need to look at a design or something a landing page. While you're working you can click to to to disable it. Click it right back on it. set it in. forget it. It's amazing. All right so flux another thing for the ambient light at night and also if you wanna stay up late in a little bit later you know you put your kids to bed and you want to stay and watch your show with your significant other. It's not that you can't do that. But you need. If you have sleep is your priority and you want to feel good in crusher day the next day you can utilize some blue light blocking glasses or blue light-blocking shades and there's some really cool looking ones. There are some that are pretty ugly all right. But you know. And i've experimented with all this stuff so these are just some other little hacks that you can use but the best thing bottom line outside of the hacks because we can hack ourselves to death is give yourself a screen curfew you know. Give yourself some time to not be on your device before you go to bed. And this is more getting back in touch with what we're designed for like human the human brain is always looking for patterns and neuroses we get ready for work we get ready to take our kids to school. We get ready to go to parties. But we don't get ready to go to bed anymore. You know so that whole process can create like an evening ritual in creating sleep sanctuaries. Well which we could touch on. But that's the real real key here is giving yourself some time to be off the device. Connect with other people you know. Do some physical reading a book Play some games. That might be something a little bit more interesting than instagram. Hopefully but you know you gotta fill that space with something that's more valuable than the device which it's kinda hard to do sometimes today. Yeah i hear ya and that's other key pieces so we've got like a caffeine curfew and we've got a screen curfew and those are good for us to set ourselves up but then let's move into this sleep sanctuary idea. Well how do we set up our sleep area to where it's most optimal for us. Perfect so our bedroom was so crazy. Is you know for many of us. We spend one third of our life in our bedroom specifically in our bed. That's a that's like a lot like a lot years right. if are expected we're expecting. We're gonna live ninety years thirty years. You're on that mattress. That's crazy so you wanna make sure that that is serving you and not creating problems for you all right. So we're going to talk about the environment in the bedroom specifically so we want that bedroom to be because again. We're all about these neuro associations. Brain is looking for patterns. So if your bedroom has been a place where you go and watch television even if you go into your bedroom with the intention of going to bed neurons in your brain are going to be firing expecting to watch. Tv already synoptic clefts in the the Mylan has been laid down. You've got these pathways. It's looking in their firing to watch television right. We've created this neurosurgeon or especially. Even bigger crime. Is doing your work in your bedroom. She never bring your work in bed with all right. So you wanna make sure that your bedroom is for sleep and sex. It's for those two things primarily all right. Now we wanna make sure we get the device out of our room for that purpose number number one number two the electromagnetic frequencies electromagnetic noise that for years like it was just kind of dismissed in popular culture by like sham scientists that these things aren't affecting us which is totally crazy. It's absolutely insane because even on a cell phone like if you actually read some of the warnings it'll tell you don't put it up to your head like i cannot believe it is right there in black and white because those signals in cited a bunch of research like solid solid research showing greater incidents of mid brain tumors. The more that people are on their cell phones specifically it's happening more and more in younger populations because kids are born into this now. We remember time when there weren't cell phones. But the more and more exposure. They're having their finally inoperable tumors are showing up and man. It's just. It's really something that we need to be more aware of and so get those devices out of your bedroom. It doesn't have any place in your bedroom. I promise you the world is not going to end and if it does. I'll text you and you probably won't get it anyways so just understand. We want to create a sanctuary. Get those devices out. One more thing i want to share is that we want to make sure that the environment is cool and dark. Cool dark so your body is a process called thermal regulation and this is a natural dropping your core body temperature every single night if your body's working metabolic glee correct. There's a drop in your core body temperatures to facilitate sleep. Your body cools off automatically to facilitate sleep in it. Activates programs related to sleep and repair. If your your body has to fight to cool itself down because the environment is too hot. It's a problem all right. So according to research between sixty two and sixty eight degrees fahrenheit is the ideal temperature for optimal sleet and for some people. They might hear them like that is so cold. It's ridiculous can still use your covers. And all that stuff and i promise you going gonna sleep better and also you can have a strategy because for a lot of people. It's more so the waking up in the morning and it's cold just have your significant other whatever hop out of bed and turn the heat on for you. And so that's what i do my wife because he's more cold body person body. Excuse me and even this morning. She's like you know what's the deal. Because i didn't turn the heat on and so But i'm getting up in the morning. And i turn the heat on four her so she can hop out of bed and not feel like you know. It's a winter wonderland or whatever but she sleep so much better. She knows it you know. There's no like we have a greater tendency to be sweating and really specifically it's our head. It's your brain that doesn't want to be hot as why they cool pillow feels good. You know when you flip. That pillow always wondered that. That's why it's a thing you know cooler than the zedillo it's thing and so there's actually study that found that insomniacs when they put a cooling cap on them that just it was just a one degree lower temperature. They every single person across the board had improved sleep onset so they fell asleep faster and they stayed asleep longer to degree that on average in the study they fell asleep faster than people. That didn't have insomnia crazy just by cooling off their head so make sure it's cool. Make sure that his star cornell university found that even in a relatively it was dark environment. The test subject. They put a light of fiber optic cable fiber optic cable with the size in. It was the size of a quarter this light behind their knee while they slept and that was enough to disrupt their sleep cycle right. Your skin picks up light. This is how you can. You know like your skin. Actually as photo that pick up light and it sends messages to your brain and nervous system that hey it could be like the sun is coming up. It's date. I don't know if throws off your hormones so get your room as dark as possible If you live in especially if you live in an urban or suburban areas like street lights outside porch lights and cars driving up and down the street definitely want to get some blackout curtains. I would highly highly recommend that if you live in more of a area where they don't have all that stuff going on it's artificial light not natural light from the moon stars. Things like that as not what i'm talking about. Humans have evolved with that kind of light exposure. When i'm talking about artificial light so get yourself some blackout curtains for me of everything that i've talked about this far when i got those blackout curtains the very first time when i did live in more of a a a city environment or you know like the kind of suburban neighborhood when i got those blackout curtains my goodness ban it turned into like it was like asleep cave. You know. I got the deep bisley bad had in a long time. And i've been a big advocate of that ever since that's awesome so we talk a little bit about what you can do for yourself as well as for your environment. You sleep environment. I have this one nagging question. Though that i gotta ask what about naps first question would be deposed to anybody is. Are you a baby are you. Are you not a baby and if you are in fact not a baby anymore. Then it's not advantageous or something. That's really necessary for you to take naps now. That full disclosure. A good nap is a good nap. You know a good like sunday afternoon. Lazy day nap or you know even a power nap every now and then. It's all good but what naps tend to be is a supplement to poor quality sleep right. So that's what we really need to understand is that we want to make sure there are sleep. Quality isn't compromised so that we absolutely to have a nap or just not any good. We don't want to live like that you know and so like today for example. I've been it's You know it's getting close to four o'clock here and i've been up doing my thing you know. Help them in my kids get to where they need to be. And actually i got one kid who didn't have school today and so a bit dealing with that. Blew my work doing interviews writing all this stuff sitting some emails and i feel amazing. I feel amazing. All day of in had any type of lull in my energy or need to to take a nap. You know. of course there's like higher energy moments and just kind of baseline but your baseline changes right with getting higher quality sleep. You don't have those drops in so naps. What they can do is kind of force. A hormonal secretion hormonal switch which in some cases like we really do need a man like somebody's like training. You know three hours a day and then it got all his work load and all this stuff and absolutely nap can be a supplement. You know it could be something that's advantageous. But in general we don't want to force our body to go into a different hormonal shift. If we don't want it to in the wrong time so a good nap is good nap. Every now and then but we don't wanna create a situation where we're not getting great sleep quality at night and so that we need to take a nap or we're just not any good to the world okay so we could and should probably in the long run focus on getting the quality sleep in the evenings when we should and the naps won't be as necessary or at all exactly exactly but a good net again goes yes. A good nap is a good nap. Or even if you don't fall asleep taking a good fifteen twenty minutes to close your eyes and quiet the world. Yes still some benefit there to tons of benefit tons of benefit. I talk about that in breathing exercises meditation all that stuff clinically proven to help sleep quality as well awesome. Sean this has not. This is like the tip of the the sleep iceberg or the sleep hack iceberg. There's so much more in your book. Let's point pupil to that and to your site anti you're awesome podcast. Thank you so much. Yeah so my the show the podcast that you can listen to where you're listening to this awesome episode here with eric is i check it out. I stitcher wherever you listen to podcasts. And it's called the model health show the model health show and a very very honored to say that we've been featured as number one. In the united states dozens of times in nutritionist fitness. and also number one in health as well. And we've got a lot of amazing episodes like masterclasses on different subject matter ranging from natural treatments for diabetes to obviously lots of great stuff on sleep as well Weight loss hacks things like that. So lots of great stuff there. We have a great time. So you can check that out also. The website is the model held. Show dot com. we've got videos of the episodes. I do some pretty epic articles there as well and all my social media you can catch up with me there and you can find sleep smarter. At any of your favorite bookstores. barnes and noble independent bookstores or online amazon dot com and actually amazon now has a physical store now apparently when your past guests pat. Flynn sent me a text and he saw my book in amazon store which i had no idea about which is so cool to see So you could check it out there or little cool thing that i don't tell people about enough is my wife has just been like basically yelling at me because i don't talk about enough but i did a lot of work before the book came out and really kind of beat myself down a little bit to get this done before i went on the book. Tour I created twenty-one videos for each chapter so each chapter has a corresponding video. That you get for free at sleep smarter book dot com when you get the book there so you can actually get that bonus of the twenty one bonus videos that go along with each of the twenty one strategies and sleep smarter very cool. Yeah off to make sure to link all of this up in the show. Notes for this episode sean. This has been awesome. And i can't wait to get some better sleep and and everybody else hopefully out there to thanks for coming on the show. It was my pleasure. Thank you for asking awesome questions and It's been my pleasure. Thank you so much eric. I really hope you enjoyed this conversation. And i really hope that you got something out of this even just one piece of advice or guidance. From sean in this episode could make a huge difference in your sleep life and a huge difference in your sleep. Life will make a huge difference in your daily life and your productivity trust me. I'm already finding that to be true for myself. So make sure to go. Grab his podcast. The model health show and to his sleep smarter book to dive even deeper into go into stuff of a how to get more sleep better sleep etc than we even cover here in this conversation. Thanks again for listening cnn episode.
Gender equity at the senior leadership level
"In this episode is brought to you by audi canada. The canadian medical association has partnered with audi candidate to offer. Cma members preferred incentive on select vehicle models purchase any new qualifying audi model receive an additional cash incentive based on the purchase tight details of the incentive program can be found at audi professional dot ca explore the full line of vehicles available to suit your lifestyle. The audi driving experience is like no other to shingles age isn't just a number. Do you have patients fifty or older. They're at high risk of getting shingles. Don't wait talk about shingles with your patients over fifty today. Shingles is indicated for the prevention of herpes zoster. H that are shingles in adults fifty years of age or older a product monograph gnk dossier slash slash pm for contraindications warnings and precautions adverse reactions interactions dosing administration information. You're cross the product monograph or to report an adverse event. Please call eight hundred three seven seven three seven four learn more at thinks Dot ca mitts has an inequity problem especially at the senior leadership level. The fact is in causes a complex or the well-documented despite our understanding of the size of the problem actually getting gender equity is tricky. Although it's important not least so that we can optimize creative problem solving complex problems in the health system. I'm dr kisan patrick. Executive editor for the canadian medical association journal today. I'm talking to professor andrea trico. And dr ainslie more two of the offices of an analysis article who outlined practical ways of advancing gender equity in medicine. The article is published in sam aj. I've reached andrian. toronto and ainsley in hamilton. Welcome to see image a. Podcasts hi thank you so much for having us. It's a real pleasure to be here today. High having sleet and it's it's a pleasure to be here. It really is an honor and privilege to share with you today in your listeners. So i'd like to start off with each of you telling our listeners. A little bit about who. You are andrea. My name is andrea trico. And i'm a scientist at saint michael's hospital at unity health toronto. I'm also an associate professor in the school of public health at the university of toronto. I've been conducting research within the gender identity realm for the last couple of years and ainsley. Hi i'm ainsley. Family talk on a faculty with family medicine as an associate clinical professor of medicine at mcmaster university I also serve as vice chair to the canadian task force on preventive health care and i am passionate about women's health reproductive health and reproductive health rights. Great to have you with us today. So let's go ahead with deconstructing this article for listeners. Enter been other recent law schools calling the problem of gender inequity in medicine. Can you explain what your goal was in writing this particular. Yes absolutely So before i begin describing that i do wanna mention that. Gender is a multifaceted concept and usually when we think about gender traditionally has been more from a binary perspective so we usually think of it as male and female and most of the research is focused on the the binary division for gender however. We want to note that gender is not binary and so it's actually a continuum so just to note that Something important for us to keep in mind when reading the article in that. We're we're talking about their research. And is very focused on male versus female when in real life genders is actually not binary in terms of the goal for the paper. So basically what we wanted to do. We wanted to summarize some of the excellent research that has been conducted on gender equity within medicine and the focus that we wanted was to focus on the solutions because we wanted to share these solutions with those working in the field so we wanted to bring a bit more attention to the issue However putting the real appreciative lands on it in an really focusing on what can we do now. I think it's always a lot easier to describe the size of a problem than to think about. How do we solve this problem. So i think this article great from that point of view. It gives lots of practical ideas of what we should actually be doing to solve the problem. Ainsley what is the scale of gender inequity at the leadership level in medicine. Yeah i do think about scale and size and to get at the nuts and bolts contain about the scale or the scope of the problem you can think about how entrenched how far back what these storks roots are and you can look at how how wide spread or what the breadth of a problem is looking back historically. We know that that women have outnumbered men in canadian medical schools for well over a quarter of a century now but as as you mentioned carson are canadian studies consistently identified these gaps in Medical leadership not only in research Medical leadership but also in clinical leadership