20 Episode results for "canadian medical association"
Voice In Canada - Canadians are Embracing Virtual Health Care through Alexa
"Skills hair hope you're having a great start your week. It's terry here and i've got some interesting being news that came out of a study about canadians and healthcare and voice technology and there was a study done recently by the canadian medical association and it shows interestingly. I happen to be very interested in this because i am a physician is that people canadians are now starting to embrace the idea of having their healthcare delivered by a voice technology smart speaker such as amazon lexi serey or otherwise in fact back. The study shows that now forty six percent of canadians support the idea of going digital and they're willing to entrust their personal information to devices like lexi. I i find that number very interesting because there's always the conversation about what about privacy and in some ways it's similar to banking right. I mean we bank online or bank. Thank using voice technology. There is that similar element of having protected private information so i am very curious about your feeling on this. Would you be willing to get which some of your medical care through amazon lexi hit the twitter dr terry fisher d._a._r._t. E. r. i. f._i._s._h._e._r. and i'd love to hear your thoughts on that looking forward to hearing from you. Take take care brief cast dot f._m.
Dr. Alika Lafontaine becomes first Indigenous president of the Canadian Medical Association
"From cbc podcasts and the fifth estate brainwashed is a part investigation into the cia experiments in mind control from the cold war and m. k. Ultra to the so-called war on terror. We learn about a psychiatrist who used his patients as human guinea pigs. And what happens when the military and medicine collide. Listen to brainwashed on the cbc. Listen up or wherever you get your podcasts. This is a cbc podcast. for years. Dr leaker lafontaine has been seen as someone with an important voice in canadian medicine. He's listed on the medical posts doctors with sway a list of the top thirty most influential physicians in the country. Now that influence will come to be felt in a new position. Dr lafontant has been chosen as the next president of the canadian medical association which represents doctors across this country he has an anesthesiologist and grande prairie alberta. And we'll be the first indigenous doctor to head that organization. Dr lafontant good morning. Good morning why did you want this position. I didn't really map out. My leadership journey to arrive here but i think in the past year with the pandemic. It's been pretty clear that the weight of a lot of the pressures with an assistant and following on top of the shoulders physicians and looking around to my colleagues in my own experience. I really felt like. I wanted to do something to make a difference. And that's one of the reasons why became involved in the in the election campaign. I mentioned in the introduction that you are also the first indigenous dr to lead the. What does that mean to you. I think that it's it's a moment where people get you re frame expectation for what the canadian medical association gets Anytime that you get a person who has a different type of lived experience and for those who are indigenous can see their own people within these leadership positions. I think you trigger an opportunity for people to hope for something different. And i think that's the real promise of you know diverse and inclusive leadership positions as we can imagine a different future. Let's talk about your lived experience. He come from treaty. Four territory in southern saskatchewan. What was it that made you want to become a doctor. So when i was young my mom used to talk to me. Lots about her experiences within healthcare system and as i got older things became more specific. I have a memory of my mom actually coming on the very first day officially became a doctor's she'd come by me walking around the hospital with you know my white coat and stethoscope seeing patients and other things and she shared with me. Just how scary it sometimes to come into the health system and how relieved she was that if she got sick. She'd have some that she could trust to help her navigate system. That's often very complex. And at times unfriendly to patients and i think for me becoming a doctor was really a way to circle back and make sure that my family felt safe and was seen when they navigated the system. Now that's obviously scaled to including patients who experience regionalization and other types of disempowerment. So not just the digits but other people experiences like sexism ablest mc cetera and. I think that that's one of the focuses that i really wanna have and my role as president-elect and moving onto the other roles. Cma what did she tell you about what she faced in the healthcare system. She shared some specific experiences where she felt like trust and communication wasn't as that she would have expected She talked about feeling like she didn't have the same sort of choices other patients and you know as a provider i have a perspective kind of layer on top of that experience where i know that in the ways that we talk in the ways that we present information and in the ways that we accept true that comes from patients often leaking frame the relationship in a way where patients do feel these ways. You know. I never say to any of my colleagues at any of us ever come to work wanting to harm patients but because of the things that we've inherited through this culture of colonialization that You know it's been a part of history and because of the way that medical culture just starting to tap into understanding this disempowerment. I think it's a real risk for patients and something we need to address. I think of what happened to joy session. Quan who is a young woman in quebec who recorded and posted on facebook the last moments of her life in a hospital where she was in great distress and screaming in pain and you heard healthcare providers in the Making degrading comments calling her stupid. And what have you obviously. It's not What happened with your mother is not as extreme as that but did sound familiar to you. When you learned that the story of choice astrakan. I think one of the things for canadian. Just understand about racial ization within the healthcare system is the first time you see it. It's never the first time the fact that joyce went out of her way to start that facebook live as a way to documented. Validate her lived experience. I mean she must have gone through that many many times. And i think that's what you heard when you talk to her family and her friends who knew her and went through some similar experiences in the area that they receive care When you look at the continuum of discomfort and pain for people who experience this disempowerment. And i think it. It speaks more broadly to use the experience with healthcare system The question isn't really whether or not it was worth i think. I think it's whether or not it's crossed the threshold of whether or not it should be a part of healthcare system. You know patients should be able to come to see physicians and other providers and just go through their experience in the healthcare system in a way where they feel empowered and trusted and can have faith in their providers to make decisions that really co create this pathway through you know disease complexity and i think that we struggle sometimes when it comes to certain patient demographics and that's a cultural thing but also thanks to its stemming problem where we haven't made the proper investments in resources and because of that we increase in magnify these experiences. And if you don't have that trust again in conversations that i've had with joyce family. They talked about how they wouldn't trust the system that they wouldn't go if they were in distress. They wouldn't feel comfortable going to the hospital or seeing the doctor. What's the cost of that absence of trust. There's a. There's a different definition of health and wellness that i came across where it talks about it being ability for someone to manage their disease process. He's without the assistance system. You know and depending on the social context that you live in that may come earlier later in your disease process now for persons who lack trust and expect negative experiences when they come into healthcare systems that that threshold often a lot higher. You know you may wait quite a bit longer with a chronic disease process before presenting. And you'll be sicker and more complex and have less of an opportunity for the system to intervene in a positive way and that burden of health and sickness is worn on the shoulders of people who are disempowered and not only. Is that morally not right. It's also just bad medical practice. It's always more cost effective for the system when we intervene as early as possible. And i think that it's just better medical practice to make sure that we create these environments. That are free of hostility so persons can feel safe coming to healthcare. So how do you go about addressing that you have said that you reject incremental change in some ways is it. Is it just about who is in the room or what else has to happen so that that systemic racism that you've talked about that it's the health minister has talked about that. The minister of indigenous services has talked about that is addressed in a meaningful way. How do you go about doing so are multi-layered but in reality. They're not very complex. You know anyone who's lived experience. Where they feel disempowered they can imagine themselves and what they want. In order to create a system that actually eliminates a lot of hostility. That's present i one of the things that the canadian medical association has been working on and part of the work that i want to carry on is changing the culture of medicine. You know what we feel is reasonable. What we believe is normal at one of the things that came out in clear out of the experience of choice was that there was a normalization of this behavior. You know within within systems people do things that they feel are reasonable and they feel that they don't have to be afraid of repercussion. You know so when we're mean to patients when are hostile to patients and examines. It's because we feel that it's okay for us to do that. And part of the cultural change that needs to happen is to reset. You know those expectations. And i think more broadly. It's important to really communicate and translate to the general canadian population that if one patient as disempowered that means everyone can be empowered. You know having those abnormal expectations eventually bleeds into everybody's experience and that's something that we need to make sure that we protect our system against told the court that i'm wrong to talk us. One small man giant wheel. I do wish say official that. I'm wrongfully imprisoned right now. Uncover season seven dead wrong killed pepple if they guess maybe not available on. Cbc listen and wherever you get your podcasts. You're smart funny friends. Who always seem to have the best celebrity gossip. I'm talking about the ones who always know. We should be watching reading or listening to or what have you could pick their brains. Every week pop chat is a brand new podcast. But does exactly that and feels like spending time with your best friends so join me. L. levin mood and a panel of the smartest culture that i know as we dissect the discourse but also have a great time doing it. You are taking this role as we come out of. Hopefully he said with his fingers crossed. this pandemic that we've been in for the last year and i wonder what you have learned about the state of of health care in canada. Three colored i think the pandemic has accelerated the inevitable end of a lot of decisions that we've made over the last ten or twenty years. You know one one. That's been weighing heavily on my mind. Is this idea. That austerity would eventually lead to sustainability. But somehow we cut and cut costs and you know shrunk the system. We'd be able to reach that that point where we'd have a better functioning system and the pandemic has really shown that that wasn't true. You know i it was. It was an idea that i think at the time was worth exploring. But we cut too much and decreased our resiliency too much That our healthcare system actually can't provide the promise of what it's supposed to provide and so we have a couple of options here. We can either reinvest within the system or we can change. The system is what people expect from the system. And that's a social choice that we're going to have to make and that word choices really important. Because health care systems produce the outcomes that we designed them to produce. It's not a mistake. Or you know luck of whether or not you get good care or bad care. Great access or poor access because of the investment choices and the rules that we've created that enable these environments. I think moving forward into the future and the system that we want post pandemic. It's really important for us to focus on what those choices are and make sure that we look back to history to make better choices so when you talk about investing in the system that's one thing and and the idea of austerity and i mean you're in alberta. The government and alberto has had a pretty testy relationship. I think it's fair to say with many doctors in that province. Something that seems to be on the road to being patched up but the idea of what. The system is is really intriguing. What do you mean by that. I mean what could what are the opportunities that this moment that we're in present in terms of rethinking. What the healthcare system is in canada. canada health. Act it's really a a financial agreement between the federal government and the provinces on you know the structure of how the money's supposed to be shifted been spent. I think we could have a lot more prescribed sheep to that you know. There's different countries in the world. Have things like patient bills of rights. You know where you actually create a floor for what a healthcare system is and must be you know helping to frame out the role of primary care as essential part of healthcare systems that needs to be supported even if you know. Austerity needs to be implemented because the reality of fiscal income and other things those types of conversations. I think are important to have you know we. We take this program approach sometimes with healthcare where we infamous while pilots and then we see whether or not they end up having impact when we could take a different approach where we can look at outcomes and you know what we actually want the system to do versus the operationalizing. Think it should give me an example. I mean it. Boil that down for for for people who who may not be in your world but they you know the system is is what keeps them healthy and alive. What would that look like. Yeah yes so you take something for like patientsafety right. So patients are on a surgical floor. They wanna make sure that not only their providers can operate safely but they also feel safe so when we go through cost cutting cutting mechanisms were decrease the ratios of safe nurses to patients eventually comes a threshold where you have too few nurses for the patients that you have and the acuity that carry and so we don't do a great job within the system of actually using that metric to push things forward we instead have the priority of cost saving kind of overwhelming bat and so the discussion ends up being a lot. More simple when you talk about the different priorities that you're trying to cheat and i think that that's the conversation that patients can really plug into in order to understand how decision making works within the system. You know one of the beautiful things with the pandemic because we've all kind of become armchair epidemiologists straighten and We had the opportunity to sit back and absorb information and critically think about things. I think that it's the time for canadians. True really start to critically. Think about the choices that were making and the conflicting priorities that we achieved. You know. i don't think there's there's such a thing as trade offs with the healthcare system. I think there's things that you do and things that you don't you know and moving towards decisions and critical thinking and making sure canadian can plug into. What are we actually balancing when we're going to these changes within healthcare systems is going to be a positive thing to help people understand what we're actually building post pandemic do you think that that demands greater responsibility and role for the federal government. It's a bit of a third rail because the federal government funds healthcare but it's the provinces that have the jurisdiction over. But i just wonder whether patients to your point where patients care about jurisdiction or whether the care but care i think at the end of the day patients care about care. You know it matters less. Who's in charge and more about the systems that they create but even the discussion about jurisdictions of federal versus provincial. We look at medical assisted dying and just from a structural point of view. It's a medical intervention that the federal government has actually created an environment where all provinces have to provide this service. You know there's not a lot of things within healthcare that are structured that way and i think things like creating that threshold or that floor whether it's a patient bill of rights or whether it's rewriting and health act in a way that's maybe a little bit more. Prescriptive is one of the ways that we enable that system exchange the federal government having leadership in health care is probably one of the most important things that we need in order to create a better post pandemic world and is that going to be one of the focuses of your time leading the is pushing that federal government to take leadership role. I think when it comes to access to care that definitely will be within that umbrella. I there's a lot of different rules for people to play and within healthcare with all the different stakeholders that participate. It's important for all to kinda lift where we stand out. One of the big themes of my campaign was amplify your voice and i personally believe that if we amplify physicians voices that then empowers physicians on the frontlines to amplify the voices of their patients in the priorities and focuses that governments with the provincial. Federal and you to focus on So it's really coming down to those end states that we want equality of access to one ensuring that people are able to have interactions in a way the tree of oskoui and you know full of trust And if the federal government taking a leadership role falls under the those embellish absolutely it's going to be a focus just before i let you go This has been a hard year for so many people in a lot of people have had the opportunity or been forced to reassess rethink who they are where they are what they do. What is coming down the road. We've been asking people about hope. And this is across different walks of life from inside the medical system the system that you know so well what is giving you hope right now. I think what gives me hope is seeing my colleagues in the midst of an extremely challenging year and a whirlwind of transformation really still providing good care for patients and i think that post pandemic when people get the chance to slow down providers across the system are gonna realize just how much they sacrificed their own lives in order to make sure that patients when they came to the system didn't fall into those cracks that we know there you know and so it gives me hope that i work in live in an environment where persons are willing to sacrifice themselves for others. You know it gives me hope that patients are starting to understand the complexity of of healthcare and it gives me a lot of hope that people care you know people are speaking up and talking about issues that really matter to them and engagement is a byproduct of and so i'm very very hopeful going into this post pandemic face. I hope we have the chance to talk again in the meantime. Congratulations and thank you for speaking with us this morning. I really appreciate it. You have a great team doctor. League la fontaine will be the new president of the canadian medical association once. He's confirmed that their annual general meeting in august. He was in grand prairie for more. Cbc podcasts go to cbc dot ca slash podcasts.