and medical education and a really good example of the scale when you look at the last Hundred and fifty years of the canadian medical association. They've only been eight women Presidents out of a hundred and fifty two. So that's just kind of a snapshot picture of the of the the the history of the debt and if you look at medical education it's even more entrenched resistant to change so look at the upper levels of medical education training the the first woman dean of a faculty of medicine it took a hundred and seventeen years to get there and and it didn't occur until nineteen ninety nine and send their only a total of eight out of one hundred and fifty two teams and not think about when schools were established in canada. So that's over one hundred years ago. They've only been eight Today so far. There's there's other metrics okay. These metrics that are key to achieving leadership. Success so i am thinking about the problem that way. There's a really interesting study from two thousand and eighteen. That looked at Presenters at medical grounds in into canadian cities institutions. Toronto calgary and and what they found was that there were substantially. Fewer women presenters at these medical grounds. Well below what you'd expect well below that proportion that. I talked about a female med students and residents in the program and so the the towns share the the probably. Hear that ground rounds. We know. they're there opportunities you so casey researchers you present your expertise and your identify yourself as a resource. Those metrics are key because they're important outlet for recognition there the materials that we use the measures that we use as as we submit our applications to go forward for tenure and promotion. It but the other problem is you know grand rounds or their their opportunities for wool modeling and enter connecting to others. So so that's an important gap. The other like critical gap that that's connected to success relate to a national research funding competition. So this happens both the scientist level as as well as the product. There's again a big gender gap in terms of Who is successful with those grants. And of course that feeds the whole the whole machinery grants publication supervises strength of your cd your application to move forward in the senate with with With tenure. I mean those are. Some pictures are glimpses of the scale of the problem. We know those Gender gaps in. Pay in canadian medicine. But that's not specifically identifying leadership cats above there are connected to have those snapshots because what you're saying. This is not a minority problem. This is a problem where women are now. Equally represented within the whole medical workforce. They're just not rising to levels of leadership on the whole that men are Andrea in the article. You talk about the importance of considering the intersection of gender race when evaluating inequity can you explain what you mean by that is absolutely so much researchers have found that focusing on gender is not enough so we have to go beyond gender and we have to actually consider all facets of people's lived experiences and in order for us to do this We have to look at all the factors that one would go through In their lives and this is helpful because it can help us to understand the root of the problem and for us to identify potential solutions So so in particular. We do need to think about and focus on the intersection with of power and privilege and oppression. These need to be considered so any research relationship or within any organization. We have these informal and sometimes formalized systems of power as well as privilege and oppression and until we fully understand this and understand what goes on within relationships and within organizations. We can't bring about change. So consistently within research we found by inequities are further. Increased when gender intersects with other factors and a good example is race is because if we think about race racialized women as an example. The experienced challenges in actually in an exaggerated way and this has actually been termed a double jeopardy of race and gender bias so unfortunately when we have gender combined with other factors it actually exacerbates the problem. So until we understand the intersection. Eighty and understand all these factors very very. Well we won't be able to get to those Solutions that we really need to move things forward So one example would be systemic and structural issues of racism. This would actually contribute to realize women who had experienced more significant poverty as a child as well as an adult and they would experience more financial. Hardships were the death of spouse as well as looking after age parents so again when we see genders intersecting with other factors it just exacerbates everything and We will be able to fully understand this until we look at the whole entire picture so we need the context in order for us to to to move forward. Unfortunately the issue is that we often don't collect intersection data or we don't collect very well So so that's a problem in the primary studies so when we look at the medical literature not only is it being collected in the primary studies. But then if we're trying to synthesize it. So i do a lot of work with knowledge synthesis as an example so if i want to do systematic review it's very challenging for me to look at intersex analogy even though i would like to because it's never been fully reported in the primary studies And so not only with that. We don't collect a report on the data within our organizations so we don't know the extent of the problem Meaning that we can't really address it so until we realize the importance of this and until we are committed to collecting data on this. We really won't be able to get to those solutions that we desperately need within medicine so it seems to me that you're saying that even though i was saying oh it's easier to the size of a than it is to outline the solutions. It's actually not always easy to really get at the size of the problem. Because the problem's complex and we don't collect the right data to be able to sketch out it also sounds like you're saying that some that we need to look at this in kind of individual way. So it's not a one-size-fits-all solution to getting equity in medicine as more like we need to understand the particular challenges or hurdles or whatever that individual women face and and helped him to overcome those in. Where do you think the problems starts with gender inequity What contributes to this gender inequity in leadership rules beyond what. You've already highlighted. Who probably is going help to just go back from it and think about Gender norms and clarify Clarify that concept so gender norms our society's expectations hump shins about how men women boys girls behave in it. It you know. There's something about all aspects of life. How trina cate dress. What roles we take on What we're expected to take on and it defines dynamics within relationships. And so these these determine life trajectories they determined employment opportunities advancements etc and so Think about where it starts a good place to sort of recognize that but another main Recognition that sets keita figuring out where the starts is just think about gender equity as a fundamental human rights and gender equity is really a process. Gender issues gets you to the outcome. It gets you to gender equality and that's equal treatment in in all aspects of society without discrimination. So where's the starts early starts in childhood and all the importance that That were exposed to in our lives but it becomes exacerbated as we move forward And certainly we see that in medicine systems supported by gender norms perpetuate and continue differential in in gender and leadership So it starts in society but it's perpetuated by our systems and our structures and these are your the systems and structures that are in place in education medical practice as well as academia higher. You go up in the leadership lottery. The greater the inequity become there's only twenty four percent of full professors in medicine are women andrea mentioned How gender race and culture that further exacerbates Those challenges higher up the systems are in place and they con- reward metrics. They just don't favor the capacity or the don't favor currently women in positions Trying to get to to higher levels of leadership we know that women say disproportionate exposure to disruptive behaviors and harassment and those serb to entrench existing power structures. It's pretty talented to come forward With concerns this easy to track down. Just keep going and it's easier to not expose yourself to risks as you as you advance in in your career And so there's there's another level of this week we've we we've understood. Exposure to macro level disruptive behaviors and the impact. They have. But there's a new fledgling air. That's looking Microaggressions neither interpersonal or private level interactions that really reflect sort of micro in validations micro insults Indirect they're more subtle expressions of judgment and prejudice. And and they're they're different. They're constant they're they're insidious and they they an impact on widdling away in you know self esteem and they can serve to limit women's interest in in being hired or Going forward for promotion as well as Competence in going forward and and the way the system values work care. If you look at the gender pay gap the specialties that women tend to dominate the psychiatry at the pi trix and those are the lowest end of the net income. Scale and well dominated. Specialties like cardiac Diagnostic radiology up all their disproportionately much much higher. Income generating specialty. So it's how the system rewards work. There's a lot of factors. I'm just hitting a. They'll high level. Ones that are impactful and and easily communicated you're talking about Things that are set up at the system level that kind of impede women's progress in medicine and so it strikes me that the way that we work towards gender equity will be about dismantling some of those structures or changing them andrea. What are some of the ideas that you've put forward in the article that you'd like to highlight for listeners. About how we actually practically gets to gender equity in medicine yes completely green in it is not about women leaning in as you're alluding to As well as web just repeating what ends lead mentioned that this issue is very at the very highest level in all levels in indefinitely. We need structural changes to occur So we're not asking women to lean in here. It's more about breaking down structural and cultural barriers and men need to be involved so actually everyone needs to be involved. Society needs to be involved for us to actually see some of these changes so as we mentioned earlier today we need solutions that are contextualized multiple levels. So we we need to think about the organizational level. We need to think about the team level. We need to think about the individual level So soon order for us to see the gains in the changes. It's really a focus on holistic and multi faceted solution at all levels of medical organizations. So as you as you mentioned we did bring up many many different interventions in the article potential solutions. We're not saying that one approach is better than the other. We feel that a range in multifaceted in holistic approach would be fast so beginning with thinking about the quantification of the problem so unfortunately as we said sometimes we may know information on gender but oftentimes it's just binary it's not all the genders and all so often times. We don't have any other additional intersection data. So we don't have the intersection of gender and other factors as we mentioned previously such as engine indigenous as well as raised as big examples. So we need to have an idea of what the problem actually it is. And unfortunately this heartened been focus until recently i and we just don't have the data so it's hard for us to make a very contextualized solution. We don't know the extent of the problem so We're we're suggesting that we have annual reporting a very basic minimum on gender as well as intersection already and this is a good start because it can help to increase the awareness of the issue however that is not sufficient on its own. And unfortunately when you look at the literature most of the interventions that have been researched or steadied have focused on increasing awareness and so increasing awareness is actually not enough. It's just the tip of the iceberg. So we need to go much much deeper so we need to think about things. Such as a career flexibilities so thinking through non gendered parental leave schemes. An example how do we increase the visibility recognition and representation so building off of some of the issues that inslee mentioning previously. So how how can we provide all genders with opportunities for presenting at medical grand rounds as an example. How can we give them opportunities to speak with the media. Rights overseeing during covid seem a lot of my male colleagues in the media. And i'm seeing a lot less of my female colleagues as an example. How do we highlight the achievements of everyone who we provide opportunities for everyone on also thinking through about opportunities for mentorship and sponsorship so thinking about formal programs where we link up mentors with mentese's so this is something that my institute has been thinking of and working on in the last couple of years as an example because having a is so important with an academic madison and within medicine so so having a mentor will help and how do we make sure that we have equal opportunities for all genders to have supportive mentorship as well as sponsorship with which goes beyond mentorship. It really is important Other examples would be something like financial support so on there are some national funding bodies. Internationally that have come up with these lotteries so instead of doing the whole peer review process they actually run a lottery and so he were randomly assigned to whether you're successful or not So so this is a way. Because as i included who as before with our canadian institutes of health research we looked up at grants and researchers have found that there is some gender bias in the scientists that are funding as well as up there at the project level. So when we do this lottery happens is it. The attempt or the focuses to try to reduce the potential for gender bias that may occur. And hopefully you were moving towards more behavioral and systemic changes so thinking about role models modeling principles by leaders of all of our organizations seeing more diverse leaders. There that can be role model. I'm having diversity in our hiring panel so making sure that not only is everyone aware of the processes and aware of the potential. Bic's that can happen. When we're selecting candidates for organizations making sure there are panel themselves are diverse so that people can relate and feel welcome and feel safe and also so that we are able to hire diverse candidates oftentimes times. When they've done research into this they find. That lake tend to hire lake rate. So i hire this person. Because i can relate to them and i see myself in them so it's very important for us to make sure that we have hiring panels that are diverse one example that i did want to highlight. Today is the scientific woman's academic network or the swan athena swan initiative and this one is very multifaceted and they include several different interventions. So some some examples would be things like monitoring and looking at different statistics and and looking at the issues over time career transition. Planning they also have items related to flexible working. And there's also a big focus on organizational and cultural changes So the athena swan initiative is something that has actually gained great arbitrarily around the world and Was being worked on in here and candidate is well. And when they have evaluated has found on some good outcomes such as increased faction Different genders in particular women the focused women's initiative so it has been shown to increase action which is great however one limitation that has been found with athena swan is at the people who tend to be the main beneficiaries of this program. Are white middle class women so so we believe that the athena swan initiative is fantastic and it definitely is bringing us further along however it is not sufficient on its own and again we need to to get back to the interception. Alexey focused again and thinking about. How can we make sure that everyone wins. And how can we make sure that we provide equal opportunities to everyone regardless of your gender regardless of your race indigenous status disability status regardless of any of those intersection factors. We want to make sure that everyone is is being provided with equal opportunities. Hopefully this will lead to equal satisfaction and workplace and also as we discussed in the article. You know we do believe that Having diversity does help and we've seen that female representation for example on corporate boards or as well as hospital wards. It can result in more thoughtful decision making as well as less corruption and also there have been many studies showing that women who are physicians. They actually provide high quality patient care in particular they Some research was found that it lets to better quality of care for diabetes lower rates mortality hospital readmissions emergency department visits etcetera So it's definitely needed. We need gender equity in medicine But not only do we need to think about gender. We need to think about intersection. Aladin and again. How can we make our teams more diverse. How can we make medicine more diverse and hopefully increase patient care. How can women who are rising in their medical career s. Help others to do the same. If you look at the games that we have made i think would have to acknowledge at least honor. The will of informal mentorship that You know so. Look at our careers key. Individuals that have supported our pathways absolutely in our mentors and our sponsors in just a real privilege and on so wonderful to have the opportunities to have the sponsorship mentorship from many leaders in the field. So so that's definitely a real plus. Well i've had great mentor. Ship from both women and men have helped me to advance. And so i couldn't agree more. Thank you ainsley in for joining me. Stay on the podcast. It's good to have you discussed this really important article. Thank you kristen eck you so much. I've been speaking with dr ainslie more and professor andrew trico to read the article. They've co-authored visit sanjay dot ca. Also don't forget to subscribe to see a major podcast on soundcloud podcast app and let us know howard doing by leaving her reaching. I'm dr patrick executive editor. Cma jay thank you for listening.
Alcohol use disorder & anticraving medication
"Many adults may not be aware that simply being over fifty puts them at increased risk for shingles help prevent shingles and patients over fifty shingai. Six shingles is indicated for the prevention of herpes zoster. H that are shingles in adults. Fifty years of age or older. Consult a product monographic. Jfk dossier slash singer slash pm for contraindications warnings and precautions adverse reactions interactions dosing administration information to request a product monograph report adverse event. Please call one eight hundred three eight seven seven three seven four learn more at think. Shingle dot ca. This episode is brought to you by audi canada. The canadian medical association has partnered with audi canada to offer seamy members preferred incentive on select vehicle models purchase any new qualifying outta model and receive an additional cash incentive based on the purchase tight details of the incentive program can be found at audi professional dot ca explore the full line of vehicles available to suit your lifestyle. The audi driving experience is like no other. Roughly twenty percent of canadians will meet criteria for alcohol use disorder at some point in their lives fewer than a third of those people will ever receive addiction treatment and only a small group will receive medications meant to help reduce alcohol consumption. Roughly half a percent of canadians with alcohol use disorder will end up using anti craving medications now. Atty craving medications are in fact a good option for primary care physicians to keep in mind for patients with moderate to severe alcohol use disorder. I'm dr during rush. Hour deputy editor for the canadian medical association journal today. I'm talking to dr john. Mong and dr paxton bach there joining me today to talk about anti craving medication for alcohol use disorder. They co-authored a practice article published in. Cma along with colleague. Dr keith hamad. I've reached them in vancouver and ottawa. Welcome hi there. I think so to begin with. Can you tell us about yourselves. Yeah absolutely so first off. Thank you so much for having us on. It's it's really Exciting thing to be able to talk about it. i'm john. I may general internet's working at the ottawa hospital with a clinical focus in addiction medicine. I also work with e substitute for grand council team. And i'm doing my masters in quality improvement and patient safety through the university of toronto. I h peony. I really became interested in medicine. You know during my training in internal medicine because so often we would see patients admitted to the t. with substance use issues and while we could take care of their acute issue whether it was osteomyelitis or alcohol withdrawal where alcohol titus. It often felt a bit lake. We were putting a band aid on with lucien and not really helping them with their underlying substance used issue and that sort of led me to get interested into into this area of medicine and I think it's been such a useful set of skills to and i'm really excited to be talking about it today. Accident yes thanks. Thanks to our in. Thanks very much for inviting span. Podcast today My name's toxin become. I'm a clinical assistant professor at the university of british columbia here. Thank hoover and general insurance and addiction position working at saint pauls hospital in downtown lancaster also in addition to that the program director for the bbc center on substance use clinical addiction medicine fellowship. And in that role. I get to work with a lot of trainees Teach about the principles of addiction medicine. Which is an area that i i also very passionate about. I like john. Emma general internist and was really struck by My inability to to help a lot of the patients on c. T. with some of the underlying drivers of of of many of the presentations. And that's what led me to explore this area medicine. And i would just actor jonah. Dovetails very well with my skill. Set his general internist and it's a really satisfying era of medicine to practice but also to teach him. Because i think it's it's under appreciated. How how much evidence. And how many tools do have to help people dealing with substance use disorders. Thanks for the introduction. Actually it does give me some context as to how you're seeing the world and the problem of alcohol use actually quite far down. It's true jerry by the time people already affected in hospital so john. Can you talk to listeners. Who are working in primary care who might just want to know. How do i know if the person in front of me has an alcohol use disorder. Absolutely and i think that's a. That's an excellent question. Whenever i talk with trainees or even colleagues about what constitutes alcohol use disorder. Invariably someone asks well what about that time. I got drunk and blocked out In undergrad. I have an alcohol use disorder and at the end of the day. It boils down to sure. There are the diagnostic criteria in the dsm. Five but the way that The thing that really separates an alcohol use disorder from using alcohol. More generally speaking are something that we tend to convince the four cs and those stand for cravings compulsions control and consequences. And so when you break it down Essentially those features which will separate someone with any sort of substance use disorder alcohol included from again someone who simply use the substance so breaking it down a bit more creating is essentially. It's almost like a physical pain like hunger that someone has to to use the substance and compulsions are there like an overpowering urge to use at substance consequences of course are when someone continues to use a substance or has negative consequences as a result of use and control is When patients and people like no longer have that ability to moderate or temper how much they use. And it's really those for sees that. I keep in mind when you know discussing us with patients and whether or not you know. A patient fuse patterns Disorder or simply If just occasional regulate use that's really helpful to moving beyond just a straight counting approach to alcohol intake so you you're wanting to look at at the bigger picture in a person's life paxton. So can you help us understand than i. Guess what we're talking about. Now is the conversion of of evidence based medicine into practice. Because when we're talking about anti cribbing drugs we're talking about People who have moderate to severe alcohol use disorder. How do you differentiate that group from people with a milder addiction who might not necessarily benefit from from anti craving drugs. I think you said really nicely there that we do have criteria to make these designations through the dsm but as you alluded to you know Treating the patient friend who is not necessarily that Black and white. And i think it's important to remember that people will fluctuate with may potentially fluctuate along that spectrum at different points in their life as well. So what may at one point to meet criteria for cigarette alcohol use disorder at another point not not necessarily do so i think that for me at least i move a little bit beyond the dsm criteria. This point. and i just have conversation with the patient. And i think that's the way that this was frampton me once. Fight by some work with really approaching these questions and these conversations with curiosity Because i think there remains a fair amount of stigma in canada around people with substance use disorders alcohol included and so there can be some reticence. I think on the side of a patient to really open up in disgust draw. Call us so approaching it with curiosity and a non judgmental way i think is is really important scene. That's gonna translate through all the message we talk about today for me. The pieces that i really focus on that helped me Make this distinction between mild to more moderate or severe As well as to who might benefit from a more intensive treatment with things like article therapy really comes down to as john mentioned those foresees in particular how much success they've had in the past using other approaches trying to cut back Many people may at some point in their life accessed some psycho social supports for their alcohol use disorder or maybe just tried to cut back on their own and so that is really helpful Question to frame where. Somebody's as well. As as the consequences. they're experiencing and somebody who is experiencing very significant health or social or financial consequences related to the alcohol use. That's i think. A real red flag that they may be progressing further along that spectrum but really what it comes down to. I think is is just making sure. Patients are aware of their options and can kind of choice from from anything's donald therapy or psychosocial resources To to help them meet whatever their goals are at that moment in time. So that's really interesting if we're talking about a spectrum. I'm imagining step therapy. I'm imagining that. The anti craving drugs are going to be further down that spectrum. But i guess before we start walking through the spectrum my question to be. Would you ever start on almost like the first thing you do. Introducing an anti creating drug say simultaneously with other interventions or. Would you always make that a stepped a step conversation. You know it's interesting that you bring up the idea of a soda here or staff you know try the psychosocial intervention first before you know quote unquote progressing to therapy. And i think that again because these medications haven't been so well you or a well-known we tend to think of them as the next step with the big guns whereas really they've got great evidence to be used in conjunction with or even Solely as the first line therapy when it comes to things like not trucks on a camper sake and i think to reiterate what action was saying. Is that these are one of many tools that you know. We exhibitions in our back pocket when it comes to helping patients meet their goals. And so i think it's really being able to know what options are available and the able to have a conversation with each patient about what they want what they think will work for and you know what they eventually want to you. Know what their goals are in terms of what treatment They eventually start. you know. i think it would be entirely reasonable to offer patients pharmacotherapy in conjunction with psychosocial interventions or. It would be entirely reasonable for a patient to have that conversation about pharmacotherapy. Decide that they don't want it Initially and it would be again entirely reasonable for a patient to say you know. I only want to knock truck zone. I you know really want to join a crew or go to therapy and you know. I think it's important that we have these Available because without them. We're not doing the best that we can for fictions. Actually what i'm hearing reminds me a lot about psychiatric practice and quite honestly as a psychiatrist very much to person's personal preference When we're talking about medications or or menu of interventions. So i guess it doesn't it shouldn't be a surprise that we could think the same way about alcohol interventions along that conversation. Have either of you figured out a good way to start that sensitive topic to start moving the conversation toward alcohol use and say in a primary care setting so i guess i should say for full disclosure during that. I am addiction medicine specialist. I were primarily in an inpatient setting or in a in a specialty clinic so that's not an environment that that that i tend to operate in. I what i what i often talk about with. with providers is two things. It's it's really about one. I think normalizing this a conversation as a part of Part of general primary care I think we talked to people. People are generally fairly used to talking about things like smoking. I think at this point and so just really normalizing. This conversation is just just a part of a conversation about somebody's habits and lifestyle and making it part of your routine care. One of the one of the documents that we did that. I will reference often in at least in my teaching british columbia center on substance use guidelines for the management of high risk drinking and alcohol use disorder which is a a quite a lengthy guideline. That came out just over a year ago. Now and and really Contains a lot of really helpful details in terms of how to manage these situations. I should also mention that. It's it's currently translate into a national guideline and that's project that's underway but one of the tools that it highlights. As as as incorporating into general primary care is is screening for alcohol use disorder and recommend screening annually. Just using something called the single alcohol screening question which is simply asking somebody in the past year. Have you consume more than three drinks for women in four drinks or rings from in which as you mentioned earlier i think i- i shy away sometimes from being to Linear thinking around. How many drinks is okay or not. Okay but it is a very helpful. Screening question i think to broach the subject and allow you to begin to explore it. A little bit more again with curiosity without judgment just talking to somebody about about their health in general and and how alcohol fits into the life how do you tease out. Cravings in that conversation. Yeah i mean. I would start by by simply asking something i mean i think many people do clearly identify their cravings as such but If i can take a step back. I think that one of the really important questions that i find helpful in guiding treatment for any substance use disorder at all is acting somebody why they used their substance of choice. Just y And letting them go wherever they want to take that question and it can be incredibly illuminating. Some people don't really know how to answer and they'll just those. They say that they do but a lot of people. But a lot of insight into why they use in it may be that they clearly identify very significant cravings or an inability to to to to get drinking or or other substance out of their mind. It may be very different. A lot of people tell you the truth because of anxiety or because it's part of their routine or out of boredom you people have many Answers to that question. I think can really help guide the conversation further and really helped me as the clinician. Get a sense of what treatments. I think i think maybe worth exploring a little bit with them. Keeping kind of sad that y right at the front of the conversation kind of like that approach at again. I'm going to ask if i could about a little follow up here So if you if you try if you're hearing from somebody that they're feeling bored at their drinking because of boredom or the drinking because of anxiety. Are there specifics that you're listening to will help. Guide your choice to to move toward anti craving medication that that's a really excellent question during something that's actually We talk about this a lot. because I would like to think that that is true I think that we conceptualize alcohol use disorders one entity. I think that that's not really It's doing a disservice to our patients. It's you know it's a very heterogeneous condition were were Disorder and people do drink for very different reasons very different patterns at very different times in their likes. So i often think about that heterogeneity and whether we can gain a better understanding of what treatments might work for somebody based on those patterns. That being said. I don't think we really have the evidence yet to support that So it's something that's certainly in my mind. But i i tend to moving into a little bit about medications. Specifically at this point. I do tend to try and stick with the first line medications for most patients as our first options. I'm just because they are. They do the best evidence supporting him. The best tolerated And they tend to be more effective so while i. I hope that we gain that ability to be granular in that sort of way At some point if you're not quite sure that We have the evidence is quite that at least so i'm hearing that. There's quite a lot of non specificity in both language that people use to describe their drinking and and also an in the language that we use around Medications another words. What type of language would get somebody to be on medications. Would their language change as they start to describe that feeling when they're taking the medication Yeah i i would agree with that. I think that everyone Has unique experiences with alcohol or substance of choice and again i am endlessly surprised by by patients. And what what may work for for one or or may not work for another. So i try not to come in any preconceived notions The nice thing about these medications as we've mentioned this article is they're they're they're generally quite well tolerated And you can get a sense of their effectiveness quite quickly so I i work with patients to when when the decisions made to try medication. I'll work with the patient will pick one and start it And we'll go from there. And i'm happy to to rotate through as many k. Medications as needed in conjunction with other supports to took to find a combination that works well since. We're talking about medications. Why don't we move onto the question of what anti creating medications are and how they work physiologically absolutely. So you know this is the part that sorta tickled my fancy as as an internist. The pharmacology and i just find it absolutely fascinating anti creating medications baird group of medication. Similar to how with an anti hypertensive got eighth inhibitors beata blockers and and all fat so the two first line agents for alcohol use disorder in anti medications are truck zone and a camper sick and now trek zone You might say hey. Wait a second. That sounds a bit like the lock zone at an opiate blocker. How does that work in alcohol use disorder. And and you're right now. Trucks own is similar to unlock zone in that a An opioid blocker and the way that it works very. Interestingly that it blocks. The effect of endogenous opioids in our limbic system in our reward pathway and in patients with alcohol use disorder. They have an outside a higher than normal response of opioid endogenous opioid released using audible. And the thought is by providing tricks zone. You can block Bats reward pathway and so by the principles of operan conditioning When patients with alcohol use disorder or on trucks alcohol. They don't get that same pleasurable back. And so there's less of a drive or a desire to use alcohol a camper sake. The mechanism of action is less well known but if sought to modulate the gabba and an mba receptors. And it can help to mitigate some of the sub acute withdrawal symptoms of withdrawal symptoms fat. You know last maybe weeks to months after cessation of all and again just going back to that idea of you. Patients are saying and an alcohol use disorder people use alcohol for reasons very heterogenous disorder as it turns out not trucks. Oh oil is is really quite good for patients who want to reduce their heavy drinking days. In fact it has the number needed to treat a twelve traduced. Heavy drinking days But it's also pretty good for helping patients maintain Cessation from alcoholics got number needed to treat a twenty And captivates a bit different. It only helps patients who wish to achieve station from alcohol. Which pointed has a number needed to treat of twelve and you know as an internist. These numbers are ridiculous crate. Right you know. I'm used to seeing an mtv of thirty forty fifty. So when i first heard about these meds and you know that they've got an mtv twelve to twenty you know it's almost criminal how underutilized they are and you know they. They have very direct pharmacologic mechanisms of option and their evidence and they work so okay looking at the two. let's just let's just start with naltrexone campus. Eight and say again thinking in primary care office. And you're having to think okay. Which one should. I try which prescribe for which is safer. Are there anything special things. I should know about one of the other end prescribing. Yeah absolutely so. I think it comes down to the individual patient. Any specific corker medical conditions and whatever. Medications are wrong so the first question i tend to ask myself is What the patient school if the patient wishes to achieve alcohol cessation and maintain alcohol to station. Then i'd be leaning towards a cap As opposed to simply because If the evidence is better for maintaining station that being said bears a whole host of other factors it camper state is dosed re times a day and and of course you know it's it's tough to even remember to take a medication one day You know just speaking from personal experience and so three times a day can be a bit tougher for patients to remember now trucks on conversely is once a day and so it's just a bit easier for patients to remember to take and it can just help If patients you know are out of the house quite a bit or if They don't have a very regular schedule. Then maybe not truck so might be a better choice from a dosing perspective in terms of contraindications and side effects. Therapy different as well. So now trek so again going back to that idea that works similarly to the lock zone. If patients are opioids or you know not includes Opioid agonists therapy like methadone or Ben not truck. So news contra indicated because it will inhibit or stop at the opioids working so if someone is also prescribe opioids of any kind then not trucks owners is out the window unfortunately and now trucks zone is also contraindicated if there is that severe hepatitis or liver disease. There's no hard and fast cuddle but You know a probably in the fifties and fish liver disease. The you know you don't wanna be used trucks. And in that case or they have a s year lt more than two times. The upper limit normal so those are also contraindications. Chenault trucks in comparison. Aac appreciate can be used even in in liver failure. But if contraindicated when craton america's lower and you just have those digestion case crandon clearances less than fifty. And i can't use it. If the credit influences lesson i am as paxson was saying earlier. Both sides are pretty well integrated Side effects tend to be pretty. Transient for a knock. Trek zone Some fatigue sometimes a bit of gi upset but again Quite transient and very well. Tolerated and It's similarly for ak- per se to the major side. Effect is is upset but again. Transient and very well tolerated. And so you know. The magnitude of the potential benefits i think really quite strongly outweighs any you know minimal side effects that might Might rise now. Can i ask you About availability and i recall not long ago. There was a shortage in canada of a camper sate. Is that still happening now. We're like in other words. We're talking about a campus eight but can people actually get it in canada right now. Thankfully yes i believe. The storage ended in july of last year. But you're right. There was a shortage For a while with a camper seat but as of right now both medications are available. And i believe covered under most provincial programs. I believe so in ontario there are certainly covered under the all. You codes I wouldn't know fisher gotta provinces paxton any any Full coverage in british columbia they. They are covered covered In british columbia under something called collaborate prescriber agreement so yes both of those are also available in in our clients and we've talked a little bit about starting to medications introduced the to the best known ones del tracks in on campus. Eight in your article you mentioned till pyramid gabar penton which we don't have time really to go into here and i think people are more interested can look at your article and and further readings but i want to ask you both actually about the the flip side to starting a medication and that is how do you know it's time to stop a medication. That's another excellent question during an obvious in one of the first questions that comes up from patients where we are initiating these medications i typically suggests you know starting stations and As i mentioned earlier quite quickly you should be able to establish whether they're achieving any benefit were or not from medication so usually a transient back in two weeks. And but if. I a month into a good trial of medication. Not seeing any benefit it'd be looking at alternative options if they are seeing benefit that that becomes the question In terms of how long do we carry on down this road and it. It really varies. And i put as much as possible to the patient. Generally y- twelve weeks is most typical duration that these medications are studied so we tend to not have a deal of data beyond that that point in time so i usually recommend that we retry medication for a minimum of three months if they're achieving benefit and then we sit down reassess and if somebody feels that they're really obtaining benefit and it's really helpful. They're meeting their goals and their feeling good And they want to carry on. That's fine Then we can carry it on. As john mentioned the very well tolerated medications and i'm happy to keep going with them for as long as they feel There there helping them similarily. If somebody three months decides that they'd like to stop and kind of see how things go. I'm supportive of that as well And will take a data time and see how things go and if they do stop and they find that crazy. Comeback will then. I'm more than happy. Start the medications Carry on for for for a period of time beyond that. That's usually my suggestion as an within our guidelines as well as three to six months as our initial trial and then and then from there You can reassess and make that decision collaboratively with your patient just out of curiosity A lot of psychiatric drugs. Has you know have withdrawal and rebound symptoms if you stop them all of a sudden especially if you've been taking precedence for a while Has anything like that. Been described with the anti cribbing drugs. No one of the one of the fortune things. Everybody's medications is that really There's not a starting and stopping them is is quite straightforward at least with these first medications trucks on an account prostate so It's not something we have to worry about as much with these medications which is again. Why they're such unhelpful tools and really quite easy to incorporate into your practice that kind of leads me to the next question I know john is expressed very strongly His sense that the antiquated drugs are underused in medical practice. So i wonder if we could put this sort of final section of our discussion around How eddie craving medications have been received both by medical experts and by consumers. I think there has been Quite a bit of interest From both sides about You know these anti hyphen medications. Which again is not to say that. They're a magic bullet or panacea to help patients with alcohol use disorder but they are a valuable tool in our toolbox. And you know anytime that there's something that could potentially all patients i think and especially because there it's robust evidence that they help you know. I think there is going to be interest. Certainly you know locally within the ottawa. Hospital know initiatives to improve their use have been very warmly. Received and a lot of patients are interested in it. Because you know some patients aren't necessarily interested in be psychosocial non triumph logic interventions and. Some are interested in A medication that will help them And of course some arkan and that's totally valid. It's well but you know again i. I think there's been a lot of interest in beef medications than their use. I think should be increased knowledge in how to use them should be more widely disseminated and i would just echo that i think from a patient perspective. People are just really Happy to have to be provided with options Especially ones that they may not have tried to access in the past for people who this is not their first attempted this from a provider perspective. You know. I think that's a medicine. In general we tend to shy away from questions or conditions where we don't feel as if we are very well equipped to deal with them I think sets you know It's pretty natural instinct for clinicians in any specialty to gravitate towards problems. If they feel that they can address and so providing providers with tools and the toolkit as john mentioned giving people options that they can employ when they run into the situations. I think that really really affirming and really Helps encourage providers to ask these questions and kind of go down this path of patients. It's much more satisfying to have these conversations when you feel as if you are equipped to provide them with some helpers answers and so I think that the feedback that i get is almost universally positive from both patients and providers alike. Thank you for joining me today. Thank you very much for having us. It was a pleasure. Yes thank you for having us and thank you for bringing us on the show To talk about something that we feel pretty strongly about it was. It was a pleasure to share conversation with you. I've been speaking with. Dr john long and dr paxton balk botch among is a. General internist working at the ottawa hospital with clinical focus in addiction medicine. Doctor bach is a clinical assistant professor of the department of medicine at ub see and a general internist and addiction specialist at saint pauls hospital in vancouver bc to read. The article. co-authored along with dr. keith muhammad visit. Cma j. dot c. a. also. Don't forget to subscribe to see image. A podcast on soundcloud or podcast app and let us know how we're doing by leaving a rating. I'm dr dish our deputy editor for. Cma j. thank you for listening.