Calls to relax restrictions on hospital visits
"Throughout the nineteen eighty s strange phenomenon with sweeping north america. They were in a panic and like people in a panic. They want solutions allegations of underground satanic cults torturing and terrorizing children. The thing is there were no satanic cults preying on children and nearly thirty years later the people touched by it all are still picking up the pieces a work of fiction. This is a work of history satanic panic. The latest cbc. I'm cover available now. This is a cbc podcast. There's not much that hasn't been completely changed by covid hospitals for obvious. Reasons have become hyper vigilant around. Who comes through their doors and this meant that visitors are limited. If they're allowed in at all a new study published in the canadian medical association journal says restrictions on visitors are too tough and need to be lifted to help both the patients and the medical staff and a few minutes. I'll speak with one of the authors of that report but first christina stewart is on the line her nineteen year old son quinn. Just in hospital. He has refractory. Epilepsy and a rare chromosome deletion. He's nonverbal. and so when he went into hospital in winnipeg his mom wanted to be there but covid restrictions meant that. Quinn was on his own christina stewart. Good morning good morning quince. Been home for a few days. how's he doing. He's doing ok now When i first got him from hostile wasn't doing also well but he's all right now. Yeah yeah doing actually great. Now when you first arrived at hospital with quinn what happened Ten thirty grandma t shirts and under an hour. So i had to call the ambulance of course and we end up spending thirty hours in the er and then as soon as they were to admit them. I was told within under an hour. That's it you have to leave. So i had to leave him there so when you explained his his special needs to. Did you ask about staying or visiting business yes. I made a little bit of arguments with the nurses and doctors which actually they wanted me there. It was the administration and that was just the worst day of my life to tell you the truth I've never left. When never been away from him that long never anything and that was terrifying. So what did they say back to when you when you explain you know obviously what you need to do and how you needed to be there with him. What was their response. They just kept telling me no. I didn't give up through the whole ordeal. The full time he was there. I kept making phone calls every morning every day. all through the evening even Conference calls with administration. It was still no matter. What contacting l. As what have you it. Matter what i did and when you and that initial moment you said they gave you how long until you had to leave. It was not an hour an hour. How much help do you give quinn everyday I'm his primary caregiver. So i have to bathe him. I have to feed him. I have to change safer and you'd never really been apart from him. You know other than getting my normal wrist bite here and there but during this kobe from normally the rest pates my respite worker. Does it while. i'm at home. Even though no i never. How long was he in hospital without you. Eight days eight days and you said when we started talking. When i asked you how he was he said that when you initially picked him up he wasn't doing well tell me about that They had 'em they promised me all the time. Phone calls which i got very minimal They promised me that he was at the first bed at the nurses station so i was assuming that they could see him. They were telling me that they could see him from the nurses station. So when i finally got the phone call was just all of sudden out of the blue on a wednesday evening. So i picked him up and then i was allowed on the word of course so i get there and they had him so sedated. That took two to three days after. I mean home for to even be able to walk. He couldn't anything. I had to carry him in from bed into wheelchair. Which normally we just have built here because he has a lot of drop seizures. And what have you. That's for when we're out and about not for just walking around at home or anything like that so i had to let him from the bed into the wheelchair. They had him so sedated. It wasn't really funny and they called you to tell you to come and pick him up. Yep just out of the blue. I didn't even know. I was getting paid. And you allowed to go into the hospital to pick them up then. So did you find that confusing given the fact that you weren't allowed to be in the hospital when he was actually in the hospital. Yes i even asked about it. They said they have no clue. And i wasn't even allowed to speak to a doctor what i picked up. It was just and that was that they were actually on my side. They want one actually. Even stated to me that i the he looked at me the walkie e with clinton because there was one point where throughout the night. The nurses the doctor touch base with me in the morning and the nurses had contacted the doctor throughout the night knowing whether it was seizures. Quinn was having or not which i'll be. Obviously it was yours. But if i were there of course i would've known that it was teachers that he was having trouble tonight just to be clear. What was the reason why you weren't allowed. What were you told about why you couldn't be there with your son code red and that the code red would prevent you that that's the rule and so there's no visitors allowed greg and no matter what angle i took no matter who i called nothing. Do you understand the the need for hospitals from their perspective to be as careful as as they have to be as cautious as possible but any possible risk that that could spread cova. I understand them being careful. But what i don't understand is that they let me in the er for thirty hours with people that are being tested for kobina all around us when we were tested and we're negative the let me sit in er with all this covert around but yet when we were tested negative not go up to code pre award with him and when i got onto that were to pick them up there with people walking from room to room. It was just one big kerfuffle. It didn't make any sense to me whatsoever. This is what would you say then to those who who run hospitals as they try to balance cova distractions and the needs of their patients. And we're seeing across the country in many parts cases rise and they're you know other lockdowns are in place or other. Lockdowns are coming into place so in the midst of all of that. What would you say to those administrators that you weren't able to speak with in that moment About the situation that you found herself in. I mean it's just ridiculous as caregivers. We need to be there. I mean there's no way. Quinn communicates to anybody over there. Saying that he thirsty or hungry or anything in them understand what he's trying emotion to and plus our healthcare workers are so overworked. Why wouldn't you want to relieve them. Apparently being with somebody like quinn. Twenty four seven as opposed to them being able to be somewhere else where they could be needed as where i could be just right there and do their job. It just doesn't make any sense. We asked shared health manitoba to speak with us. They declined and interview but sent a statement that reads in part essential care partner access restricted. But we'll be supported in certain circumstances to support patients who require assistance with communication. Care planning decision making as well as those who normally have constant care or attendance patients and their families are asked to work with their care team and facility to arrange visitation for essential care partners. Where in person support is required. It sounds as though that didn't happen for you though it didn't happen and the i even brought that up to them and that didn't didn't matter what would happen if quinn were needed needed to go back to the hospital right now. It's a big fear if he were to have a big cluster of seizures like you had prior and needed to go into hostile. Of course i'm going to have to take him but it's a big fear. Because what if i can't be with him again and going through that again is just would be just horrifying and i can only imagine held west for clinton Me being his mom. I've never left his side and going through that. And all that. And i'm not there and just being sedated all that time and what have you been. Who knows what really went on. I have no clue. I appreciate you speaking with us this morning. Christina and quinn's doing okay. Thanks again for talking to us. Thank you so much. Christina stewart son quinn was in hospital in winnipeg. I'm i host of ideas in this age of click on shouting. Ideas is a meeting ground for people who want to deepen their understanding of the world. Join me as we crack. Open a concept to see how it plays out over place and time and how. It matters today from the rise of authoritarianism to the history of cult movies. No idea is off. Limits ideas is on the cbc listener. or wherever. You find your podcasts. Hi i'm josh. Block host of uncover escaping nexium from. Cbc podcasts. I pull back the curtain on the secret of self help group. That experts call a cult and follow one woman's harrowing journey to get out. The podcast was featured in rolling stone magazine and named one of the best podcasts of two thousand eighteen in the atlantic. Listen to uncover escaping nexium on. Cbc listen or wherever you get your podcasts. Those rules around hospital. Visitors vary across the country but many doctors are calling hospitals to ease the restrictions doctor. Levin monchy is a critical care physician at mount sinai hospital in toronto. And she's a lead author of commentary in the canadian medical association journal which makes the case for relaxing hospital visit restrictions. Dr good morning good morning. Thanks for having me. Thanks joining us. What were you thinking. Because you listen to christina. Tell her story i my. My heart goes out to christina and quinn and and and there are many stories and fortunately during this pandemic Similar to to what clinton christina experienced. And i think as healthcare providers. We're really trying to understand the balance and establish the right balance between restrictor restrictive immigration policies As well as bringing a family members and essential care partners to the bedside. Let's talk about that balance because it's one thing. I think to hear from a worried mother from a medical perspective. What what are the effects of keeping all visitors out So my length here is a critical care. Physician is in the setting of an acute care institution. Being admitted it's scary. It can be overwhelming and family presence. are not merely perceived as visitors in many cases. There are a central players in the delivery of patient centered care and anything. Some of us perceive us healthcare workers as as visitors in the patient's life in their healthcare. There's been ample evidence that shows that family presence is essential facilitating care needs feeding mobility hygiene and reorientation participating in communication such as in the setting of language barriers delirium acting as substitute decision-makers even advocates for their loved ones and then supporting patients emotionally through throughout the illness And there has been evidence particularly in critical care world wear in the setting of acute confusion delirium that family presence and family engagement is associated with less delirium short length of stays in hospital and improve psychological recovery after discharge for both the patient as well as the caregiver and so if the restrictions were to be. What would that practically look like. So currently we've already seen after we've won an even restriction from the more stringent policies that will adopted at least in the area that i work in so when we won in the critical care units for example we had strict visitation policies. There were certain exceptions that were made at certain institutions such as the end of life and in certain circumstances where patients did have high care needs for which a caregiver it to be present to facilitate care when we reflect upon the impact of the visit restrictions during wave when at least in the critical care units during we've too we felt given the evolving data out there of the risk benefit of visitor restrictions at our hospital. We've actually liberalism slightly to now allow visitors to come for critically. Ill patients but every second day it has to be one. Possibly to visitors been can't come at the same time and they have to be present for a limited amount of time with strict Screening at the entrance of the hospital. The other side of this. And i mean it's not to say there's one side of the other but if you're looking at it as a balanced the restrictions were imposed for a reason we're in the midst of a pandemic. The second wave is brutal in many parts of this country. What risk is there. Cova transmission if visitors are allowed in out of a hospital. So i i absolutely see that. There definitely is another side to this and during the first of the pandemic when the strict visitation policies were Were adopted it was because we saw healthcare systems overwhelmed in different parts of the world such as new york in italy so the intentions of the visit restrictions definitely made sense as our understanding of covid nineteen in the transmission of vault but interestingly when we looked to the data there actually wasn't a wealth of data demonstrating that visitors are major vectors for hospital acquisition or transmission of covid nineteen and in fact we came across two small studies showing that covert nineteen was necessarily A major problem when it came to visitors bringing it to the hospital however we do acknowledge that the absence of evidence does not mean that. It's not true and abuser. In the settings of well implemented infection and prevention