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Mandatory vaccination for health care workers
"This episode is brought to you by Audi Canada. The Canadian Medical Association has partnered with Audi Canada to offer see members preferred incentive on select vehicle models purchase. Any new qualifying Audi models receive an additional cash incentive based on the purchase type details of the incentive program can be found at Audi professional explore the full line of vehicles available to suit your lifestyle. The Audi Driving Experience is like no other immunization against the virus that causes covid-19 is a top priority in Canada presence with multiple levels of government working hard to vaccinate key populations as quickly as possible. The vaccinations rollout is prioritizing health care workers, especially stuff caring for patients with covid-19. But as with other vaccines some health care workers will opt not to receive it which leads many people to wander can and should the vaccine be made public. Natori for health care workers in Canada. I'm Chris and Patrick executive editor for the Canadian Medical Association Journal today. I'm talking to Colleen flood one of the authors of the same age as my analysis article that explores the legalities around mandating vaccination for health care workers Colleen is a professor in the faculty of law at the University of Ottawa and the inaugural director of the University of Ottawa Center for Health law policy and ethics. Hello Colleen. Hi Kristin. So thanks for joining me today. Let's start off by you giving us a bit of insight into why you wrote this up as a home for CMHA. What are you and your co-authors talking about in your circles at the moment? Yeah. Thanks Kristen. Well my colleague doctor cumin in Wilson and Page Brian Thomas and I have been thinking about questions around immunity certificates vaccination certificates and mandatory vaccinations dead. Probably because we're seeing you know, a lot of discussion about access to vaccinations and who will get vaccinations and in what order but we wanted to sort of I think a little bit ahead of that and to think about the question of whether or not we we could or should actually require health care workers to be vaccinated right at the moment we can think about is people who want the vaccination know being able to get access to it. But over time I think we're going to be starting to ask the question. Well, you know should we would be requiring certain categories of people in this case healthcare workers to be vaccinated both to protect themselves and their patients that they're working with but other healthcare workers as well. So the past there has been mandatory vaccination policies in place particularly for influenza, which you look at in this article, but I just wanted to talk about some the two routes Thursday. This might go by in the article you say that it could happen at the employee level or at the provincial government level. So could you talk us through the difference between those two thousand and which one you think is best for sure. You know, I think this is all fairly complicated legal questions, but the important thing to understand is that they're really two policy routes to take here. If we're looking at mandatory vaccinations. The first is what has tended to happen in the past is that governments leaves up to the decision-making of individual employers. So AB to Regional Health authorities or different public hospitals different Long-Term Care Homes different Lifetime and homes, you know, it's really up to those individual employers to make that decision. And if that happens then we really in the realm of labor law and we're looking down. At what claims? For example, our Union could make to contest a decision by an employer for example a public hospital to mandate that home workers be vaccinated for size curvy too on the other hand. The other policy route would be if and this to the policy route that we prefer would be if the government took clear rules that would apply across all Healthcare spaces. So across retirement homes across Long-Term Care Homes across public hospitals long. We think that that's important and that we shouldn't just leave it for example to individual retirement homes to make decisions about whether or not to reject the healthcare workers to be vaccinated or two individual public hospitals. So in that case if the government itself sets a clear rule then it is much more Club. See that that could be contested and the Charter of Rights and Freedoms. So really there are sort of two two conduits to policy kind words whiners of individual employers make this kind of decision and then we're in the realm of labor law and the other is if in the one that we prefer is if the government sits clear rules to apply a class or Health Care spaces and then I think we're in the realm of thought a potential Charter challenge. So a healthcare worker that didn't want to be vaccinated bringing in a challenge to a rule that the government may have that a vaccination is requires month. So let's go back to that a little bit later. Yeah. Sure. So when we're talking about size Covey to vaccination, there are no legal precedents for this right now, but it could be a good place for employers to mandate vaccination for health care workers. And why would that be well the tricky thing as we point out in the article is dead. I now we don't have clear slam dunk scientific proof that sad cozy to vaccination will prevent transmission of the virus. However the expectation and certainly the hope is that that will be the case but assuming assuming that they're does come to pass then the obviously the reason that we want health care workers to be vaccinated is to protect the patients particularly vulnerable patients that they're working with and other healthcare workers as well. As I think we also have a public interest in the health care workers themselves not falling ill with Cove has so that they're able to provide care of patients. So there's a a bunch of reasons there some predicated on evidence coming forward or you know being demonstrated that the that the vaccination actual birth. Transmission but some and also grounded and just protecting the health of the health care worker him or herself in a kind of instrumental way in that we removed for health care workers who are able to be providing care at this time. And that that second function is sort of seems to be quite clearly supported by evidence of the trials that that fewer people acquire the virus if they're vaccinated so we can expect much less illness in vaccinated health care workers. That's right. So in the past month that have been mandatory vaccination policies in different jurisdictions for influenza and in your article, you look at some of the case law that's come out of challenges to vaccinations a mandates for influenza. Can you tell us a little bit about that show so most of the case law so far as in labor law because as I said most of the decision Have been left to individual employers so public hospitals and so forth. And so what happens then is in the case of influenza sometimes unions had challenged if it's by hospitals to impose blue vaccination requirements on for example nurses other health care workers on the ground seemed such a mandate is unreasonable unilateral exercise of managerial rights. So on the whole the the way that the case law has evolved which is when we're talking Coastal here, we're talking about decisions of labor arbitrators on the way. The way that this has evolved is that labor arbitrators hath upheld mandates and the mandates are you must be vaccinated or wear a mask and the time of an influenza outbreak however wage Side of the context of an of an outbreak there is some decisions that suggests that such a mandate is an unreasonable exercise managerial rights and have them and they and these challenges have actually suggested that really there's no there's no evidence of benefits from wearing masks and protective gear and that context and the context of the home. So I think all of this is very interesting because of course the evidence around mass and personal protective clothing have evolved considerably in the context of sauce goes into and so, you know, when you come to the question of vaccination for size Kobe to the the context is very very different from influenza. And I think that's a really important point to take away from this is that the case lower if you like and the responses how the law has responded to managing. For influenza vaccine will be different for size could be too because the context of SARS could be two is so very different. So when you were talking about government mandates, so that would mean that the government would say that all Healthcare institutions would need to require vaccinations for workers who were in contact with patients when that happens you're talking about I think at the provincial level because the federal government doesn't hold that sway. Yeah. So what would be the consequence of that? How would that make things easier for employers or not make things easier for employers and how may people challenge something like that potential? I think it would make it easier for employers that you know, they wouldn't have to take this on views of The Challenge from unions individually. They need to rely on a clear rule from the provincial territorial government about what needs to happen across the board. But as I said, then it would be much more clearly subject. A chat a challenge because it is a government action, which is something that an individual could bring a challenge for example under Section seven of the Charter of Rights and Freedoms, which protects one's rights to life liberty and security of the person. So requiring somebody to have a vaccine may be seen as an accomplishment upon one's Liberty and security of the person now to be clear when we're talking about mandatory vaccines here. We're not actually talking about holding somebody down and you know off and needle in them when they physically are resisting but rather to say that, you know, if when doesn't want to have the vaccine then one may have to stay home from work without pay or possibly that that when has to wear personal protective clothing or something along those lines. So when we talk about a mass That we not actually talking about a pure mandate or a hard men date, but rather that you probably have an unpalatable option of not being paid if you weren't vaccinated off. So the question is whether or not one could bring a challenge to that under Section seven of the Charter of Rights and Freedoms. Now what we argue in the in the paper is that provided you know, that this isn't physically forcing anybody to have a vaccination against their will but rather giving them this unpalatable, perhaps wage economic option of not being paid that we don't think that this is engaging with one's section seven Liberty and security interests because this is often described as an economic right and section seven of the charter has not historically protected economic rights like the right to practice their profession or essentially to earn money. So we don't think it would be engaged by section seven of the charter. But even if we're wrong about that, we think that otherwise the government could defend it under other aspects of the chatter analysis. So for example that to require mandatory vaccinations in the context of size KO V. Mm is in accordance with the principles of fundamental Justice. This is another aspect or part of a test of section seven and then going on from that that it was it's also defensible under section one of the Shadow which basically says that the deprivation of the right has to be proportionate or reasonable. And again, all of this is in the context of covid-19 and says could be too so all of the factors, you know, the risks of covid-19 the harm that's been caused by it the benefits and evidence about the vaccine all of these thoughts. Had to go into the mix to determine whether or not a mandate for a vaccination for health care workers is justifiable under the Charter of Rights and Freedoms. Am sorry. It's a lot to go now. It's all great. So thanks for clarifying those nuances. If we come back to the individual health care worker you talked about choices that they might have you ever talked about our masks and vaccinate for wear PPE or vaccinators and stay home know if an individual health care worker were to argue that they need to be vaccinated because they are complying fully with PPE requirements. Would that justify their right to not have a vaccine as we say in the article? We think that's probably the the greatest likelihood of a challenge is off to a mandate is a is a health care worker arguing. Well look, you know, I don't want to be vaccinated and we're in p p e or I'm taking other dog. Into precautions and so this is sufficiently protective of folks and over myself. So on that score again, it's just come down to the evidence and it's very important for governments. If they wish to uphold a mandate to carefully consider that evidence. That's the first thing they can't just be located. They have to consider the evidence of the benefits of vaccination the extent evidence and the extent evidence of the benefits of PPE and last month and other factors might come in here such as you know, when people are using p p e how well do they use it the costs down and you know prospects of securing appropriate PPE or those things might come in to the mix into into considering whether or not it is dead. Essentially reasonable for a healthcare worker just say I don't want to be vaccinated. I just want to wear PPE. So we think that you know applying the brake questioning principle that governments would still be within the realm of reasonableness if they are asking health care workers to be vaccinated and of course winning, you know as we're rolling this out we will be health care workers will be wearing p p e and being vaccinated all at the same time. But we think apply the precautionary principle that is reasonable wage for governments to say look. We we want you to be vaccinated as well as wearing p p e and over the long run that people should not be a substitute for vaccinations. But as I say, you know, it is really important governments can't just say this actually need to really consider it and I think we argue that the dog. The government should really be helping the province has here collecting the real world evidence of how the vaccine is working, you know in the different populations that weren't included in the trials and off of the relative efficacy of PPE and masking so on and in different situations, so that provincial governments have the best evidence base from which to make a promise to determinations about vaccine mandates and to calibrate them over time. What about exemptions for a vaccine mandate? Yes. Absolutely. I should have actually reiterated has to be 2 before but to be constitutionally compliant as we say to to survive a chat a challenge then they're clearly has to be exemptions from categories of individuals. So for example, those who for health reasons and able to take the vaccine and those for whom there is genuine religious. Conscience objections, they'll be very few real religious, you know objections to having a vaccine and conscience objections are a little bit more complex because one might imagine that people who are just you know, anti-vaxxers perhaps or suspect of vaccinations, you know, suspicious of pharmaceutical companies and governments and so forth. The extent law is that I don't think that an anti vaxxer can essentially argue a conscience objection, but still, you know, those with genuine religious or conscience objections, they will need to be Exempted under any mandate as well. And then as as we've just discussed. Is the question of whether or not an individual could argue that they should also be attempted if they if they wear PPE and as discussed we continue age No, they shouldn't in the next few months or a year has the vaccine rolls out and people are being vaccinated. What do you see as the possibilities for mandating a vaccination or not in Canada? Well, I I think despite what we would like to see I think unfortunately provincial and territorial governments are more likely just to leave this to individual employers and I think that's you know, so we'll have sort of spotty kinds of implementation across the country and what I worry is that choice as we've seen with our focus on hospitals and Physicians as opposed to long-term care homes and personal support workers. And so on is that this kind of approach will mean that where we have the most vulnerable is not necessarily where we will see all the people that should be vaccinated being vaccinated the health care workers and personal support workers. I would include there so that is our Concern and you know, the politics of covid-19 in Canada has been one of I think for me, you know defection of accountability and Devolution of decisions to to more the local level, but individual Public Health units to individual Long-Term Care Homes Etc off and I think we've won the consequences of that what I would like to see and I think my co-workers to is that that really provincial and territorial governments that did not see the middle of the responsibilities here. I mean, we've we've sort of I think a lot of this our decision-making it has been predicated on the hope of the vaccine all the dead of winter here. So let's make sure that we redeploy them appropriately and that we really have our eye on all of where the risks are and that requires off. We set some firm rules across both private and public settings. So I think it's it's important to underscore that in this article. We're not talking about a blanket vaccination date for the whole population. You're just talking about some health care workers and they're particularly important role in keeping the population safe as a were. Absolutely. Yeah now we're not that across-the-board vaccinations that would be the topic for a separate paper, but that you know, the evidence is about the risks the risks and the benefits are very important for a legal analysis. And so, you know, the particular risks for health care workers and the impact on this on their ability to deliver Health Care off in the context of the pandemic, you know are critical to how a court would approach the review of any Charter challenge warning label or challenge to a mandate dead. Well, thanks for this great discussion, and thank you for joining me today. It's been very enlightening be my pleasure coast and and thank you very much for your interest in this. I've been speaking with Professor college instead of the University of Ottawa to read the article. She co-authored visit. Cmaj. And don't forget to subscribe to CMHA podcast on Soundcloud or podcast app. Let us know how we're doing by leaving a rating. I'm dr. Carson Patrick executive editor for c m a g. Thank you for listening.
Long-distance travel for birth for Indigenous people
"Welcome to the. Cmha podcast in this episode. Of course a big issue for indigenous families is that because of colonial policies indigenous pregnant people often don't have options to birth close to home. This has particular relevance for for stations unanimity. People were actually being born where you're from because the land is a relative If you have to move away from where you're from it's like leaving a very important relative out of the birth experience. I'm dr kirsten patrick. Interim editor in chief of cmag. A new research study has used data from the canadian maternity experiences survey to look at how far pregnant people traveled to give birth in canada and to look specifically at differences between indigenous peoples and the general canadian population with regard to travel for birth with me today to discuss striking findings of their research. The problems that these findings highlights and the potential solutions to the disparities that they noted our office janet smiley a family practitioner and professor of public health and evelyn george. A registered midwife but first a word from our sponsors. This episode is brought to you by dr bill. Dr bill makes building on go easy and pain free at a patient in as little as three seconds and submit a claim with just a few taps. Start your forty five day. Free trial today visit bill dot apps last. Cma that's d. r. b. i. l. l. dot ap slash cma to get started. Many may not be aware that simply being over fifty puts them at increased risk for shingles help prevent shingles and patients over fifty wishing greeks shingles is indicated for the prevention of disaster h shingles in adults fifty years of age or older consult the product monograph jfk dot ca slash pm for contraindications warnings and precautions adverse reactions interactions dosing and administration information to request a product monograph or to report an adverse event. Please call one eight hundred three eight seven seven three seven four learn more at things shingles dot ca janet and evelyn. Thank you so much for joining us on the sanjay podcast today. Thank you for happiness. Thank you for the invitation. I'm ask you to tell our listeners. A little bit about who. You are sure. So janet smiley i'm May decree woman with a long. Umbro can maternal kin line of mixed ancestry. My paternal kin lines on route back to ireland county down. Ireland is where the smiley came from an words generation settlers. I've been a family doctor and practicing medicine across geographies in contexts. Since two thousand and three after about five years of practicing family medicine. I went back and did a master's in public health in since then i've had an increasingly research focused career currently. I'm a professor in the dow. Lana school of public health and the faculty of medicine department of family and community medicine at the university of toronto. I tier one. Canada research chair in advancing generative health services for indigenous populations in canada and also the director of the well living house action research center in an active staff. Physician saint michael's hospital in toronto. Evelyn could you tell us about you. My name is evelyn george. In newbie seeing schnabel que- from nip passing first nation on god's side and french canadian on my mom's side an non-practising registered midwife living in seattle stare tori nbc in a community called sin. Pinkston i'm at community engagement. Lead for neck him national aboriginal council me wives and i work closely with indigenous communities in nations working to restore birth in midwifery and i also indigenous student coordinator for the bbc midwifery program where i work closely with indigenous students. Now we're discussing this really interesting. Study that you've conducted on the distance that women travel to give birth and how that's difference or indigenous swimming versus those of the general community. Can you tell me a little bit about why you wanted to study this sure. Actually i had the fortune of being involved with the canadian maternity experiences survey since its inception and when we were done this study and we were trying to think about what kinds of analyses would be relevant in useful for first nations. may t- people. We asked various first. Nations would end me t in national indigenous organizations and We in particular worked with a native women's association of canada who has representatives on this paper as well and of course a big issue for indigenous families is that because of colonial policies indigenous pregnant people. Often don't have options to birth close to home. This has particular relevance for for stations People were actually being born where you're from because the land is a relative If you have to move away from where you're from it's like leaving a very important relative out of the birth experience and for indigenous peoples of course we have a lot of diversity. But i'm not aware of an indigenous community where it is very important to be birthing close to home or on the land where you're from so the native women's association of canada. We had some emerging qualitative evidence. That was showing that this historic and ongoing colonial policy was harmful to indigenous peoples indigenous identity causing a breakdown in our web of relations very stressful practically stressful because children were than having to be left with caregivers who weren't their birth parents Mothers were often having to travel without any family or partners so they wanted us to take this opportunity to understand quantitatively. How common this was. That was Community identified priority. That's a good approach and indigenous research. Unfortunately even when we have strong evidence through our community members of course. It's the numbers that Will be acceptable to policy so this opportunity to do a rigorous scientific study that would support the much-needed policy change and actually quantify our hypothesis that the maternity care services in rural areas are hypothesis was that they were disproportionately nearer and set up closer to non-indigenous communities so in the beginning of your answer you talked about the data instruments that years now. Can you tell us a little bit about the survey. Yes so the canadian maternity experiences survey is the one and only comprehensive maternity experiences. Survey that We have in canada and actually it happened in two thousand and six two thousand seven. So we're very much overdue for another one. And in fact. I in our recommendations we're talking about the need even for indigenous specific reproductive health surveys. This survey actually did include several hundred for extinctions excluded for stations mothers living on reserve Which is a strong reason why we need a repeat survey. It was designed by a multidisciplinary group of people under the umbrella of the canadian. Perinatal surveillance system. And i was a member of that group which was part of the public health agency of canada at that time. and we designed survey comprehensive survey better understand maternity experiences for pregnant people in canada and we interviewed parents who had given birth. The maternity experienced survey itself interviewed mothers So i think it was actually defined as mother's at that time in two thousand and five thousand six. Who had had infants that. We're living with them three months before the two thousand six canadian census and the mothers were actually interviewed then when they're infants were between the ages of five months to fourteen months. Netherlands different birthing options for people living in rural canada. What do they look like. Well i guess it depends on where you are and our steady has shown that it also depends on who you are but we know that increasingly maternity services have been leaving. The smaller rural areas and people have been needing to leave to go to urban areas to have reproductive health services and particularly around birth services. There aren't a whole lot of options. We know that in different parts of the country family physicians are more active in providing maternity care and in some places not so much in some parts of the country. There are midwifery practices that are located rurally where that might be an option and in other parts of the country may refer repurchases are quite scarce in especially in rural communities can be very far distances from one another so it can. It just really depends on where you are. Yes it really does depend on where you live. And that was kind of our hypothesis was then that it will be privileging. Non-indigenous canadian-born people living in rural areas. Which actually was our comparison group so we compared Indigenous people to non-indigenous canadian-born population. Just because we know people who have immigrated to canada more recently have different birth outcomes in terms of access to service the options in rural areas. Our community basement whiff free but that's not available in all rural areas. It's probably only available in the minority of rural areas and then to give birth in like a burst center or a hospital so as family physicians We're trained to attend bursts at percenters. In in hospitals midwives are trained to attend bursts at homes in birth centers in in hospitals. One thing for all women living in rural areas is that your opportunities to be born. Outside of a large urban center might be limited by any complications. You might have in the current or Previous pregnancy one of the things we were able to do in this study because the data set was large enough. Because i think there's often an assumption that the reason indigenous women more often to birth experiences far from home is because they have more medical complications but in fact we are able to control for medical complications and show that wants. Medical complications were taken into account. They were still much more likely to give birth away from whole compared to non-indigenous canadian-born women living in rural areas. He wanna give us a kind of broad overview of the things that you've found in this study yes. As i mentioned our hypothesis going in was that indigenous woman would more often have to travel for birth compared to non-indigenous canadian-born women when we looked at what was happening in urban areas. In fact there was Just very small numbers because of course some. There's lots of options for birth in in urban areas. Not all culturally safe But when midwives family doctors and birthing centers exist on their most commonly existed in urban centers so we focused on rural and remote areas with the limitation that the maternity experienced survey excluded for stations woman living on reserve what we found in the study sore steady results. Actually i never imagined. I knew there would be a disparity. But i never imagined that the disparity would be so extreme particularly since we weren't including first nations woman on reserve because to exclude them would actually moderate the effect right. 'cause there's very few first nations on reserve communities that have a birthing facility or a hospital there so by definition moms would have to travel so what we actually found is that indigenous women were more than five times more likely to have to travel two hundred kilometers for birth compared to non-indigenous smothers. And as i mentioned though a communist section is the reason why that happens is because indigenous mothers might have higher rates of medical complication pregnancy. So then what we did was what's called an adjusted analysis and then even more strikingly. We found that when we took into account medical complications of pregnancy. The result was even stronger. Indigenous women were sixteen times more likely to have to travel more than two hundred kilometers for birth compared to non-indigenous canadian born women living in rural areas by that time numbers were getting a little small So the ninety five percent confidence interval is eat to thirty three times but that was much higher and it's extremely striking to see that disparity in a rigorous quantitative study. So you're looking not across the board. You're looking at people who live in rural areas and this great discrepancy holds for only people who live in rural areas. It is very very striking yet. With respect to this striking disparity i think It's an important finding because often what we hear about. And i see that. Indigenous health gets conflated with rural health. Because of course for all families in rural regions indigenous and non-indigenous There's fewer hospitals Schumer midwives fear family docs and fewer specialists and birth facilities per capita. But here we see that actually it may not be appropriate to be conflicting rural health inequities and indigenous health inequities in rural areas Because as often happens. There's an intersection happening. So that indigenous people living in rural areas actually are experiencing like a synergistic disadvantage. So it will be very important. Moving forward to not complete. Indigenous health disparities enroll areas with more general rural health disparities. We need to actually look very specifically at these striking indigenous health disparities. And i think too when we see the results of this and see how extreme the disparity is and then we think will that doesn't include people from on reserve which is going to add add to that also but it also doesn't include people who are incarcerated or people who had their babies apprehended and we know that in those populations we have an over representation of indigenous people as well and so take that number that already looks extreme and add to it an attitude attitude again and it's very striking ebola. New make an important point there that janet raised as well that this is very likely an underestimate of the discrepancy because the population of the study is is fairly limited that speaks to some of the challenges and barriers to studying this question. Perhaps you could talk about those a little bit. So the opportunity was the canadian maternity experienced survey. I'm in the survey itself was actually committed to Specifically looking at the birth experiences of canadian youth as well as first nations may t- people but the first challenge in barrier was even though it would be very important to get samples that were large enough so we could understand across diversities. This specific experiences of first nations inuit in may t- women so that would have required oversampling up first May women and even though that was stated steady objective at the time a policy decision was made not to oversample first nations. Inuit inmates he women so we're not adequately powered to give us the data that we actually need to respond. So we know that. There's this big disparity but we do not know you know. Is this a problem. Mostly for annually women and first nations women or is it a problem mostly for me women because it's not adequately power to desegregate. The data so the indigenous sample was inadequate. Another barrier is that just the way that tom a lot of the surveys are structured. That come out of statistics. Canada they build on a census sample. So we know at least for stations not living in urban related geographies for example. Only one out of four or only one out of five indigenous. People does the census. I'm imagining. There's under participation in rural and remote areas as well and actually it would be a biased under-participation because the people who are participating will be different than the people who don't participate in order to participate. You need to feel safe picking up the phone and answering it when stats canada. Or the federal government gives you a call. We did try to mitigate some of these things. We had the opportunity for people to have interpreters but still even it would require you to have a phone. Which is something matt tom. We don't take for granted in first nations Communities where there's a disproportionate socioeconomic challenge so one opportunity. 'cause challenge also just is the way that traditional quantitative epi methods work they often leave out. Indigenous ideas paradigms and perspectives. But actually i feel good about this study And i'm interested here. Whatever thinks as well. But i think what we've tried to do is bringing indigenous lens indigenous paradigm to a quantitative epidemiologic steady. So of course for stations in may t- people. I'm a woman but where i come from. We were impure assist to live on the land. You have to be an expert at empirical observation and tracking because we were surviving on the land. So here we tried to actually ground this study. As much as we could in indigenous processes so for example coming up with a question that was purge highest prioritized by indigenous community and show that we can use quantitative methods and we always have as people as a way of understanding and than planning for better health and wellbeing in our communities so it what is the experience of birthing how far people having to travel if we can quantify that then we can plan you know what kind of services and i imagine are midwives traditionally in healers would have done that as well even just to survive. How big is our community right. How many babies are being born this year. Do we need to move our community somewhere else where there's more food to support us because there's changes in this environment from my perspective Living on reserve with the way that relationships exist in kind of our colonial context You know there are some real barriers around trust in like wet. Janet says you know picking up the phone and then continuing conversation on the phone and being willing to to share information. That can be very difficult for people to to talk about in the first place. I see that being a challenge in. I would love to see a future study where we can kind of go about the study. From beginning to end in terms of the data collection You know from an indigenous perspective because they think that people will will potentially be much more open in sharing. You're talking a little bit about how the study question here for this. Quantitative study came out of other work that you had done and i'm curious to know whether that work elicited understandings of how difficult it is for indigenous women to travel for birthing. Yes so of course evelyn. I have attended bursts in diverse contexts. But i'm sure as any person who's part of a family who's had to experience the impact of traveling for birth far away from home. It's scary right. I used to even find it scary. So i've worked in rural and remote first nations and meaty communities. I'm for good parts of my career. Even when i was a family physician. I used to find it scary when i had to walk into the obstetric ward at the health. Science center in winnipeg right all of a sudden i went from being one of the most important people in the hierarchy to disposable. Imagine how the patient feels. And as i mentioned at the beginning there's that added component than not only of leaving your family members. Because there's like kat it's only very recently That we had reversed federal policy that did not fund partners or support a family members to travel with women. Right we know when when a pick health science centers where brian sinclair was left to die in the emergency room. So we know it. C- exception that indigenous people actually have a good experience at urban hospital versus that created in discriminatory manner. So and then there's the added thing that now you're being taken away not only from your human relatives but from the land base which is also an equally or perhaps even more foundational relative and then for families that have multiple kids you might be in your labor actually worrying about who take care of your kids because we've had generations of family disruption right in and part of the legacy of that is there is always reliable people at home to provide those supports. So i think that's like a terrible context in which to give birth this combination of having to anticipate and be fearful of attitude systemic racism in a hospital to be isolated from the other humans in your life to have to worry about the health and safety of your children and then to be torn away from the lands where your people have lived for generations. Something that actually we've shown in other work only that relationship to land For indigenous people actually is something that promotes health So yeah if you tried to plan like It's almost like a perfect storm of how to activate people get our systems working in ways that are going to actually undermine a safe labour if we're talking about the impact of traveling for birth you know it's it's very profound and i think as healthcare providers were always placing it in the lens of the birthing person and were always focusing on them and there is definitely multiple layers of trauma that occur for that person but also like they don't exist in a vacuum they exist within families and communities and those people have an impact also from that person being removed for that amount of time. I'm for however long it is for some people. It's a few days for other people can be over month depending on where you're traveling from at the community level in at the family level this is it's really lived out as an experience with family. Separation and using the words family separation is important when we talk about indigenous