control measures and visitors have to be honest about their symptoms at screening. So we're still really trying to understand the risk visitors. But i was gonna say just i mean. Help me understand this. If the data isn't there but there are a number of we speak with the manitoba health organization. They declined to speak with us about the restrictions. Scotch health authority also declined. The ontario hospital association also declined. Why are hospitals opting to keep their visitor restrictions in place. If as you say the data isn't there to show that visitors are necessarily bringing coast into the hospital. We have to do is we have to acknowledge that throat. These next few months we still need to be humble about cohen nineteen or understanding of covid nineteen or understanding of transmission is constantly evolving. And i think at every few months of the pandemic we need to pause and reevaluate what we know and what is no longer true. And then make sure that the policies that we implement reflect this evolving knowledge. So i think after one we realized is that possibly the risk of the visitor bringing covert nineteen with appropriate screening and infection. Control measures may not be so high and then we also realized after reflecting upon as one that there is ample evidence demonstrating in certain. Specific scenarios is a benefit to have family and caregivers at the bedside so in some jurisdictions at least where i practice we actually have been an evolution in the visitation policies reflecting this evolving knowledge. And so i think we still want to continue to learn and understand and we would hope that as we have continued Understanding i've transmission and the risks as well as the concentration the communities that are visitor policies. Continue to Reflect our knowledge of transmission as those families and patients just in the last couple of minutes that we have. What have you seen as a critical care physician in terms of the benefits of being flexible of understanding the situation that you're in the situation that families and patients are in and not just rigid around the rules so the first wave was was very hard for myself and all of my healthcare colleagues and once again we fully understand the intention of the visitor restrictions but our patients were scared and it was very difficult and a huge responsibility for us to be place holders For families when patients are scared when they were delirious or even the end of life. So what we've noticed is with the gradual relaxation. In specific circumstances that anxiety is less across patients and caregivers in these specific circumstances But there's still room for improvement And there are still certain Areas in the hospital where the visitor restrictions could potentially Be considered to be more liberal for certain patients that are higher risk such as those with delirium cognitive impairments unless as well visibly for for caregivers like yourself for the for for physicians like yourself who are thrust into this position and as you said end up being a placeholder for family members they presumably the easing those restrictions would help you as well. Absolutely like there's plenty of data out there From way one from different countries as well as from the sars pandemic about the psychological impact of healthcare workers having to be place holders For family members and the psychological impact is that can last up or has been shown to lost up to a year following the pandemic during during the stars. One pandemic in two thousand and three dr Appreciates us speaking with us. Thank you for the work that you're doing and thanks for your time this morning. Thank you doctor levin. A monkey a critical care physician about sinai hospital in toronto would be interested to hear your thoughts on this and how you have experienced The healthcare system as a visitor or patient. You can email us the current at cbc dot ca for more cbc podcasts. Go to cbc dot ca slash podcasts.
Gender equity at the senior leadership level
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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.
Examining Dr. William Osler's racist past
"Seven of my car before the police f running up and down the street until honest That we need to get out. I'm adrian lam and mike flanagan. Tv podcast world on fire. Our latest episode. We're taking you to the western united states where fires are burning unprecedented rate. And we're finding out how it's affecting here in canada get world on fire on. Cbc listened or wherever you get your podcast. This is a cbc podcast. The name dr. William ostler may sound familiar to many of you. That name adorns numerous public schools across the country. A library at mcgill university an entire hospital network in the greater toronto area just to name a few as graduate of mcgill and one of the founders of johns hopkins hospital in baltimore maryland. He's often described. As the father of modern medicine. He created the first residency programs and was the first to teach students at patients bedsides but now ulcers legacy is being questioned. A commentary published this week in the canadian medical association journal points to the racist statements that he made arguing that he should not be held up as a medical hero. Dr persad is a co author of the commentary. He is canada research chair in health justice and an associate professor at the university of toronto. Dr good morning. Good morning why did you want to write this commentary on dr willing. Osler william ostler is one of the most famous physicians of all time. He wrote a textbook that was translated into multiple languages and republished in multiple editions because it was in such high demand around the world. He was the first physician and chief at john hopkins university in baltimore and he went on to be regis professor of medicine at the university of oxford. Today there are regularly meetings to discuss his work and his contributions and yet You know i have been learning more recently about Some of the concerning Statements that he made concerning behaviors and on the centenary of his death in december of two thousand and nineteen multiple articles. Were written holding out william as an example Who should be followed today by medical students and others. What are some of the things racist things that he said or that he wrote in a speech in nineteen fourteen He declared canada white. Man's country at the time There was a ship the come tomorrow That was docked in a port vancouver and there would be canadians from india Who were hoping to emigrate here. And there was a strong view at the time that these people should be admitted to canada They were british subjects and And later that same year they would be expected to fight alongside canadians in world. War one But there was also a different view and oastler in the White man's country speech Worried openly about Quote swarm of yellow and brown men entering this country. I was there also practice medicine on segregated wards in baltimore After the civil war in the united states and he would have seen What american people were experiencing at the time and although he's held out for his love of humanity and he wrote copiously. He didn't write about racism and didn't describe the experiences of racialized people on those segregated words in fact when an intern was concerned about the deaths of six african americans within the course of several hours ostler dismiss those deaths with a racist remark. He is often seen as i said as the father of modern medicine. What has the response been like to you questioning how. He is held up in the medical world as expected There's many different view you know before. Our article was published There've been two biographies written about dozens of articles written including recently and almost all of those articles Praise ler And talk about what we as physicians and others can learn from him and so i've been somewhat disappointed though that When we have pointed out racist statements that have always been available. You know the white man's country speech was given in a public venue and it was reproduced and newspaper. So all those those have been accessible to my colleagues for years They have mostly been Ignored and where they've been mentioned. Downplayed and i think the response to our article has reproduced. A lot of what has happened In the hundred years since ostler died people have said he was Bound to make racist statements because he was a product of his time even though People who lived at the same time ostler has very different views from him and and and and many fought against racism I think somehow worried that we cherry picked Recess statements when in fact We were highly selective in which racist statements we included at many others. exists and. I'm sure my colleagues know about them have listened to nadeem two billion who's a medical registrar just out of sydney australia. He wrote one of the rebuttals. Your commentary in the canadian medical association journal. Here's what he said dole. Though i accept that there are issues with racial inequality in medicine of the insinuation. That's when the most was racist is is remarkable and it's very difficult to come to that conclusion considering the amount of information available about his life especially with regards to his strong feeling of you know brotherhood which he espoused in very many of his lectures is the dominant kind of theme in his life. And they're very explicit remarks in his bibliography to prove that and from his colleagues including racialized. Physicians always always actually very warm towards people of all different classes and backgrounds. There's clear cut evidence that there was not treating physicians in a derogatory manner or that. He was dismissive of them. Rather say contrary he was very supportive of them. It's crystal clear it's not something that one could be confused about. dr persad. what do you make of that. That that there's a lot of evidence that willie mostly was inclusive and supportive of racialized colleagues. I think the way that racism can play out is that someone can say racist. Things would have an important effect for example The white man's country speech a prominent position at the time was invited to come back to canada and decided to make a pronouncement about immigration policy. That was clearly racist and at the same time that person can turn around and be nice and warm and supportive to an individual racialized person who they've met especially in a professional context where a prominent person like there would be expected to behave professionally And i don't think that the fact that was there was nice and supportive to some individual racialized. Physicians means that we should excuse him talking about a swarm of yellow and brown men entering canada. Is it fair to judge. His statements By the current standards by today's standards. No it's not and we didn't do that. We compare does layers conduct to the conduct of others in fact other physicians who lived at the same time as one example was alexander thomas augusta who studied at trinity college in toronto. Shortly after did and Augusta had to come here because he couldn't gain admittance to medical school in the united states after he finished his training in canada He decided With wife mary to Work against racism in canada and he They together formed several organizations that help to address racism when the civil war started in the united states. He wrote to abraham lincoln and volunteer to fight fight against racism to fight against slavery and he risked his life to do so. He's someone I never heard about when i was in medical school. Although i was expected to know what was learned quotes And and i heard about all the time. I never heard about Augusta though he trained in toronto and the piece that you wrote you say a statues of once revered individuals who participated in racist crimes are being removed around the world. We should change ostler's plays in medical curricula and explicitly address racism in medicine. We spoke on this program before about racism in the medical profession. What have you faced during your career. I'm relatively privileged. I think because. I'm a physician so i don't receive the worst type of racist abuse and also Because i i'm a man. I receive different treatment. I think than than racialized women do but i think racism is part of society. I deal with it on a daily basis at the hospital and outside of the hospital And i think that having a hospital Like william ozone health system that serves people in brampton in the northwest part of toronto including wreck. Stale named after someone Who thought that. Canada was a white man's country. is an additional Humiliation insult That i object to. And i think You know recently as a you know. There's some more recognition of racism especially after this summer. Multiple institutions including hospitals have issued statements against racism and have pledged to do some of the hard work to address racism systemic racism as it pertains to healthcare and that can involve changing hiring policies Changing who's among the leadership of hospitals right now changing the culture in hospitals and other healthcare institutions. All of that is hard work I think it's relatively easy to change the name of a hospital away from the name of someone who made racist statements. And i'm disappointed. I think that some institutions have shown some reluctance and a lack of openness To making that change doctor persad. It's good to speak with you but this thank you. Thank you lecture now persad. Has the candidate research chair in health justice and associate professor at the university of toronto. He co wrote a commentary published this week in the canadian medical association journal titled william ostler saint in a white man's dominion his co authors. Were heather butts. And dr phillip burger for more. Cbc podcasts go to cbc dot ca slash podcasts.