health because of history and because of the impacts that it has intergenerational and the colonial context around it. I think it's important to frayne saying. And we know that those stress responses interfere with bonding and attachment. And we know that those all kinds of things could be happening in families. There's never an easier a good time to to leave family for an extended period of time you know for any family But like janet was saying around in our family context Can be really difficult to start with. And it can be really challenging for some people to find care for their children over that length of time but they can feel comfortable and safe about with the escorts with with you know companions for birth even that you know it does support birthing person for sure and there are advantages there but it's also really difficult because that's not paid time off right and you know people find it really difficult even to go for a short amounts of time and so it. It really ends up that we need to have birth closer to home. We really need to have birth on territory within our family circles in our kinship circles within our communities. I'm because that's where we can be intact as people you outlined at the beginning that this is Quantitative research to highlight a problem. But what's really needed is some solutions. And you've picked up on a few there which you see as the next steps out of this work. I think that. I'm we've had some huge successes in particular parts of the country with community based indigenous midway free returning birth to communities And of course the examples that you could maybe look up or the examples in university of northern quebec and also secretions is well known for restoring birth in their community in it community based way in when we say community based we mean community owned. The foundation is a cultural foundation and is placed geographically within our community. Also and we've had huge successes. Indigenous midwives have important skill sets and knowledge bases and to competencies that are really important in restoring birth To communities and communities are safer when there are more care providers in them and not just visiting and we know for communities as often the case that people are kind of in and out and the people themselves who are receiving care also in and out of the community is very disruptive and we have just really strong examples of how this can still work. And you know when we think back to. How did we come to be here. In the first place right indigenous midwifery was was there was was part of our communities all the way up until it was removed and replaced with. Eventually what has become the current model and we have strong examples of how this can still work and can be an important way of improving community wellness. Generally and you know. Indigenous midwives are expert on our on our people we have important skills and knowledge that can offer cultural approaches to care in and approaches that are significant in hold meaning to our community people as well you know. Midwives in indigenous monroe is we. We work within the greater landscape of health. Care in canada right. We don't work in isolation either and Working as collaborative members on teams whether that is some people who are placed in the community are not. Because we're we're part of is kind of web of Services service providers in care providers. You know in wherever we find ourselves there are there are always other people involved and it's always important to be thinking about those relationships and when we think of indigenous midwifery i think you know maybe people have a certain idea of what that is and and i always encourage people to really get to know. Maybe there's a local practice of midwives are get to know the example is and how they work in the finer details of how they work within the larger landscape of maternity care And how those relationships are. Because i think they're always a lot of assumption is that working in isolation or and that's just not the way that it is done just to build on what evelyn says to me. It's not a coincidence. That berthing facilities in birthing providers in rural areas are concentrated in non indigenous communities. So for me that big some kind of reconciliatory action so at this time of trc when also has to think about the fact that in canada one of the reasons why our infant mortality rate lakes behind that of other relatively affluent countries is because we still have this persistent disparity infant mortality rates were the infant mortality rates for first nations than any would infants are two to four times higher than those for non indigenous or the general canadian population. Basically there is a need for population based indigenous specific investments in access to birth close to home for first nations and maty living in rural and remote areas. And i see three arms up this. The first would be as evelyn's mentioned support indigenous midwives. And you know we've just seen like for example a concrete policy like laurentian university is under-funded like we need to make sure that the indigenous midwifery program at laurentian is not shutdown. The second is facilities. And as i mentioned. I think i'm we have very few indigenous specific berthing facilities in rural and remote areas. So we need a dramatic mess men in these facilities and you know we saw one close. I have great confidence in indigenous midwives. with the support of other indigenous primary care providers and health service providers. I'm always say that. With the leadership of indigenous midwives like indigenous services family doctors and specialists in our allies and we can work together so and then the third piece is. We do need urgently at first nations inuit may t- reproductive maternity health survey. I think canada's a whole urgently needs like And another maternity experiences survey which hopefully would be expanded to reproductive health and maternity experiences survey It was meant to be along the tutorial survey but it hasn't happened since two thousand and five two thousand and six. I think that this survey needs to include first nations women on reserve but also to continue to support participation a first nations relatives who were living off reserve. I'm not in any week. i'm so those are the three ways that i see him. Quite i can also add to. That is just you know. There's always going to be a need for travel for birth because there was always going to be people who need that extra level of care but it's more the the routine you for two evacuation for birth or policies around traveling birth in the lack of health services closer to indigenous communities in indigenous communities Jury to which it is happening for low risk birth. that is especially problematic. And there's always going to need to travel anything. This is the thing that people always say they like. You know. it's such a small number of people and half of them are leaving the community than you. Do you have enough. I to sustain a service of any kind and is bigger than the birth itself it impacts the entire community and if we can look at it through an expanded lines around Community experiences and and trauma and indigenous rights and indigenous communities having rights to reclaim their their ways and and their own and owning their own health services and things like this just kind of expanding that view to allow for a deeper conversation about it. Well thank you so much for joining me today on our podcast and talking about your really important and interesting research spin. Great to talk to you both. Thanks kristen so much for having us. I'm kirsten patrick. Interim editor in chief of cma jay. Thanks for listening to this. Episode of the cj podcast. You can read the article. I discussed with my guests today at c. J. dot ca. The title of the article is long distance. Travel for birthing among indigenous and non-indigenous mothers in canada surgeries both in art and a science. We checked out both on cold. Steel official podcasts. Canadian journalist surgery. I'm chad ball. The co editor in chief of the canadian journal surgery. And i'm a mere for route associate digital editor for the canadian journal. Surgery each episode. We're joined by amazing guests ranging from iconic sturdiness from around the world as well as leaders in other fields such as coaching counting law. And more as we try to understand how to become better surgeons conditions and even being listened to cold steel. Wherever you get your podcasts.
"In this episode is brought to you by audi canada. The canadian medical association has partnered with audi candidate to offer. Cma members preferred incentive on select vehicle models purchase any new qualifying audi model receive an additional cash incentive based on the purchase type details of the incentive program can be found at audi professional dot ca explore the full line of vehicles available to suit your lifestyle. The audi driving experience is like no other Phenomenon of inappropriate prescribing that often occurs in the treatment of older adults cold. A prescribing cascade is important for physicians to be aware of although it's not always easy to detect. I'm dr patrick. Executive editor for the canadian medical association journal today. I'm talking to dr paula. Rochon who is one of the office of the image a practice ought to cold five things to know about prescribing cascades in older adults police geriatrician at women's college hospital and the arts. Yo chair in geriatric medicine at the university of toronto. I've reached her today wrong. Sir hello cola lou. How are you. I'm great thanks for joining me today. Disarray really interesting problem. So can you stop. I telling us what is prescribing cascade. exactly well prescribing. Cascade is something that i i saw in clinical practice when i was working as geriatrician in the long term care setting and it occurs when a drug therapy is prescribed when a side effect later develops and as a result of that. The provider prescribes additional medications to treat that side effect without realizing that. It's a related to an earlier medication and this in turn puts the individual at risk for further drug related problems complications. What are some noteworthy examples that you have seen perhaps in clinics well i. I've seen a number of them. And i think when i go back to when when i started recognizing this problem i remember again in the long term care setting being asked to see an older woman who at that time had what was recurrent and very painful gout known as you can imagine. That's not a pleasant sort of thing to have and after going through medications it it looked like perhaps this gout was being triggered by a diuretic therapy that she was being given to treat some very mild leg. Dima you know so. She had a bit of swelling at her physician. Would head started her. On a diuretic to treat that swelling and by figuring this out. And i must say it wasn't something that i figured out immediately. It took a while before we sort of saw this pattern. We realize that this was really a prescribing cascade. And when we were able to recognize it we were able to stop the diabetic and were able to prevent the further episodes of gout developing. And you know we were able to find other ways to treat on the idea that she had. That didn't involve a medication. So it is kind of interesting because the fact that this person was in long term care meant that it was somebody that we were able to see over time and to be able to see this develop but it. It did bring to my attention the fact that the sequences often not recognize. Because it's something that develops in weeks and months and people might often say oh in an older person. Perhaps a little bit of swelling might not be unusual so they may think it's it's age related and just dismiss it and it's also not really recognized as something that would necessarily be drug related so people don't really make the connection. But i guess when you see people over time and you had a chance to look for patterns. That's where things like. This became apparent. So i'm curious you said it took a little while to figure it out and it seems to me like you need to be bit of detective. So how did you manage to figure it out will in this particular case. I think i saw that individual more than once. You know I must say before. I was able to identify that sequence but it makes you realize that really important to always look at medications which is something i think especially people working with older people know it's really important to look at medications and it's important to look at the sequence of things In terms of the way they're prescribed because that gives you a clue you know. What were you on first. Then what happened. What did you get put on next to be able to help understand that And in in fact it was a very interesting paper that was led by katina piggott. Who talked about using Process maps to help identify this sort of thing. So you're able to basically illustrate draw sketches and figures about sequences of events to see how these patterns might emerge because they think unless you think about it and sort of asked specifically about it and look for sequences events. It's very easily missed and prescribing cascades. Very common do we know how common they are. So i think prescribing cascades are really common when we first started looking at this. I think we identified about three different prescribing cascades. And that's what got us thinking about it. But it's a pattern that you see so often if you really look for and when we wrote about it a couple of years ago i think we we identified over twenty different prescribing cascades and end that number has multiplied many times. Since that time as new therapies come on the market. They'll continue to be identified. Because it's it's sort of. It's a pattern that keeps repeating itself we've also When we've looked at prescribing cascades. We initially were looking at a drug leading to a side effect. That was that was missed. And then as a result of that New medical condition and another drug prescribed. We've also realized that it it also relates to drugs that are being given our or taken over the counter so it's not just a prescribed medicine so there's many of these you know as a physician you may not see unless you really ask about. What other kinds of medications an individual is taken and it can also lead to the use of a medical device. So you know. The the peace we've talked about is is one component of the prescribing cascade. And there's many such prescribing cascade but there's other pieces to it as well that i think are important so let's just stick with them with drugs. Can you talk about whether prescribing cascades. Contribute to poly pharmacy in old adult. I think they are a big component of poly pharmacy. And in fact when you think about colleague pharmacy one of the definitions of poly pharmacy is something called problematic poly pharmacy and that's when drugs are used. Multiple drugs are us in a way. That isn't really appropriate. Ended didn't providing benefit and when you look at the components of problematic parley poly pharmacy. One of the components is when a medication is being a prescribed as part of prescribing cascade. So we're not only. Does that lead to poly pharmacy. But it's part of the definition of problematic poly pharmacy and of course poly pharmacy is such a big issue for older people especially women and so by thinking about the prescribing cascade. That's one way to focus attention. On on drug therapies that could potentially be stopped and therefore could reduce the problem apollo pharmacy. So i wonder if you've given us one example from your own cynical practice with what kind of a really really common prescribing cascade leads to poly pharmacy. What sort of chain of events might we see in a hypothetical situation. Well one of the ones that i think is a pretty common. One is if you can imagine you know. Somebody comes in with some sort of arthritis. And they're having problems you know. Say with their knee and they may get prescribed non steroidal anti inflammatory drugs. You know that's something that would happen or could happen fairly commonly amongst older people in particular. And what may happen in that scenario. Is you may see an elevation of blood pressure. That may happen over time. These things don't usually happen immediately. It's it's over weeks and months at this might be noted and older person coming in with an elevated blood pressure. You know again. That might not be thought of as being unusual people may may think that it could be associated in part with age and therefore would put them on anti hypertensive medicine and that of course could put people at risk for further problems. That may cars potential harm. So that's an example. A non-surgical anti-inflammatory drug leading to hypertension. And therefore the initiation of anti hypertensive i think is an example. That is one of the common ones and you can imagine the that could be the result of prescribed medication or it could potentially be something taken over the counter. Yeah imagine that is very common. So what's the best way for physicians to prevent prescribing cascades in the first place. Well i think when when you're thinking about Prescribing you know. I think you always need to think about when you're starting the drug is you know. Is this drug needed at all. So if you're if you're thinking about somebody showing up for example wisdom. Something like arthritis comfort is possible that you could think about a non pharmacologic approach so that would be an obvious sort of place that you might wanna start but if you are thinking about starting a drug therapy you obviously want to pick something that has the fewest potential side effects associated with it and using the lowest dose that you potentially need to do so. That's sort of one of the things that you might be doing going forward but if you're thinking about the the prescribing cascade and when you're looking at a person who's in front of you and you're you're thinking about their medications. I think it's important to sort of stop and always sort of look at the medications and you know wonder if these potentially could be leading to prescribing cascade. And if they are you would the way you might identified as understanding the sequence of events that has developed in terms of how that came to be. And then you'd have to ask you know. Take a look at the initial medication like for example in this case the inside and you might ask first off. Do they need that medicine. Is it something that they need it. All could there be non pharmacologic approach could the dose be lowered or another therapy. That could be used instead that wouldn't result in such a prescribing cascade. So i think it's it's important that people think very carefully when people come in front of come to them and review their medications to determine what's needed and what's not and to think about whether they might potentially causing a prescribing cascade in terms of say might be thinking about prescribing or also looking to identify. That may already exist and therefore what they might need to do to potentially reverse that process. I find that interesting and just to share little thing of my own is. I'm in my late forties. I take ibuprofen on the regular for costs. Rightous i told my family physician about this and she said to me but you need to bear in. Mind that if you take those drugs. They put you at risk of hypertension. So i wanted if it's prudence to Talk to patients and even caregivers adults And educate them to be aware of this phenomenon that they might need to think about in the future. I think that's a very important piece that we must think about doing. I think it's very important to involve patients and where they're involved caregivers in that whole process so making people aware of what some of the potential issues might be related to the drug therapy so if that were to occur they would know perhaps what it might be related to in allow them to ask questions about their medicines so i. I think that is a really important thing that you want people to do. It's also i think one of the things that strikes me is often. It's difficult for people to remember for example why their drugs were prescribed and when they were prescribed and so. If you knew that information you could often understand perhaps the sequence of events you know what you were prescribed first and then what happened next which would make it easy to start to see. Some of these problems emerge and i think that relates to the way we prescribe and very helpful for patients for example to have the list of their medications to have the dates when they were started and to have an understanding of the kind of benefit that they expect to get from those medications but also some of the common side effects So they're aware of these of these things. I always wonder how easy it is for people who aren't a fair number of medications to keep track of them and when they were started. So i'm thinking about somebody who has admitted to hospital in. A medication was started on discharge or started by specialist at the family. Doctors know about and how feasible it is for them to keep track of which doctor prescribes which medication but probably useful for them to do that. Right yeah i. I hear what you're saying. We obviously have systems to do this. We have electronic systems that we can use and we should use for this purpose as well. But i do think it's helpful for patients to have that information wherever it is feasible. Because they're often the ones that know a lot of this background information you know why it was started in when in the circumstances and so i think it is really important for them to see that and also when we think about prescribing cascades. They often happen in my view. When care becomes a little bit fragmented shall we say so for example one of the ones that we talked about a lot or early on we wrote about that i thought was important. Was the use of coal industries inhibitor. Medications for the management of for dementia and one of the complications related to that is that people often developed urinary incontinence. But it would happen. You know down the road you know months down the road but what might happen. An individual would be referred to a urologist to have that evaluated and so they were sort of. You know somewhat outside of the of the initial decisions around the therapies and they may go on and Suggest investigations and further drug treatment without it necessarily going back in time back necessarily to the medications and so it's it's important that sort of this sequence of events is always brought back and brought to people's attention because i think these prescribing. Huskies are more likely to happen. When it's it's different settings and involve settings of care and different prescribers also involved in the process so it is complicated. But i think there are things that we can do to help prevent them and when they're identified to make sure that Where it makes sense that they're reversed now if it if physicians done their detective or can they've identified a prescribing cascade in patients determining that the symptoms are in fact in advance reaction to prescribe drug. What's the next thing they should do. Well i think that the first step is i think they need to recognize it and they need to sign what the appropriate approach might be so in some cases it may make sense that they recognize it. But it's something that they decide that they need to continue with. In in other cases it may be that they can take other options to sort of minimize the side effects. So for example. If we're looking at the one. I just mentioned about colon. Ashtrays inhibitors leading to incontinence. You know the decision might be around the use of the cholesterol inhibitors. Did it provide benefit and if it was providing benefit. Then maybe the decision would be that. Therefore we will treat the incontinence. And that's going to be how we're going to focus our management but it if it wasn't providing the benefit that you wanted then people may go back in question the need for the original drug. So i think physicians have to take the information and then customize it to what the best approach and answer is for that individual so in the case that You mentioned earlier around the idea of an end. Say being used to treat some. Let's say some knee discomfort you. Would you could look at that. And if a person was on an end say for this neatest comfort ended up getting some hypertension report on an anti hypertensive and you look at that scenario and you said goodness That knee discomfort could be managed with the non pharmacologic approach. Maybe it was exercise or something like that. And i don't need this drug than you're able to stop the medicine for the hypertension and stop the end sade and take away those additional risks and that would be of great benefit to the person in another scenario. Maybe it means if you feel that they do need some of that medication maybe they could just reduce the dose and that may minimize the impact in terms of hypertension or in some cases. Maybe the discomfort could be managed with the different Sort of Medication like perhaps the benefit could be adequate. So people have to kind of customize their response to the individual. There's not always a single right answer but the important thing is i think people need to recognize it. Because in many cases it can mean that a- doses are reduced or drugs or stopped and then That not only takes away the need for possibly to medications but in some in some cases this cascade is gone further than just that and there's been other medications involved as well so i think it's It's really important to think about that. And then to figure out obviously how you can minimize that impact. Now these articles five things to know in practice already handy tips for practising docs to keep up to date and often the people who ride them have a particular agenda we want people to know about this conditional. We want them to know these particular things about it. So what do you want physicians to remember about prescribing case. That made you to write this article. I think we want physicians to think about it. And so success. I think is that when you have a patient that you're seeing who may be presents with the problem maybe somebody showing up with With hypertension you might be asking. Could it be related to that in. Say that they're on and you need to be starting to think about whether the medications that the person is on could be contributing to this prescribing cascade kind of process because you you really want physicians to sort of ask those questions so that they can really look at the medicine that people are on and make sure that people are only on the medicines that they need to be on that such an important strategy for our reducing poly pharmacy as we've talked about but also the risks associated with poly pharmacy and it's particularly important for older people and women who who are likely to be on more medications paula. Thank you for joining me today to talk about this short practise article and expand on what you've written in your one pager. It's been great to talk to you. Thank you very much. Thank you for the invitation. Thanks caller. i've been speaking with toronto. Jared attrition dr paula on to read the article she co authored visit. Cmha dot ca. Also don't forget to subscribe to see him. Aj pod costs on soundcloud or podcast app and let us know how we're doing by leaving a rating. I'm dr patrick executive editor. Cmag thank you for listening.
Involving patients at CMAJ
"Francine buchanan and her husband were overwhelmed as new parents. This is because their son. Cristiano now bubbly and social eight-year-old who attend school and camp was born extremely premature. He was hooked up to several monitors and machines constantly for the first years of his life. The experience led francine to become involved as a patient advisor at the kids and to pursue studies in health services research. Today i'm talking to francine about her experiences as a caregiver and as a patient adviser will also talk about an article she's written. Cmha it's part of a special journal issue that's devoted to patient involvement in healthcare in research and at cmag at so. I'm also chatting with victorious cycle lead of patient involvement at cmag to discuss how cma jay is starting to integrate patient voices in journal governance and content. But first my conversation with francine right after this short break. This episode is brought to you by audi canada. 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Please call one eight hundred three eight seven seven three seven four learn more at Dot ca Hi francine i there. Thanks so much for joining me on the podcast today. So i tell me a little bit about your son. Cristiano so christiana is an amazing little eight year. Old boy He was born quite premature with a twenty six weaker and immediately upon birth He had a number of birth defects in essence he had thirteen surgeries and A lot of other procedures in the year and a half he spent in the icu. Hospital mcintyre year and a half. I was by his bedside. And that was my introduction to health care and the i was right into the deepa. So he's eight now and this has been quite a journey for you. I mean and i was thinking when you said it was my introduction to and i was thinking you were gonna say being parents and shuddering to think how that must've been. Tell me how you felt for those first. Few days and weeks when your son was discharged after Being in hospital for so long yes has so. Imagine a year and a half. In the icu. So always having a team of nurses and doctors the push of a button and then we were discharged home and my son required a ventilator a catch to a tracheostomy had a feeding hump and he required supplemental oxygen so we had to monitor that as well so anytime he was awake or asleep he was attached to about three different machines at the same time. And all those machines we had to learn we had to figure out and we had to manage Basically twenty four seven. So you can imagine that Going from a doctor to push of a button to it being my husband and i you know by ourselves except for immersive at night more trying to sleep. It was a little bit overwhelming to say. The i can imagine it. Does your son need continuous ventilation. Or only intimate. So he required continuous that television for the first four years of his life. I'm we eventually weaned him off and now he is only ventilated at night But for the first four years you're required supplemental oxygen and full length elation to the point where you know even if he was disconnected for Near seconds you could see the color of his lips start to change blue and he required immediate intervention. I'm trying to put myself in your shoes. So the prospects of bringing your son home for the first time. Did you feel that it was something that the hospital gave you a lot of confidence in your ability to manage or did you feel absolutely overwhelmed. Undaunted interesting feeling because for starters you want to get home you know. There's nothing more that you want then to. Especially since he was hospitalized right at earth is nothing more that you want than to bond with your child to be in your house. Do you wanna get out of the oslo. You really really do. But at the same time the prospect of leaving the hospital where there is that safety insecurity having healthcare providers around you. It is a daunting prospect. So you would hope that the hospital gave you all the support you need it but honestly you don't know what kind of support you may never lived outside the hospital with your child before so it's hard to think that you know. Did i get all the training. Did i listened during the training. Did i ask the right questions. Those are all questions you can't really ask because you don't know until after what that feeling is like or what the needs are you require so the difficult question to answer because you just don't know so what did you face the first day that you were home a lot of sleepless nights so you can imagine you know. We brought home with us. The same beeping that you hear in hospital route right. So you know. The beeping of a pulse oximeter the beeping of event. That's become disconnected the beeping of feeding pump demanding more food than me put into the bay. All those speaks came home with us but we were now the ones in charge of addressing those. You're constantly on your toes. Did i hook up everything right. Did i do everything so you know. Those first few days were relieving. Because now you were home but incredibly intimidating incredibly nerve-wracking don't think we left my son's ru probably for the first. You know two months except to leave to catch a nap in another room because it was difficult for him to move you know. We had to move three pieces of equipment at the same time But it was also you know. We didn't want to move anything because we didn't know what would happen if we moved. It would remove it incorrectly. Something go wrong so you know. We can't out in his room and we made the best of it and we did all the things we needed to do. To catch. Up bonding repleting. The story times those sorts of thing. But you know it was still a stressful process. But again you're buoyed on by this prospect of like. We're not an awesome. This is our. Did you feel that you had direct line to the hospital. They were open to you calling needing help asking any questions that you wanted. It's a difficult question to answer because we were always told and you always hear this. We have any questions protocol. Where here have you need us. But what's a silly question. When are we bothering. We spent a year. And a half that i see. We knew how busy they were. We knew that you know if we call the front desk. They had to find a nurse and to find a nurse who knew who we were renew. Christiano a new his needs and then define find them. But they're probably busy with someone else do you don't wanna bother people necessarily and if it was a dire emergency than we were already in the car to the hospital or we were already calling nine one one. So it's an interesting question because you don't know necessarily when it urgent enough to call not urgent. Maybe you can figure it out. Maybe should figure it out because this is your responsibility. They sent us. Hope we should be okay. Those are all the messages you hear. Which kind of a little bit louder than the follow me need anything absolutely now. You've made this journey to being a leader in patient involvement advocacy space at the kids. How did that journey happen. You don't know how it happened. Actually it was largest little steps here in there In terms of being a patient advisor on a number of different projects. Also learning about patient advisory through my graduate studies and seeing how i could involve patients in my studies. And then some projects that evolved around you know. How do we train for this. How do we include the patient perspective. And how we teach patient in nature to other researchers and then The opportunity arose for a job at sick kids to manage this. And i applied and got the job and now i find that unbalancing a lot of different perspectives in terms of you know. How do we develop the space so that it includes the patient voice the family waste but also keeping the needs and minds of researchers not unlimited budgets. There's not a lot of time to do this work you know. So how do we make it efficient. How do we make valuable for patients. And that's kind of the worst undoing now and it's a really accumulation of different areas around like francine. Do you remember the first time you were asked to participate as a patient perspective in a research study. How were you approached. I don't think i was ever approached the first one. I think it was me just kind of a slightly asking. The questions slowly insert myself so when people ask me. What was my introduction to research my introduction to research. I didn't start my graduate work. My son was discharge from hospital. And the reason that i started my graduate work was wanted to be involved in research. What keith to. My interest was really sitting in that room with my son and every once in a while being asked to complete a survey every once in awhile asking we would consent to being part of a research and it was in those moments that i would read the survey and ask me a question like you know. How do you rate something from you. Know least impactful to more impactful or least important to more or but the questions were asked that were relating to my life. Those questions were worded in a way that made sense to me you know. How can i answer a question about a what is important to me when my entire life of my child had a situated in a hospital. What does it mean to be asked a question wallop patients in a hospital. And it's those sorts of things that you know. I would say to the researcher after you know. Just you know this question. Kind of make sense to me. So the way that i answered it might not make sense to you. And then having those conversations afterwards is how fully got involved in advisory work and then after that it was really around going to researchers in saying you know. This is a problem that i felt. How can we make this better. And it was really those conversations. I call them. Elevator talks where we would be sitting in an elevator together. How's things going in all this. You know this aerobic problem. I was thinking about it is there. Women can do this as a solution. And that's really how i got involved in this live project. And that's really how i got involved with developing solutions with that linkage to supporting patients going home from hospital and when you are having those conversations and asking those questions how hard or easy was it for you ask. Them and get answers was never hard to ask. They were always burning questions. They were always questions that i thought if there is an answer i'd be happy with what the answer is right. If if the answer is a we already tried it and it didn't work happy with this. That is the harder part. was trying to understand. Why when solutions were so prevalent and we knew kind of advisors from different areas why it was so hard to get implemented. That was the challenge for me to understand this world of research in terms. Of how long does it take. What's involved in it. Those were the harder things to understand because the short the were so understandable to researchers like oh we need a grant or we don't have funding for that didn't make sense to me as an outsider and slowly learnt what those things are. But i think those are the big challenges for me to understand what is going on here. I don't get it seems so challenging and so difficult but the answer seem to be already there. Identify with that as somebody outside oxides the world of academia and seeking of grants that. It's it seems like a bit of a black box that only those people on the inside know anything about so. I'm curious what you think. The main challenges of involving patients in a meaningful way in health research are emmy the biggest challenges at the health research and academia is such a stringent strict protocol. That is going on for years and years and years. There's a way to do things and everyone knows that we'd six as we start to change and think about well. Maybe there's a different way we could do things in respect to being patient and family oriented or there's a different way of doing things in terms of capturing that insight from the patient It's hard to incorporate that with the existing systems and services in procedures applying for grants things like that it is a world that is unknown to though outside of the so when you try to incorporate these ideas of patient involvement. It's not only the practicalities of it. And you know how do i do. How do i get in touch with someone how to find the patient but it's also in the processes into a system that existed in a certain race along we are attempting to engage in an that is not familiar to us but the experience of healthcare is very finale. What we're trying to do is engage in that aspect that is at background. How do you support the methods us. How you know rights the things you write become a store all that background stuff or not familiar with but the front end of healthcare. Were very very familiar. I think putting that message out there will make people who are engaging in healthcare. Understand that you know we need to listen to the story because it is a precursor for something else. Don't question the story. Take that story and figure out how we can integrated that behind. The healthcare has changed over the years. You know we used to shield people in the hospital. Send them home. How now we are experienced in healthcare in the community. Much much more than we ever did before in that community. Experience of healthcare. I think is a major gap medical teaching in medical publishing. In you know. I think that's the area that would help to improve. The experience of healthcare is no longer just a hospital experience. So i see us sort of a parallel actually with the with medical publishing medical publishing a bit of a black box except for people on the inside who understand it and and it's difficult to involve people who don't understand the dynamics and cj is trying to Increase patient goldman in the journal in the running of the journal in co authoring of articles. And we're really happy that you've authored an article for us. How do you think journals could make patients more involved in medicine or help to make patients more involved in medicine. There is definitely a parallel again on medical publishing has been in a way of for a long long time. And you know. I'll take for example. The idea you know. Peer reviews cornerstone of academic publishing. The others have taken a look at your work and question it in a way to make it better And question it to filter out research the that might not you know beat the highest of standards and when you consider that when you're bringing in voices from other areas it might be difficult just even on the onset to to think about how we integrate those so patients in patient stories are truly just ends of one right so we have a story we filter experienced through our lives and then we tell our story as much as you know we try it integrate other people that have similar stories. We still are an that doesn't work in medical publishing you'll look at. How many survey respondents there were you look at. You know how many others have looked at were there you know three peer reviewers to peer reviewers you look for multiple people to look at something and say yep. This looks like something that has you