Antivaccine sentiment as power: the Montral vaccine riots of 1885
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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.
Prone positioning (chest down) for COVID-19
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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.
"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.
"This is a CBC podcast. Hi, I'm Lou the host of love me, a CBC podcast about the messy -ness of human connection are brand new season is coming soon, featuring deeply personal stories like a man who becomes obsessed with a mysterious painting two brothers stuck sharing room again as adults and a note slipped into the back pocket of someone's genes that leads to a surprising late night encounter. Subscribe at CBC dot CA slash love me or wherever you get your podcasts. The new season launches November thirteenth. I'm Dr Brian Goldman, this is white coat black art the show that looks at medicine from all sides of the gurney. Lately, there's been a lot of talk about Dr burnout just last month, the Canadian medical association released the results of a survey that found one in four doctors who said they were affected by it. The survey also found that just fifteen percent of them were inclined to ask for help dealing with burnout is also a hot topic in the US were two. Studies were published in September in the journal of American Medical Association. One found that women and doctors in certain high stress specialties, we're more likely to experience symptoms of burn out like emotional exhaustion, regrettable career choice. Burnett was also a big topic of conversation during the international conference of physician health in Toronto in October on our show a year ago. I had a revealing conversation with Dr Shelly, Dev, a Toronto physician who went public with her story of burnout, and what it means for patients when their physicians looking. After their own mental health needs from Tober two thousand eighteen here is that program. As doctors there's the surgical masks that we wear in the OR to block our germs. But there's this other mask the metaphorical one. That does the same thing with our innermost thoughts and feelings rarely the mask slips. That's what happened earlier this month at an after hours clinic in Gainesville, Florida when a patient got into an argument with her doctor about along she had to wait to be seen. Starting to his I knew my out. We've already been working on the daughter of the patient record of the altercation on her phone and the patient posted it on Facebook. I don't know how. Did you? But. Really? Really go to the yarn for nine afterwards. The doctor released a statement saying he regretted losing his temper and speaking to the patient and for daughter in a most unprofessional manner the exchange went viral, not so much because of the patient's behavior, but because it's so unusual to see a doctor act human like everyone else and lose it with a patient. Makes you wonder what was on the doctor's mind temporary stress to patients an argument with his partner, or maybe it's burn out. Studies show close to half of Canada's doctors are burned out and the numbers are going up the rates for nurses are as bad. If not worse health professionals are hurting like never before. If you're thinking, this is just the price doctors pay for status in a decent paycheck. Studies also show that burned out physicians affect you too less attentive and make more mistakes. They disrupt colleagues, and less empathy for you means you take longer to recover from illness need to pay a lot more attention to what's on doctors minds, these days doctors like Shelly, Deb this become the new face of physicians who've experienced burnout feeling angry at patients and feeling angry. When after discharge somebody that they would come back to the hospital admitted to be readmitted or. Feeling that I had a pressure on me to make sure that I was discharging as many patients as possible and perhaps looking too much at that goal rather than is it appropriate. These negative feelings around what the job was and feeling so distanced from ideally the reasons behind you actually becoming a doctor. That's Dr Shelly, Deb describing herself when she was a resident in internal medicine fast forward about twelve years to a time in her life when Shelley thought she had it all a respected physician in the intensive care unit married with two young kids superb teacher and an up and coming leader. It took a crisis interpersonal life her father's death due to cancer to make Shelly realize she was burned out and that she'd been that way from her earliest days as a resident a small. Disclaimer, I I met Shelly when she was a resident in internal medicine at mount Sinai's emergency department where I work I've always thought of her as a nice person yet when I spoke to her in our studio, she flew. Word me by describing yourself back. Then as bad, I think it was the best way that I could describe how I felt about myself at that time in residency. So at the time, you wouldn't have thought that you were a bad person. That's only you looking older a little older looking backing yourself. Yes. And I I think that at the time I was so mired in my feelings of inadequacy but I could not put a name to it. I could not describe it at that time because the treat those that I don't think at that time. I particularly stuck out all that much. You're exactly like them you weren't exceptional. Well, I mean in terms of you know, what I would describe as being a bad person or making certain choices. This was not me making any choices that were any different than anyone was making. It's how they were making me feel about myself, and how they were making me feel about what I thought it meant to be a doctor. So all of this is you reflecting back on yourself. So I want to get to that context. You after that residency? You went on to become an attending physician working in the intensive care unit. Had a couple of kids you went back to work and then your father became ill. Yes. When it became clear that his cancer was very very aggressive, and there would not be any room for chemotherapy, he made the decision to be palliative, and my parents moved in with my husband, and I are two kids to spend the rest of his time. And so after coming back from two year long maternity leaves I left again for several months to be with my dad every day, and when he died, and I knew he was dying. And I'm in a profession where let's people, unfortunately, die. I think I actually felt my heartbreak I think I felt it exploded my chest. And I was so overwhelmed by grief at the reality of him dying. You know, a very good colleague of mine, who's a radiation oncologist said to me, you never had the luxury of not knowing how this was gonna turn it. Yeah. And I hated that so much I the burden. I hated being the doctor in situations. So so much. Yeah. And what really really worried me about going through that was my fear of coming back to a medical environment. I'm in intensive care doctor, and I work in an intensive care unit where people are critically ill all the time. And all the time are showing the line between living and dying. And I was terrified about seeing that all the time after watching my father, get sick and die. So afterwards. And there was a long afterwards. What was your Piff any after your father died and you began to process your grief? Tell us a little bit about how you did it. And what you came what conclusions it came to? Well, I have pretty severe anxiety. And the it started manifesting as panic attacks. I was rescued by my family, doctor who knew me very well in well enough to detect that this is in you. You are not functioning the way, I know you to function and so she put me on an anti anxiety medication. So that was part of the journey. But after my dad died, I had no place in my life to feel my grief because he died in my home. And when he was sick he had all of his doctor's appointments at the hospital. I work at and everybody there had known what was going on. And I needed my own space to be sad and through one of my mentors. I mean, this story is full of angels in many ways of people who. Supported me immensely, and she referred me to a psychiatrist specifically to deal with Migrelief. And through that process. You also began to look back at your bedside manner as a resident to patients and families going through the same things that you had now gone through through the death of your father what realizations did you make about yourself? What I realized is that this job or a job of healthcare provider. Has nothing to do with me personally and everything to do with the people that I am serving. And that the ability to be compassionate and kind and about other people is I don't think it disappears goes away. I don't think we become callous, and I don't think we turn into bad people. I think that we get tired. And I think we need to refuel that tank of compassion and kindness. I look at that time at I look at someone who is so pushed and so pushed to deliver and to provide and not restoring themselves. And then I think that what ends up happening. Is we all feel the need to cope? And coping, and you know for us humans think takes many different forms. I think sometimes it comes off as he no dark humor. Sometimes it comes off his anger. Sometimes it comes off in humor towards patients towards to each other. You know in general, right lake just. It comes out in angry moments comes out, and confrontations. And sometimes it comes out with feeling this intense sense of relation and disconnection. I can tell you that that even today I feel guilty when I'm holding a Cup of coffee walking across the emergency corridor into my office. And hope nobody sees me because I'm equating I thought is they see me with a Cup of coffee, and they're thinking, you know, my my poor husband was dying. And he went for a Cup of coffee, and it's it's hard to take care of yourself. When you feel like if you do it's going to look like, you're not taking care of patient. And I'm sure you've wrestled with that dilemma. Yeah. I have to admit I have those thoughts to where I almost feel as though it's disrespectful to incorporate any type of normal life or any type of levity in an environment where things are so serious. And that may be speaks to our. Inability to see ourselves as human or fallible. I mean, our inability to have compassion for ourselves that if I have that Cup of coffee, if I have my Lynch, I will have more energy, and I will be in a better place to provide better care, right? We don't extrapolate that to a compassionate and equality of care argument. And that is what I see as being the bigger part of this. What I wanna know is is there something different today. We're hearing more and more about young doctors in particular reaching the breaking point and recent stories of suggested that there's an epidemic of young physicians, especially medical students residents. Thinking of suicide committing suicide in the US. It's actually the second leading cause of death among residents, and I I wanna know like, I know you're not an expert. I'm not an expert. Do you think something's changed in the work that we do that has led to figures like that? I think some things have changed. I think really truly would idea think is significantly changed is the emotional intelligence of our trainees. I was talking with a group of third year residents who are about to begin fellowship training. And we were talking about all of these topics, and I have really started to notice I think it speaks to the new curriculum in medical schools around wellness and around burn out. And and making it part of a dialogue from a very junior part of training. They are way more adept at this conversation, then my generation than the generation before me and before in before and what isn't different is. This job is very very hard. And what isn't different enough is. There hasn't been enough of a top down phenomenon of physicians who've been at this for a very long time. Who are giving voice to the experience of feeling burnt out or giving voice to the experience of getting well or struggling with moments in their lives because. To me that is what will take the conversation where it needs to go. These are the voices that have the most professional security. These are the voices that have leafed to lose. And yet you talked about your burn out publicly in front of your colleagues. You've shared your story. What kind of reaction have you gotten? Well, the responses have been unbelievably beautiful and supportive and thoughtful brave and thankful. They come from the whole spectrum of this of the people in this job. So multiple different roles in healthcare. It's totally been mind blowing to me if I got that much of a response with my own personal story. Can you imagine? If there was this top down dialogue about this. Like, can you imagine how comforting it would be? And then can you imagine what the downstream effects would that be? If this was a healthier work environment for our providers. And what that would mean for the people there taking care of Dr Shelly Dev thinks her colleagues at the top need to set an example and talk about their own personal struggles with burn out, but the secrecy won't end without removing the stigma around mental illness and health professionals. You're listening to white coat black art on CBC radio one Sirius XM by a podcast. I'm your host, Dr Brian Goldman this week the epidemic of burnout among doctors, and what that means for them. And for you. It took the death of her father for Dr Shelly Deb to recognize deal with their own personal distress around half of Canada's doctors perform their duties while having at least one symptom of burnout, but unlike Shelly, many don't admit or even recognize it. Dr Mumtaz got him wants to bring it out into the open the psychiatrist by training works pole time coaching positions on staying one step ahead of burn out. She's been called the doctors doctor when I met up with a recently in her office at the Ottawa hospital. She described the stages of burnout, the first that we saw was really emotional over exhaustion. This is when you get through your day. You have the energy you have the ability. You have the