know. What n of a thousand in that makes it. So how do you integrate these to view. How do you you know expose the values of that page should story within the context of you know the majority or a large population size statistical significance. It can be challenging. The other challenge. I think in terms of the parallels is that for many patients advisors asian family advisors. They work alone so they might be the only adviser on a stud. They might be a you know maybe one other adviser but they really aren't going to contact with each other and that comes from the world of medicine where each patient is kind of separated from each other. We don't wanna share anything to confidence but that also happens in writing we write as individuals and when we get the feedback from the peer reviewers. We had to absorb that feedback as individuals and sometimes that can be very challenging and that can be difficult and sometimes you need that tough skin to say i'm gonna persevered. I'm gonna get a story out there but you don't always have the confidence. Your story matters. The your story is the same story as someone else or that. Your story is even the story of you know. Sometimes you even question of. That's your story of view. Misinterpreted your store. That's i think the big challenge of. How do we build a community to support each other so that we're not just individuals. Writing stories individually is so now. I know that you have feet in both camps now. Because you're a health researcher yourself and you understand health services research so you get pair of you. May i ask you about your experience of here review for the article that you've written for this issue of cma jay. How receiving that feedback. The it was interesting because it wasn't the two sides of my brain trying to figure out the peer review. So you know. I'd get some one review that was very complimentary promoting inclusion of the patient voice but not enough criticism. There must be something that i could do that. Then you get the other side which with almost critical of the patient voice in the same way that you would be critical of someone doing a scientific research that questioning if the message was shared in the right way or questioning. Why did you not expand on this part of the store. It's a very personal story. That i was telling which was very vulnerable for me as well and there were parts of the story that i did or back because i didn't want to be exposed in that way for my own personal affection so to be asked your widened. You stand on this little. There's a reason they didn't want to extend on it. So you get the two sides of it you know. I want constructive feedback. I want to grow. I don't want to necessarily be accepted simply because of the patient story. I think that there were things that could help me write it better but also i want to be viewed as a patient story with vulnerabilities. You know with being exposed and considering that in the so it was interesting. I think i did need tough skin to get through it. I don't know of all advisors would feel as positive as i did. But i think it's something that is not an easy solution. It's to be something that has to be worked through with multiple advisors feeling different emotions with a review process and then figuring out of come out of so editors in our patient involvement lead at. Cmha are learning. I think about the different ways that patient experienced peer review. So thank you for that and thank you so much for contributing. You're in one story. How is your son. Doing now is an amazing eight-year-old. All of energy for a child to we were told would never speak a word. We'll talk your ear off. He loves people in. It's amazing to think about a child who spent so much time in hospital that he might be fearful of older. People are fearful of people in general and i have to give props to the caregivers at the hospital for sick children because of them he loves people and I smile as i say this. But you can't hear a microphone. But i smile because of he is everything that they told us she would never be francine. Thank you so much for joining us on the same age podcast to discuss your article and your experiences and your beautiful son while thank you very much listening and getting the story of channel but also the story of patient engagement out there really Francine buchanan is a phd candidate at the university of toronto. A patient family adviser a research coordinator at the hospital for sick children and mom to cristiano. Buchanan you can read her article on. Cma dot ca or you can find a link to it in the show notes. Next up victoria single lead of patient involvement at c. J. victoria joins me talk about the steps. She's taken over the last year to integrate patient. Voices at cj at many levels victoria. Hi and thank you for joining me. I think for having me on this one so victoria you've been with the journal for about a year and i remember we recruited you on the editorship of dr. Andreas pakis who was keen to advance. Imbedding patient voices at cma aj and within cmha. It's been a bit of a a ride during covid nineteen sa- joined the journal at this time. But you've done a huge amounts of work so tell us what you've been doing to improve patient involvement and engagement at cma group absolutely. So i'll start off by saying that. None of this is something that i've been doing alone obviously team. We've all been working. Quite closely members of c major staff as well as patient partners that have been on board with the journal in terms a specific ways that we've involved patients in may j. I kind of think of it as direct and indirect involvement so in terms of direct involvement of patient partners in the journal We have patients partner sitting on a number of different boards so before giant andres. The pockets had brought onboard. Jim miller and beeson dumont who are members of the editorial advisory board that provide input to the editors in editor in chief about directions that the journal should take up to patient partner sitting on the practice advisory which provide feedback about what topics should be focused on the practice section of the journal. In what form would be best to explore those issues. we've also for the past year formed. What we're kind of patient core group which is basically a small group consisting four patient partners and two that have expertise in patient partnership from a policy. Health care researcher sort of angle so couple of concrete examples of things that we've been working on in that group have been developing compensation policies to add pay. Patient partners are teams as well as authors that we commissioned to write pieces for cj providing a patient or family perspective. We've also worked as part of that group to develop an evaluation plans that we can take a look at all the initiatives that seema is doing around patient engagement going forward and see how well we are involving pupils voices in whose voices were involving in those initiatives and finally as printed group even put in a lot of focus on developing supports for patient authors other authors that might be new to the academic publishing process to make it more accessible to people on top of that over the past few months we started involving patients in our peer review processes starting off with the three sixty cases which i'm excited that we're launching this part of the special issue. We've also been working to help support patient. Authors were patient co-authors to be involved in the journal Involving patients as interviewees on podcasts and also seem marijuana's leading the series called the patient portraits in which she interviews into the profile on patient. So those are a couple. Direct waste patients are involved and then in terms of ways that we've been trying to indirectly involved patient priorities in everything. You do a big focus that we've been taking a look at is how can encourage patient authorship and make it easier for those working with patients on their teams to recognize their accomplishments in work when submitting to the journal. So one of the things. We've been taking a look at quite closely is looking at our submission processes Our instructions to authors to those clearer and more intuitive for people new to the process. We've also changed our online submission platform by adding a couple of questions for non patient authors. If they're the corresponding authors who they can indicate if there is a patient author on the team or if patients involved so that we can have take a look at those submissions and understand if additional support may be needed on those teams. And we're also asking that any research. Submissions that come in that have patient involvement also complete. What's known as the gripped to questionnaire which is basically reporting guidelines for patient in albany research as much before another couple indirect ways that we're looking to involve patients in seamy j. over the past year developing policies like already alluded to for patient authorship in compensation and we've also been exploring ways that a patient partners on our team as well as patients outside the journal can help identify priorities for topics that should be covered in our content going forward as well as ways to explore adding patient perspectives to more clinically focused content. That journal is already publishing. For example by developing linked or clustered pieces similar topics with a slightly different angle. So those are a big list of ways that we've been working to involve patient perspectives over the past year. And i think what's really key to know for everyone. Listening right now is that our plan is to continue evolving process with time and these are just the first initial steps. We wanna make sure that we do it right and to do it right. We have to go slowly and carefully and and really take a look at what we're doing in how can make better so you have done a lot of work a lot of level setting baseline groundwork for growing patient involvement in the future and that's great and we can talk a little bit later about how you are going to evaluate it and grow it in the future. I was just wanting to come back to. What do you mean what do we mean at. Cj when we talk about patients your great question so at cj we've chosen to use the charges for which is the cato institute for healthcare research strategy for patient oriented research. They have a very well established program for patient engagement in canada and they specifically divine patients as people that have experienced with a health condition as well as their families caregivers informal caregivers such as france. Let's talk about why. Cma doing this. Why is it so important for us to involve patients in the generation of health knowledge and Health policy yeah. I'll provide a brief answer here. But i would also recommend anyone who would like more information about this to check out of her statement of purpose for patient engagement which is available on the website but very briefly. Cj mission for a long time has been to publish knowledge that matters about healthcare and by involving patients. In what we're doing now that's answering the question of knowledge of matters to who and what we think is that by involving patients in the journal that encompasses the knowledge that matters to all canadians. That's inclusive of academics clinicians and people with a lived experience canadians who pay indirectly for the healthcare system in have a stake in it working well. In being able to achieve optimal health so a couple of key reasons specifically for the journal the patient engagement spartan his one to respect value integrate the expertise of patients who've gained this expertise through living with their condition day in and day out and so may have different perspectives on outcomes that are important or ways to improve the system that may not be seen or may not be recognized as being quite as important by those working within the system who may be only time to speak with patients for a very short amount of time during clinical physics. For example. a second reason it's really important to ensure justice fairness and equity within our journal and in candidate general patient voices are often left out of discussions about the healthcare or included. They may not have the power to enact. These changes so by working to make sure that. Cj not only includes patient voices and perspectives and what we published but encourages end encourages partnership among academics and researchers. It gives attention and more power to these voices. Third of all at cj specifically help produce more relevant and helpful content for our readers because having people who've lived experience veggies engaged in the journal says understand what their priorities in perspectives are and therefore increases the likelihood that the content that we publish. It seem may jay is meaningful and has benefits for the people. They're ultimately intended to help. We also think that it'd be a huge benefit for readers who are mostly academics finishes people interested in healthcare policy at this point because it provides a different lens to think about their work and different angles to explore. That could potentially make it more helpful for the people that that they interact with every their patients Participants were partners. And then finally we think that involving patients in the journal will help improve practice overall because hearing from patients about their conditions. And how the care they received from the healthcare system affects their life. will also help understand aspects. That work really well for people in potentially those that don't and can potentially change practice in future to be able to better help those patients in people who come to them. So i'd like to hone in on what you said on your first reason why we are in. It's important to involve patients. Were you said that patients are expert in living with their conditions. And i think you know talking as a as a doctor who has practiced. I think the way we are taught doesn't necessarily encourage us to understand that knowledge lives in different places. It doesn't only live in the things that we were taught at medical school and it doesn't only live in clinical experience but that patients themselves have this lived experience of a condition and it's about censoring that knowledge and providing a platform for that knowledge. I think so. I'd like to move on then to talk about a new kind of article that we have just now started to publish that. We've been planning for a long time. And it's called three sixty cases and the reason that we call it three sixty cases after thinking about lots and lots of different names is that we wanted to create in this article category. They perception of looking at the health care experiences off all different players in a single encounter. So the these three sixty cases are ringing off the ship in a new way to the journal. Because we are always going to have a patient or caregiver as an author on the three sixty cases and then that will be alongside A reflection from a physician or a social worker or psychologist or somebody else a knee interaction. Which you like to tell us a little bit about the process of developing these three sixty cases. Yeah absolutely so one of the. I think the goals that we had in starting to think about breeding this new article format is finding a place to talk about some of the interpersonal stomach aspects of medicine. That aren't covered off another practice articles in the journal which is where this one will ultimately land and really our hope with that will open conversations about problems out or barriers to receiving care providing care That may not be talked about quite as openly by have a real impact on on everyone providing karen receiving care that deserves more attention so a really good example of this that i remember coming up in some of our early discussions about creating the three sixty cases is that when receiving medical education you might be taught how to treat stroke but not necessarily had a treat stroke in fifty two year old. Who's a single parent with. Two young children lives an hour away. And i think it's getting to the fact that there are many different actors of play in that. No illness happens to people that are embedded in their full lives. Everything that they wanna do that publishing these three sixty cases in highlighting the perspectives of many people involved in the encounter recognizes that everyone faces constraints and pressures whether they're at work and trying to deliver the best care that they can or receiving care. Yes we have just published our first three sixty case but more in the pipeline. So watch this space victoria. Are you looking for more patient involvement than where currently have and How are you going to work How well we're doing in involving patients. Yeah absolutely so if anyone listening to this right. Now is a patient themselves for working. A part of patient partner team at are interested in being involved. Please contact me so immediately. There's three things that were looking for more partners to come on board with us. The i would be a getting more involved in our patient. Peer review process. And so if anyone wants more information about that please contact me. Ride more information will what would be involved in. See something you're interested in Also just in general were looking for more off articles that are written by patients or co-authored with patient partner teams. So that's something that you think you'd be interested in. I know it can be a little confusing to know where to start. And what seem ages requirements for article. So i'm happy to speak with anyone to get a sense of what they might be interested in writing and what seems genuine need to explain that process a little bit more and then finally one of the things that will really be looking for next year in a particular looking to recruit patient partners for in the fall. Is we're going to be creating what we're calling patient perspective word which will be in more of a long standing board of the journal which will be include people with academic research and experience backgrounds working together to continue developing kind of the structural components of what. We're doing it. Cj but in particular looking not topics and things that the journal should prioritize in terms of evaluating content and particular themes and developing related articles. That i've talked about before anyone interested in either learning more better program going forward or to be kept in the loop about calls for treatment happening for that in the fall again. Please send me an email in terms of your second question is about evaluating our patient engagement program with time We're actually going to be looking at a number of different dimensions. So the first it will be looking at what seem ajay's actually publishing that involves patient perspectives. So taking a look at who are patient authors. How many are patient author teams etc The second will be understanding the perspectives of patient partners on our team about how they think. The program is running and also formation about who they are Across all the different activities. Because we wanna make sure that the voices that were embedding within our teams in and join us on our teams are also reflective of many different experiences different canadians across the country in different provinces different disease areas. So that's something that we'll be looking at throughout the coming years in journal and then another component that will be rolled up at some point. Tvd will be understanding what our readers think about the new patient engagement initiatives and if there are any areas that they would like to hear from patients as well So those are a few different ways but we're hoping to evaluate all of these areas on an annual basis To see how that changed time in ultimately we help that you amount of patient voices. The perspectives being given Increase and are increasingly diverse. As well his time. We'll thanks victoria. Security dodge undertaking. And i feel so proud that the journal is doing this. So as you said folks who are interested in participating or learning more about can be such with you. Thanks for talking to me today. Spend a great chat. And you've victoria. Segal is lead of patient involvement at cmha cj spurs. Three sixty case explores the end of life of a woman who pasta away suddenly after an unexpected serious diagnosis. It also looks at the experiences of her family and health care providers the article co written by the woman's husband her social worker one of her nurses and the icu physician who treated her at the end of her life. We encourage you to read it in this week's patient. Engagement the issue. I'm dr kosten. Patrick interim editor in chief. I see a thank you for listening Surgeries both and art and a science we dissect. Oh both on cold steel. The official podcast. The canadian journal surgery. I'm chad ball. The co editor in chief of the canadian journal surgery. And i'm amir for rupe associate digital editor for the canadian journal. Surgery each episode. We're joined by amazing guests ringing from iconic stirred insp around the world as well as leaders in other fields such coaching counting law. And more as we try to understand how to become better surgeons physicians. Human being listened to cold steel. Wherever you get your podcasts.