knowledge and training. You have the passion and commitment. And so you get go in the morning, you do what you need to do you do it? Well, but at the end of the day, you're drained, you have no energy. So at times like this colleagues will say to me, you know, at the end of my day. I just need to have a few minutes to myself, they'll drive home and just sit in the car for few minutes. Just trying to get you know, a little bit of energy to be able to go into the host for the next phase of the day. Then. We see that, you know, graduate gradually moving into the second stage, which is depress lies ation. And at this stage. What we realized is that it's the people in our lives that are the most training for us. And so what we start to do is pull away from them. So in the workplace, again, we'll see doctors who will not go to the cafeteria and just grab a sandwich at dusk. Because it's easier will they'll maybe stopped going to meetings because there's a lot of people they have to deal with. They don't have to do that social chitchat kind of stuff, and we see this personal life to where we're less interested in doing things socially. And we also start to have these feelings of cynicism and sarcasm. And so, you know, we we start to question relationships that we've had in the past people that would have been close friends now are just one more person that wants something from me. And so we start to pull away and then at least to the last stage, which is at this stage. You know, we start to question. What we're doing in medicine, and we start to lose that sense of accomplishment. And this is the stage, we're actually physicians, you know, wonder this is not the the profession they trained for you have lost the the meaning and the passion, and this is the stage where often physicians consider leaving medicine for another career the difference between working a stressful environment and feeling burnt DOJ is that, you know, with lost the sense of joy, and we've lost a sense of meaning and the sense of commitment to it. And that that's really I I would say when when things start to change what is it about the kind of work that we as physicians do that makes us prone to Bruno. Yeah. I think it's the very high level of responsibility that we have for another person. And and for that other person's well being, and you know, we deal with issues of death and dying on a daily basis that most other professions don't in the same way that we also have to talk about the type of person that takes on that responsibility. So that you, you know, most physicians have similar personality traits of being very conscientious of being very responsible of being carrying compassionate. And and wanting to do their best and one of the things that I hear regularly is doctors telling me that when they're working harder with your resources, and they're still not providing the top level of patient care that they would like that's when it starts to feel overwhelming. And it's a specially overwhelming among ICU doctors who say they're seeing an ever increasing number of patients on ventilators who they think have no hope of recovery. Are you seeing anything like that? Yeah. Absolutely. And I think that what you're. Talking about is part of that out. I'm reminded of a colleague who told me something very similar, so she's working in in pediatric ICU. And you know, there was a young mother who had a baby born at twenty four weeks. And she said, you know, we took it was tough. We intimated the baby and the baby just did not do well and kept being excavated, and they had to basically respond to the baby in some fashion about every half hour hour all night long and the baby Assad -ly ended up dying both seven o'clock the next morning in a flash through her mind that had this baby died seven o'clock last night. I would have slept all night. And that was thought she'd never had before. And that was the moment where she said, you know, this is not me I need to be looking at what I'm doing. And what changes I need to make? Because this is not how I want to enjoy my career if half, the physicians are burned out. How do we know that that isn't just normal for physicians to be burned out? So, you know, I remember a time. Time fairly eighties nineties were I would say it was medicine at at a peak where I would see a lot of physicians who were working hard who were working long hours. But I would say that, you know, the the environment was a little bit more relaxed around. There was more support, you know, there were more resources. And I think that this is partly just you know, how men medicine is progress. You know, we are able to do more for patients patients are living longer. I think that you know, we're able to manage chronic illnesses better. So longer than we have in the past the types of medications were using are much more complicated and complex, and we, you know, the types of interventions we can do, for example, transplants, etc. Again, nothing's we were doing thirty years ago to the same extent. So I think that you know, there has been an increase pressure in what we're able to offer the patient. What we need to offer the patient. There are more pain. Percents, and you know, it hasn't necessarily trickled down into more resources and time for the physician. So okay. So I say, you know, what I need to do. You're clerical duties at my hospital, and their reply is suck it up. Buttercup be grateful that sure that you're that you're able to be a physician in this hospital that you're getting paid to do. It is not the way the culture acts. Absolutely. You know, you said a perfectly the suck it up buttercup and doctors have to be invincible in the patient has to come first. And you just do it till it's done. So what's your prescription for turning this around? Well, I think it has to be shared responsibility. And my prescription would be that we continue to do some of the things that we do for the individual physician where we do give them, you know, some support where we teach them stress management techniques, teach them resilience. And so really there is the individual approach, and I think we need to continue to do that. But that a lot of the responsibility back on the physician to heal. Oh themselves, and that doesn't address the culture doesn't. And so I think we also have to really see a physician health and physician satisfaction as a goal for healthcare organizations. And if this is something that's actually tracked and measured and benchmarked. I think that we're gonna see more attention to this. You know for most part what gets measured gets done. So I would like to put physician health and wellbeing rate up there on a on a hospital metric or healthcare organization metric, and then watch the institution, you know, succeed in cheating that. Mumba got him. But doctors doctor who specializes in burnout is calling for big changes in the system, and even bigger changes in the way, we view doctors and the way they view themselves. None of this will happen until more doctors do what Shelly Dev did it mitt. They're human and ask for help. Dr Shelly death has in fact, continued to speak up about her experience with burnt out in an Email. She tells us that since the program aired she has been lauded for honesty, and bravery, and she's also been invited to tell her story to hundreds if not thousands of experienced colleagues and those just starting out that's our show for this week, if you're a healthcare professional and have a story to tell about how you dealt with out and came out the other side, we'd love to hear it Email us at white coat at CBC dot CA. I'm on Twitter at night shift MD and the show is that CBC white coat. We're also on Facebook. We also need your help with another show. We're working on we're asking health professionals of all kinds for stories about a person who changed the way they practice medicine or nursing or any other health related job. Tell us about a lesson. You learn from a patient a colleague or a family member. And why stuck with you? And tell us how that lesson inspired you in your career our Email address once again is white coat at CBC dot CA to listen to the show anytime download the CBC radio app or the radio player Canada app. And if you're looking for more, health news and analysis subscribe to the weekly second opinion newsletter by our colleagues at the CBC health unit. You can subscribe it. Subscriptions got CBC dot CA white coat black art was produced this week by Sogeti berry and Jeff goods answering your producer daunting wall along with our digital team. That's medicine from my side of the gurney. I'm Brian Goldman CNN's week. For more CBC podcasts. Goto CBC dot CA slash podcasts.
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.
Misinformation in medicine during the COVID-19 pandemic
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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.
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. The canadian medical association has partnered with audi candidate to offer. Cma may members preferred incentive on select vehicle models purchase any new qualifying audi 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 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 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 a product monographic gs dot ca slash english slash pm for contraindications warnings and precautions adverse reactions interactions dosing administration information requested product monograph or report an adverse event. 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.
Doctors and nurses describe dread as COVID-19 cases risk overwhelming hospitals
"Hey parents if you're looking for some screen free family fun while you're staying home. Check out the story store podcasts. From cbc kids and cbc podcast new story store. Shorties are released every week. These short original and hilarious stories fit anywhere in your day from breakfast to bedtime. The story store available on smart speakers. or wherever. you get your favorite podcasts. This is a cbc podcast. Fires burning in so many different areas and right now is the time to get those under control a warning candidates chief public health officer. Dr teresa tam. Those fires are cases of covid rising across the country and manitoba on saturday. A new single day record with fifteen deaths alberta and scotch win both reported record high number of cases as well on saturday so did ontario with almost sixteen hundred new cases. That number dropped to just over twelve hundred. Yesterday and severe cases across the country are increasing over the past week there were on average every day more than fourteen hundred people being treated in hospitals. Some areas of canada have seen that they now had to scale back on routine medical procedures because the hospital beds getting four. Much concern about icu. Capacity you have specialized medical resources personnel. And they're getting exhausted as well. Dr darren markland knows exactly what dr tamas is talking about. He's an intensive care. Physician and enough at royal alexandra hospital in edmonton dr good morning. Good morning you're about to head into a shift at the icu this morning. What do you think you'll be walking into well after the weekend. I think we're going to have and very important meetings about what. We're going to resource and staffer unit today and for this week. That's a big sigh as you start to answer that question. Well i think like Most canadians Were all a little tired of this But we also see what's coming and there are cells in the air already. I mean the first one hit because of thanksgiving. And we're waiting for the next one to hit because of halloween and so when you see exponential growth without a plan brings a lot of anxiety in the frontline healthcare workers. So when you say that you're going to need to have meetings around resource allocation tell me. What does that mean. What sort of decisions are you to have to make in the next few hours. So we have had a surge plan set up from the beginning of the pandemic. But it's one of these plans that It looks good on paper but is dependent on staffing and resources and hard decisions and so up until this point we've been running a full icu. But able to turn the patients over so that everyone gets the care they need but within this week next week. We're going to have to expand the icu in start drawing resources away from the laws We've already cut down elective surgeries to bring in more resources and prevent admissions. But we're going to have to do more. We'll have to reduce more surgeries. I take on take on more staff from other units and that process will have to continue as it does You start to get stretched a little thin and as that process exceeds our capacity then you have to make more difficult decisions about things like who actually will benefit the most from care and that's called called triage and that's somewhere we don't want to get to if we don't have to do you feel that that's inevitable. I think there are things that we can do that. We have to do them quick. We have to do them rapidly and we have to initiate the process. Now we still have two weeks of surge even if we initiate things right now And so yeah. There can be some very tough decisions in the next week to two weeks in the intensive care unit serve pressure. Is there on on frontline stuff like yourself. I mean you said that we're all tired and we are certainly but you're right there and you're working long hours right you know at at at the the the the tip of the spirits they say so what kind of pressures they're on people like yourself it's interesting. There's different types of pressure. I remember during the first wave. We just kept waiting for things to hit us and when it didn't post the guilt that you know canadians were so supportive and we never hit that first wave because everyone did the right thing Now with that in our back pockets Everyone's a little more realistic. We're seeing it where we've been doing this for eight and a half months The hospital moves much slower than it used to because of isolation everything is an additional challenge putting on the appropriate. Ppe taking it off ensuring that you don't make a mistake because one mistake will lead to an outbreak which can paralyze your hospital. That is an incredible weight and then add it to our nursing and Medical staff and physicians who are also trying to keep the rest of their life in order with their kid going to school and dealing with intermittent Quarantines and sick family members at this point. We're really seeing morale in the hospital. Start to take a dip for yourself. I mean are you frightened about what you know is going to await you when you when you arrive at work today or tomorrow or later this week you know. Fear doesn't factor into it anymore. I think we just done it long enough. We've had enough experience with we know what's going on It's more a dread about seeing what's coming And not seeing a definitive clear plan to deal with it as of yet. It's kind of like the cassandra complex. We know this was coming forever. We predicted it or epidemiologist. Knew it was going to be an issue. And now it's here and following the predicted curves and yet the measures are half hearted and not effective. You mentioned nurses. I wanna bring darlene jackson into this conversation. She's president of the manitoba. Nurses union that province currently has the highest per capita rates of covert infections in the country darlene. Good morning to you morning. Tell us what's happening in the small city of steinbach. What are you hearing about the situation at the hospital her. This steinbeck is a small town. That's just a small city just about fifty kilometers to winnipeg and It has almost become an epicenter of Cova nineteen in manitoba We're hearing that nurses are Are working crazy overtime hours. Just to keep up. They are going out and triaging patients in their vehicles. in the circular driveway of the hospital just because The emergency department is so jam packed with patients. There's no bad there's nowhere to move them Patients out of emergency and in order to bring another patient in there. They're going to have to rearrange the whole department. So they're going out and triage union vehicles if the patient stable enough they stay in their vehicle at their unstable than they have to come back into the emergency department. Rearrange make a bad put a structure in a hallway to get that patient in and they are working with the same staff. They've always worked with and it just is It's actually a nightmare. In this problem right now. Sarah newfield is an er nurse at that hospital and cbc spoke with her listen to what she described. It has been mentally and emotionally and physically. Absolutely exhausting is pushed us past what we thought we were able to handle and reciting to question. How is this sustainable. Where short-staffed every day. I think everyone is feeling the weight and the pressure darlene jackson. Tell me more but what you're hearing from nurses of what it's like to work in that environment whereas you say there's not enough space in the hospital. You have to treat people in in a parking lot. Well i i will tell you that are exhausted. They're frustrated. We knew that wave two was going to be much bigger than wave one. We absolutely knew that but our government basically sat on their hands for the for the entire summer when we could have been encouraging retired nurses to come back to work stopping up doing everything we can to get ready for wave two and basically nothing was done so we've moved into way to a numbers are growing. We had almost five hundred new cases yesterday. We're up twelve percent Infection rate and nurses are exhausted. You and this province went out and bought equipment. I mean we bought hundred ventilators with the space to put an in. But we don't have anyone to man that equipment and that's the biggest issue. How concerned are nurses about contracting the virus themselves and they're right in this environment in a hospital that is full to bursting presumably vulnerable as well. Well we've had about one hundred nurses infected since it started the second wave. And you're right. They're very vulnerable. I talked to a nursing steinbach. Who tells me that When she goes to work in the er she gets one n ninety five mask and not mask is gonna last year for her twelve hour shifts. So what happens. Is that every time. You don don. On that nasa that you've been exposed to covid patients with the risk of exposure get tired. So if you're taking breaks your dawning and doping at least five times during your ship. So what's happening is nurses are now not taking that mask off to hydrate or have breaks because number one. They're so busy they don't have time for a break but there's also a huge fear they're going to expose themselves just taking up single mask off. How's it possible. I mean that sounds like something from the beginning of the first wave. And then i thought we as a nation had figured out how to get appropriate and adequate supplies of p. We're still seeing many many many facilities in many units that are monitoring and rationing and ninety five. We have an agreement with With our shared health in this province that nurses can do point of care risk-assessment Which means they basically make risks on every patient prior to contact with them and then they are supposed to decide based on that. What p p the the you but what. We're finding when a nurse does do. Pcr a and requested then ninety five in some facilities. They have to fill a questionnaire on why they need that And ninety five or answer multiple questions and justified out which no one has time for. We are crazy busy in this province. No-one has time to be justified. That they why they need in in ninety five for a patient. So we're dealing with those issues on a daily basis. And i'm and we're back with a brand new season of seat at the table. The podcast where we have in depth conversations with notable guests from media sports and pop culture. But this time we're capturing personal stories about the power of the black lives matter movement the urgency of this moment and really what it will take to move forward seat at the table is available now on. Cbc listen on spotify or wherever. You get your podcasts. i'm not. I add host of ideas in this age of click bait and online. Shouting ideas is a meeting ground for people who want to deepen their understanding of the world. Join me as we crack. Open a concept to see how it plays out over place and time and how. It matters today from the rise of authoritarianism to the history of cult movies. No idea is off. Limits ideas is on the cbc. Listen or wherever you find your podcasts. Dr collins has been listening in. She's the president of the canadian medical association. I want to bring her into this conversation. Dr good morning to you morning. It's interesting in hearing from our previous two guests. They both said we knew this was coming. We knew that the second way was going to be worse than the first wave. Why haven't we if we knew this was coming. Why haven't we been prepared. We'll certainly Your previous speakers have given gut wrenching stories about what's going on at the coalface and i think what this speaks to is that There hasn't been a lack of collaboration and coordination Our public health officials from p hack on down have been working hard They have been looking at evidence on a on a daily basis. vote where to go and how to manage this pandemic. But i think we're the breakdown has occurred. Is that that. Information has not necessarily been brought together in a collaborative way with with levels of government. And by that i mean federal provincial municipal rate out to the health authorities in the hospitals where Dr mark and and miss jackson and many other healthcare workers are working. And so there's not been a a coordinated plan to address what we're seeing now and moreover To act now to change the working situations for these Your your previous speakers. Dr collins if you take a look at the situation beyond the er icu's as we heard from. Dr markland are at a crisis. Point right now. What impact with the surgery. Cases have on the larger healthcare system for things like nonessential surgeries for diagnostic procedures. Yeah that's a great question and it's a great concern and and we actually saw that Poster the first wave or earlier this year At the canadian medical association. We just released a study that showed a marked increase in wait times for surgeries for example hip and knee replacements But we didn't look at. What we know intuitively is that the delay in patients presenting to Their healthcare providers Results in in a delay in diagnosis and treatment for some pretty serious medical conditions patients were then and we'll be now reluctant to present for the fear of of contracting kovin and in hospitals. Dr murkland pointed out You just have to move all your resources to caring for the most deal so elective surgeries will will be cut back. diagnostic procedures Emery that are important in in defining a health problem We'll be cutback. Resources have to be channel to caring for the most sick so this is going to have a far reaching effect. We know the backlog from the first wave is high. I suspect that it will be much greater given this second wave or or just. We're calling it we've seen in the last couple of days Growing concern from doctors across this country and experts calling for long strict lockdowns to get covid cases down to zero. Is that the right approach called. so what what. Cma what we're saying is that that we need to listen to the experts in this and and and public health P hack has been the bedrock of the foundation in the management of this pandemic or in providing the best or the most up-to-date recommendations. We know this virus changes. We know the science and the advice around changes so it's to listen to Whatever their best recommendations are and to recognize that there's not a one size fits all what what edmund to needs and what Northern alberta needs maybe are quite different. The atlantic bubble is a whole different situation So it it's what ever that community or that area needs to reduce its its community Presence of cove it and prevent it from getting into the hospital dr markland. What about for your as Dr collins said at the coal face Do we need not these little circuit breaker lockdowns. But something more significant to stamp this thing into the ground i think everybody's negotiating With both the public and the government right now because Our chief medical officer of health job is to try to balance the greater public need with the the medical issues that are going on and not been an issue for a while. The we had a of people put together a letter who Who argued for the circuit breaker Just so that we could at least get our contact tracing contact tracing were flying blind but that would not stop community progression and we would be at another point where resources would be overwhelmed even with a two week blocking If you look at what. They've done in melbourne They did a much more strict. Six week Lockdown and we're able to get to community spread almost enough. So what do you want. What do you want to see from the government. We asked to speak with the albert to health minister who wasn't available for an interview but said that the government is is reluctant to have lockdown. Because that would end the government's words throw people out of work indiscriminately. So what do you want to see from your government. At the very least i need two weeks At best six I need an honest. I need an honest fact based dialogue with the health minister so that we can actually know where we're going. I don't need half-measures darlene. Jackson for you. The minister of health manitoba also not available to speak with us this morning. But what do you want. See from your government. Well we are right now in a circuit breaker two weeks and maybe extended to another four weeks. And i sincerely hoping extended to another four weeks. I know that our ice to user drowning and our contact tracing is so far behind me. And we're never going to get on top transmission if we can't catch up on the contact tracing and those public health nurses are working hours and hours overtime and we can't catch up so i think we need to shutdown dr collins. What about from the federal government. We should also mention. We asked to speak with the federal health minister. Patty hi do. We didn't hear back but what can be done on a national level as calling for. Is that all governments. Come together to come up with the best path forward to protect the health of all canadians. And at this point in time most specifically we need to protect the health and the ability of our frontline healthcare workers to care for these patients and for other patients no matter what's implemented as dr mclaughlin said we've got at least another two weeks of this ahead of us and but but those people working those emergency rooms in those. Icu need to know that. Someone's got their back that they have hope in the last minute will go to you. What is your message to canadians right now. I think we've done this before. I think we could do right thing before. I know we can do the right thing now. i know we need more support for people out there for elderly and people who are marginalized. But if we don't start doing the right thing and being civil and coming together on this we will see deaths and loss of family members like we have never seen before At least in the last several decades it needs to be done now and you optimistic that we will do the right thing you say can but will we do the right thing. That depends on it. Depends on every single person out there. and de-politicize this issue of covert. I think is the first step is good luck this morning. You're about to step into a very busy situation. And i appreciate you taking some time before your shift to talk to us. Thank you my pleasure. Doctor dr collins thank you very much thank you. And darlene jackson. Our best to your members and thank you you. Dr collins is the president of the canadian medical association. Doctor darren markland intensive care physician and in a frolic at the royal alexandra hospital in edmonton just about to begin. His shift in the icu. And darlene jackson president of the manitoba nurses union for more. Cbc podcasts go to cbc dot ca slash podcasts.
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.
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.
Gun-related suicides in rural men
"Come journey across the globe in an immersive storytelling podcast with film maker, Salim, Russian Walla on pin-drop from tat this season checkout musicians trying to save an indigenous language in Lima. What happens to the tourism? Paradise Rapanui, also known as Easter Island when people stopped showing up and explore what it means to start a black utopia, you can listen to pin-drop wherever you get your podcasts. This is. podcast new research into gunshot wounds in Ontario has started an important conversation about mental health in Canada's rural communities a study in the Canadian Medical Association Journal found that more than two thirds of gun related deaths in. Ontario are suicides and the majority of those deaths are older men living in rural areas. Dr David Gomez is a trauma and acute care surgeon at Michael's Hospital in Toronto and the Lead Author of this study Dr Good. Morning. Good morning my thanks for having me. Thank you for joining us. This is important Why are older men in rural communities so much more likely to die by suicide from a gunshot wound? Well, I think this is like every difficult problem is quite multi Oriel One big aspect of this that I hope you're listening to take away from this is that there's a significant lack of access to mental health resources in rural communities, primerica practitioners, or really have so much on their plate and they don't really have the resources to screen this men at risk, and if they happen to identify someone who had risk of injuring themselves or others the resources to actually intervene are not there. It's interesting because we often hear of gun injuries or gun violence and people perhaps might think of big cities and think of gangs does this research that comes out of this study, force us to rethink that. I completely agree I think we have big problems in Ontario and Likely were able to extrapolate this to the rest of Cana downtown Toronto Downtown Hamilton. The GPA has a problem with assault related injuries and they happen in a very specific subgroup young men living in in the neighborhoods with within the lowest socioeconomic status. However, most of that says you said occur in men forty five or older ninety, six percent of of sell related injuries occurred in men and. communities that are stratified as rural were significantly over represented, and as you said, that's not the what the average they Canadian things when you think of a firearm injury however, that's how you communities most likely to be touched by fire firearm injury. It's going to be suicide your trauma surgeon in Toronto. Tell me a bit more about that. What have you experienced herself when it comes to dealing with gun violence? Might. Unfortunately, a firearm injuries are our today either I've taking care of patients in the hospital that have devastating consequences of their injuries. I see them in the emergency department almost every day I see them in my clinic while they're trying to recover not only physically. But also emotionally financially from the impacts to their families When I talked to my colleagues, corners work in rural areas suicide is there today having to drive out to the family farm to find unfortunately another victim of firearm related site on our data shows that every three days? Ontario. There is an injury or. Death secondary to self harm every three days every three days somebody is either get injured or dying by a firearm with the intent of self harm and again, this is a study about Ontario. But what is your sense as to what we would know about the demographics of gun violence in the rest of the country? I think what? One key thing. From. This is that scientists such as myself need the tools to be an able to answer this important questions. I don't know if this distribution is the same in the rest of Canada because the data's not there. There are a couple of different tracks here. To, explore in terms of how to to address this, your study is calling for better suicide prevention strategies what specifically needs to happen. My the way I address this other scientists is I try to generate as much facts possible for mental health experts and legislators to enact change, and and when we look at violence, we have to look at it like a disease. So there's a host, the person that's experiencing the violence, the environment in which they live in, and then there's the victor, which is the firearm and I think there's a wealth of international eleven showing that if. You decrease the number firearms available. You will decrease the number of violence violent events related to them including suicide However, firearms are part of the culture and the day today of a lot of rural Ontario indigenous communities. So we have to understand that we can't just say no more guns, and then all of this program will magically disappear. We have to encourage safe storage. We have to encourage storing your firearms separate from your munition. When you look at the the host, the person was experiencing this. We have to be able to first identify people who are at risk and then intervene, but we have to generate programs. That make sense for who you're trying to establish them. So if we try to generate a program that's GONNA work in downtown Toronto, it's not gonna work in Thunder Bay. So we need to generate big partnerships with urban suburban and rural practitioners to be able to first identify and generate interventions that actually make sense. To to the average rural mail. There's a humility in that in in saying that as a surgeon in downtown Toronto, you can't just go and say you know no more guns or that the solution that works best for you in an urban setting is going to work. For somebody who happens to be in a rural community to tell me more about the importance of that and understanding that it's not as they say, a one size fits all solution. At one hundred percent There's a large number of examples in medicine and society that have required large societal changes to improve our health as best is a perfect example, I large community required or had their livelihood secondary talk best us and we have to we have to completely eliminate that because of the significant health impact of as best as motor vehicle collisions are the same. We completely redesigned cars roads lower. Legislation or behavior in order to reduce the risk of being injured or dying from Motor Vehicle Collisions on the same thing needs to happen with firearms. We have to first identify unaccept- As a society that we have a problem, and then this requires as I said, large societal change legislative changes and behavioral changes from the everyday Canadian one. The things that people talk about is sort of so-called red flag laws. What are those? So in in in a variety of different settings, some states down south have laws that allow primary care practitioners, emergency department physicians that might identify people that are asked to themselves or others to be I identified, and then the authorities notified. So if they own a forum, it can be temporarily restricted to this farm. So to reduce the risk of their injuring themselves of others and this has been proven quite effective in a variety of various and I said, we have to give the people in the in the front lines I access to these resources. So we can. We can impact some change but also. The. Vast majority of fireman. Contrary responsible and and they have to have trust in the strategies that we're going to generate. So partnerships are important. Those partnerships are important again, just finally because you can imagine that there's some people who would hear some of this. Legislative controls you talking about further gun restrictions and say that you're things you're calling on would infringe on what they believe is their right to have a gun. I could and I completely understand what what they're thinking. But whenever I hear something like this, that it brings me back to to. whenever the the seal loss felt I came out and they were protests against seatbelts. Infringing on their rights as we see anti-massacre protest because we're infringing on their rights I, think my roller FA find this to provide a public health experts mental health experts, legislators with the facts needed show who's at risk, and then try to generate legislation that that is that he's going to provide the greater good for society Dr Gomez good to speak with you about this. Thank you. Thank you very much, Dr Gomez. A trauma surgeon at Saint Michael's Hospital in Toronto and the lead author of this study. If you or someone you know is in distress, this is the number for the candidate suicide prevention service. It's one, eight, three, three, four, five, six, four, five, six, you can text at four, five, six, four, five or you can go to their website to chat. It's crisis services Canada DOT CA. Hi I'm Elena Hudgens Lyle and Herman the Rodwell we're from the podcast inappropriate questions. It's a show about questions ones that might be uncomfortable inappropriate get it. We've looked at everything from how old are you too have you lost weight to how did you get pregnant? That's right and we talked to guests and experts who have been off these questions to find more respectful ways to get curious. So check us out. You could find inappropriate questions on CBC, listen or wherever you get your podcasts. I'M NOT A. Host of ideas in this age of click. On. Shouting ideas is a meeting ground for people who want to deepen their understanding of the world. Join me as we crack open concept to see how it plays out over place and time, and how it matters today from the rise of authoritarianism to the history of cult movies. No idea is off limits. Ideas is on the CBC, listen up or wherever you find your podcast. Dr Alison Crawford is the Medical Director of the Ontario Psychiatric Outreach Program with the Center for addiction and mental health. Also the chief medical officer of the Canadian suicide. Prevention. Service Dr. Crawford. Mornings to you. When you take a look at this study what is it tell you broadly about the state of mental health for men in Rural Areas Well. I, I think as Dr Gomez really expertly outlined I. Think it's really important data because it does reveal quite a significant public health risk that's associated. With the availability and the prevalence of firearms and Also, as you pointed out, we have to sink. Right. Along a continuum of interventions from prevention all the way to intervention to to combat this problem what's missing in order to connect older men in rural areas to mental health services we know that and we can talk about stigma. Stigma exists across the spectrum it comes to to mental health services. But what specifically is going on with these men forty-five and older in these communities? I think we need to understand more I. Mean I would like to see more research that aligns with this getting active of men in that age group and hearing about their lived experience. particularly men who have experienced thoughts of suicide. And again, I, think we need we need a public health approach that's coordinated. When we say mental health, we don't just think of psychiatrists but the most immediately, the study calls for us to think about access to firearms whether it's legislative and just having people aware that having firearm in their home. Creates increased risk of fivefold increase risk for self injury, and suicide, and so to have those kinds of programs that were talked about like safe storage programs red flag programs. and having people who are in primary care I think is another vantage point to to try to engage these men training people in primary care. They use that strategy in Quebec very successfully to to know that these men are at particular risk and how to do assessment. I think that there are challenges around access to psychiatry. In the north, we know that there are far fewer psychiatrists. Northern Ontario than than Toronto or other major centers. So. Addressing that and and looking at innovative models where the cadre support primary care rather than meaning fighters to necessarily see every person. But but most importantly, I think also knowing what works for for these men touched on looking at ways to intervene are culturally relevant to this group of men that are strengths based one of the things I did WANNA highlight I was so glad you Utah read up the number for the crisis line, but the suicide can be prevented in that this group of men obviously. Has Lots of strengths that comme tapped into as well. Let's talk about one of those programs a want to bring in another voice into the conversation here. Bill Farley started a local chapter of the men's sheds program and Dauphin Manitoba in twenty seventeen lives in. Minna. Dosa the Farley good morning to you good morning. What is men's sheds? Man Shut? Were started in Australia back in two thousand and seven because of suicides with older men and. The the word shed is, is the an analogy for the average. Guy Who has a shed in his backyard and as you know, any kind of repair work wood working stuff like that. So that was taken. As the analogy for the word shed. So men shed is an organization that will work with. Older men Who have not only contemplated suicide but are are in depression or or whatever. and. It's an opportunity for fellows to get together and. Do. Various. Kinds of projects like woodworking seems to be the main one but there's lots of other stuff and to give back to the community So we do a lot of work With nonprofits. And other organizations that. Require repair work or require a some something to be built for them whatever and as you mentioned any. Addressing issues of of depression. When. You launched this and you held your first meeting. Tell me a little bit about what happened who came to the meeting. Was a workup before that you know I had a lot of posters around town and radio spots and stuff and eventually. The meeting time came I'd never heard a word from anybody So I, I didn't know what was going to happen but all of a sudden five men showed up. All in the range of sixty to eighty years old I'm eighty, six myself. And I explained to them what we wanted to do, and they were quite enthusiastic and it just took off from there. I I'd like to just go back a little bit. I call for an information meeting at the local senior center. And Gain I had posters up and everything else. And when I went. To speak. There were fifty women there noman why do you think that was the case? Well Lot of the data I've seen Older. Men just do not. Want. To get involved in in programs that senior centers put on for some reason. The director of the senior center Dolphin Has Been trying for years to get older men involved, and then just just didn't happen. Alison. Crawford. How do you address that and part of it is about To Bill's point men going to maybe a senior center, but it's also about men maybe not wanting to sit around and and talk about how they feel again that goes back to the issue of of the stigma. How do you? How do you address something like that? Yeah I think it reminds me of I've heard it described as men do better shoulder to shoulder than face to face. So sitting in clinic is maybe not the right approach and I think the kinds of things that feel is doing is exactly that reaching out You know letting men know that it's available and normalizing it and and I think that reduces the stigma I think social connection is such a a protective factor against depression and into is what are you hear bill from the men who come in they're part of the program what did you hear from them about why they're there? who well have a partner at home? That's fairly large factor when I completed my talk with these women. they were quite enthusiastic because they said, that's an opportunity to get. Oh Georgia for coach in and out of the House. So I think that was one of the factors, their wives literally dragging their. Secondly Well I I need to back up a bit. we're talking to a rural area sent sort of central Manitoba. And so most of the fellows I worked with Had come off, farms they they'd. They'd sold the farm or they giving it to their sons to run and they moved into town and and that's when it all started for them. It had nothing to do. And what I've learned is that. Men Get. Their worst sense of worth from their occupation whatever they're doing. It doesn't matter if they if they get their worth and they're they're seen as being worthwhile. that seems to. keep them going from day to day. So the FELLAS I worked with. Were there because they saw an opportunity to give back to the community and feel worthwhile to to be doing something. And just to respond to previous remark. The idea of talking about feelings and and sharing personal happenings in their lives that will come later as these fellows got to know each other and. and. have. Know. The just won't talk if. If, they don't know each other alison. I I made he's six years old out of an era where men just suck it up and. Don't talk about feelings and so that's what I was doing. But as you say, if you can get people to nearly then then then they're going to be more luckily to to be able to speak openly in that way if they if they feel comfortable. Exactly Alison just finally what what gives you hope when you hear about a program like the one that bill is involved and I think those observations are so important. They're the kind of observations we don't. We don't necessarily get to spend time with people like that in psychiatric practice and I think so insightful I also think the starting when I hear the age of these men it upstream approaches that star when boys and men are younger and encourage social connection I mean girl. So really important to lay the root for that kind of social connectedness, but I think it's an incredible work. It needs to be if it works, it needs to be implemented more systematically bill. Thank you very much. Dr Crawford thank you so much. Dr Alison Crawford is the Medical Director of the Interior Psychiatric Outreach Program with the Center for Addiction and Mental Health Bill Farley started chapter of the men's sheds program in Dauphin Manitoba. If you or someone you know is in distress, this is the number for the candidate suicide prevention service. It's one, eight, three, three, four, five, six, four, five, six, six, you can text at four, five, six, four, five, or you can go to their website to chat. It's crisis services Canada DOT CA for more CBC PODCASTS TO CBC. Dot. Ca Slash 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.
Is life expectancy in Canada about to drop?
"The big story is brought to you by Scotiabank. Candida is a first world developed country. We are rich geopolitically speaking. We have universal healthcare lots of natural resources and a pretty solid safety net. So should we be worried about our life expectancy? It's still rising for now a little bit. Anyway, at least in most areas of the country, but it's definitely not climbing the way it has been and data from other countries proved that there's still room for it to grow. So why isn't it? Research from south of the border where life expectancy is actually falling for the first time since the last World War helps paint a picture, and it's not a pretty one. So what is causing American life expectancy to drop? How different are the circumstances. We face in Canada. Are there some simple solutions that governments can adopt to help put us back on the right track? Or does this problem require a rethinking of how we run our country. If you want a hint on the last one this episode features, a senior scientist at a mental health institute discussing an overhaul of federal economic policy. Jordan, heath Rawlings. And this is the big story. Dr Yergin ram is the aforementioned senior scientist at the center for addiction and mental health in Toronto. He also works at the university of Toronto rates for several journals. We're talking to him today because of a paper published in the Canadian medical association journal that suggests that yes, Canada is victim to these same factors causing life expectancy in the states to drop. Why is life expectancy such an important number to look at in a country? Eight summarizes the overall trends in mortality, and it is one of the best measures to see how a country and the country's house is developing on balance it is also related to nonfatal events. So if you look into other measures, which are way more complicated like dailies or call is they're usually not readily available on a yearly basis for scrutiny. Life expectancy still is the number one indicator which summarizes the health of a nation. Even though it does not explicitly include fatalities nonfatal events. So. What is life expectancy currently in Canada? And what are the trend lines around it? Life expectancy in Canada's currently around eighty two years that is different by sex. If we look into the higher life expectancy, which in all countries of this world has been with women women currently have alive expect him to close to eighty four years, and that been increasing from a and a half years to eighty four years in the last twenty five years since nineteen ninety for man, they have been increasing at a steeper rate from seventy four to about eighty as a life expectancy. Also in those twenty five years, the increase has had been such that in the first twenty years from nineteen ninety two thousand ten the increases were much steeper both for women. And for man, then in the last five six years. Meaning that we're cruising and we're narrowing to fresh hold in life expectancy. However, they can and should be increasing in the near future. Why because we know that those country who provide the best environment in the overall policies have had much higher life expectancy, then we experience in Canada day. So tell me quickly what is happening in America. What are the roots of a country like that seeing life expectancy fall, we see to America's one is the poor America? More rural more dominated by smaller. Towns higher unemployment overall a net decrease of income and one the urban tops educated people. With an increase in live expectancy, even over the last five years when the overall country was declining increases in income, quite substantial increases in income and a very positive outlook into the future, and those two America's have been developing in different directions. Not only income not only we hope or despair, but also with life expectancy, and if different causes of death. So explain to me what kind of contribution a lack of hope or income inequality actually makes life expectancy. How does that impact? There are free so-called deaths of despair. And this term has been coined by Angus Deaton who won the Nobel prize in economics some years ago. And it means that those deaths are. Are all directly or indirectly related to sentiments of despair. The first is suicide I think we don't have to explain a lot here. The two major diseases which are linked to sucide, depression and alcohol uses orders. Those two have been shown to be costly impacting on suicide, and I think everybody would know or what assume that depths of despair is a correct term the next category, which was impacted by those would be liver cirrhosis liver cirrhosis has been rising quite dramatically and that is in a country like the US but also in Canada, by the way, sixty seventy almost eighty percent related to alcohol use and alcohol. Used as orders the final category overdose deaths, and why there can be a lot of different overdoses the most important in the US would be opioid overdoses both from prescription opioids and from illicit opioids, and they made up several ten thousands in the last years, and they have been steadily increasing for at least ten years. I'm kind of intrigued by diseases like psoriasis of the liver because that seems to me like something that as our medical proficiency increases. But also as awareness increases around diseases caused by alcoholism that we should be seeing falling. And that sounds like a staggering number to me if that to developments going on there, and it is a staggering number. But first of all we have to realize that for a lot of our people if you look into surveys. Alcohol is mainly a beneficial truck. People do not want to realize that actually alcohol is one of the top risk factors for premature death in the developed world. What we see here is that a lot of the alcohol control mechanisms in North America have been eroding alcoholics become more and more available. The shops per square beat or have been increasing. The affordability of alcohol has been getting higher and higher affordability is not only the price. It's how much you have to work for one unit of alcohol, and there has been way way higher in the nineteen fifties sixties and has been decreasing almost constantly in all of North America. And ever kind of control mechanisms do not exist in North America. Except for some provinces in Canada. For example, north the US has no minimum price. Right. We have minimum pricing in Canada. Though. We have many comprising candidates under attack us, you know. It's the return of bucket beer in Ontario. As of today, you now have three choices for one dollar veer at the L C, B CBO and the beer stores. One of those choices hero Bacchus certain would be a decline of our minimum price and on oh for a unit of alcohol by more than twenty percent. But Canada has been one of the few countries with minimum pricing, and has always been cited in the European Parliament's as the example, where we should go and what we should do in European countries. And actually now Scotland Ireland number of other countries have been. Introducing minimum prices according to the model of Canada. Up next. I believe that we are slowly taking steps towards at least realizing what's going on and trying to prevent for problems. You can save like never before with these Scotiabank momentum plus savings account. And now for a limited time you coming up to three point two percent interest until March tenth you can find all the terms and conditions at Scotiabank dot com slash MP. I feel like and this is why we wanted to talk to you. Because I feel like we talk a lot about these factors individually. We've done an episode on an opioid crisis. We definitely did an episode on buckle beer, and whether or not that was a good thing. But we've never made the connection between that and despair, and I wonder if that that's being articulated anywhere. I think it is much more difficult for governments to tackle inequality than to tackle minimum prices. I know that a lot of governments said away from doing anything about alcohol because they fear. It will hamper their chances to be reelected, but it is still a possibility and government sees that as possibility, but to reduce inequality is much hotter, and is a real car gang twin task because inequality has all but income. Creasing in all countries almost all countries would charge developed over the last twenty thirty years. In fact, also since the second World War, and it has been increasing in the US to a degree that they have one of the highest inequality of high income countries. And that is also part of why we see the current crisis. Because even within those rural areas, it is very clear that the depths of despair are concentrated in the lower socioeconomic in the people with lower socioeconomic status, and that means that it's also not only about having a tough situation. But being in a situation there where you see that ever part. Of the country. That other groups have in the Americas are doing actually much better progressing are fulfilling their goals have hope determining the future, whereas they seem to be completely leftover part of an old style, which is no longer valid in the area of globalization. And that has led to some of that despair. You know, what it kind of sounds like you're describing the people that the New York Times and other publications described as the economically anxious people who elected Trump the correlation between electing Trump the percentage of people electing Trump and the opioid overdose prescription rate and the opioid overdose. Prescription death is a moderately high positive correlation. So it is right. You what he was saying? What what you're saying is. Something which can be empirically shown. Yes, that's been an article an article in chairma, one of the most important magazines, and they found that correlation. How different is the situation candidate is in right now from the one America finds itself end, we're not actually falling yet and life expectancy exactly basically, you can call it a class. How full if you want to defend the status quo or a class have. Mt. Are we seeing some of these signs are seeing the widening gap? What does it look like up here? Very clearly we do see some of those signs. The most recent report on public health for Canada ham has been pointing out that between two thousand eleven two thousand seventeen the alcohol attributable deaf rate for women increased by twenty six percent. And that is in a situation where our deaf rates were decreasing like for all cardio. Vascular for cancer, the alcohol attributable, desperate for man. Also increased by a lower percentage. Those are accepted the same signs. We had seen in the US and Chi. Hi hat reported in their last report that alcoholic liver cirrhosis. These are all liver cirrhosis, which have been labelled as alcoholic on the death certificate. That's vast underestimate because a lot of people don't want on the death certificate of their family member a term like alcoholic, which is still quite stigmatizing those deaths, and if he assume that the stigma has been relatively constant they have been increasing. And there have been increasing quite a lot. We have a number of other indicators like overdose deaths. The opioid crisis of Canada. You've done your own show on that. That means it must have had a certain significance overall. And we do have now four thousand opioid overdose deaths and had way less than two thousand only a few years ago. So those are the signs pointing in that wrong direction. What we do not have is the income inequality has been increasing. But not as traumatically as in the US, and we do not have increasing suicide rates, and that is something which has been increasing over a very short period for forty nine out of fifty states in the US with an average of twenty five percent over a period of five years the difference. There is that our people Canadians still do not feel desperate. They believe and if you look into surveys, and this is catchy. I admit that if you look into surveys, most people still believe that their kids have a better life than themselves. Most of the people do no longer believe that how worried are you? When you look at this data, and you put it together about the future of life expectancy in Canada. If I look at the data on both sides, I believe that we are slowly taking steps towards Elize realizing what's going on and trying to prevent for problems. I'm saying that because suddenly it's no longer to boo to look into what our health system has done in prescribing way, too many opioids a lot of those people who die later on St. opioids or on all have been made. Addictive by our healthcare system. And there's no real reason why kinda would need the second largest prescription rate of opioids in the world. We have one hundred ninety five countries, but we have the second place, and we prescribe opioids for anything I was at dentist last week refuse to take opioids with me. But I would have had a nice prescription. Opioids no problem and those kinds of things are obey Curtis, and we are currently on the right track to come up for skylines to have way. Less of those prescriptions realize that the evidence is simply not there to have done all of those prescriptions. In the first place, we cannot reduce opioid overdose deaths very quickly soon, but we can do that. And redoing steps in the right direction. Also, I'll call control policy is. Being discussed that doesn't mean that everything's going the right direction. But if you look into the two thousand eighteen report on public health on substance use it is being discussed if you look into our parliaments, it's being discussed the toughest will be the inequality. And there are a lot of that will depend on the voting behavior. We should be honest about what we want and let the politicians know that we do care about those things, and we do care about those connections associations, and that it is in our own interest to create less inequalities. Dr you're gonna ram of the center for addiction and mental health. And also the university of Toronto that was the big story podcast. Brought to you by Scotiabank. You can earn up to three point two percent interest until March tenth with these Scotiabank momentum, plus savings account conditions apply for more from us. The big story podcast dot CA is your destination that or frequency podcast network dot com. Everything you need is. There are other shows are other episodes ways to get in touch with us. That include our social media accounts at big story podcast on Twitter, Facebook or Instagram, and of course, subscribe rate review wherever you get podcasts, apple Google, Stitcher. Spotify illicit goes on thank you for listening. I'm Jordan he throwing so we'll talk tomorrow.