Red Sky in the Morning

Yesterday I travelled to Nova Scotia to visit my sister. I took an early flight that travelled into the sunrise and I could not help but notice that the sky was red, and I remembered the second half of the old rhyme:” Red sky in the morning, sailor’s warning.”

When I greeted her, my sister needed to be reminded who I am, although she began a conversation about her health readily enough. “I’ve got anemia now. They’re considering giving me a blood transfusion and I’m not sure I see the point.” She paused. She gave me a sidelong glance and said, “Just because I didn’t remember your name right away doesn’t mean I’m incompetent, and if you begin to think I am incompetent, don’t say anything.” I was contemplating what the link is between memory and competence when my sister added, “They don’t put enough items on those advance directives,” she said, “I have to consider every single, possible situation that might come up.”

“Such as?” I asked.

“Well,” she said, “I first said yes to the blood transfusion and then found out that I’d have to go to the hospital for this. I still can’t figure out why. I could probably still set it up myself. I forget stuff, but I haven’t forgotten much nursing. They drill everything you need to know into you forever. I don’t want to go to the hospital. I’ll just deal with the weakness. Once they take you to the hospital, you can’t be sure you’ll get away. I remember that too.”

What does memory have to do with competence, if anything? When memory is unrelated to understanding a medical situation, it likely has nothing to do with competence, but I am going to have to think about this. I assess the capacity of patients to make their own decisions on many days at work, but my patients rarely have memory problems.

Being with my sister in this period close to her death has really driven me to contemplate how I’ll ensure that my wishes are followed when I am at the end of my life and may not be able to discuss or assess these decisions for myself. I am such a control freak that I can see these situations being a cause of great distress, and my admiration for my palliative care colleagues intensifies once again. I can imagine families in which each sibling believes their parent would want completely opposite measures to be taken – I know some of these families already.

The statistics regarding what most of us would like at the end of our lives versus what does happens are at odds. Most of us would like to die at home, but most of us are brought to hospital. What needs to be done to change this outcome? Most of us are brought to hospital when it is no longer possible to keep us comfortable at home and I suspect that my sister is correct. It’s not possible to contemplate beforehand every situation that might need to be in an advance directive to ensure that your wishes are faithfully followed.

My flights to and from Halifax were trouble-free. The weather was fine in both places all day. The warning was for a more ominous situation than weather, and I’m not sure what steps to take while I am still competent.

Take warning.

New York State of Mind

Once again this year I will represent Medical Women’s International Association at the United Nations Commission on the Status of Women, in New York City. I keep pondering the irony that the priority theme of this year’s Commission is Challenges and opportunities in achieving gender equality and the empowerment of rural women and girls and that we are focusing on this theme in such an urban setting as New York City.

It is only five years ago that the plight of rural women was considered at the Commission. This same theme is being considered once again because the meetings five years ago did not result in agreement being reached on how to meet the challenges facing rural women and girls. During the past five years, UN agencies and Civil Society have been working regularly to develop a proposed Outcome Document that stands a better chance of agreement. This document sets out the legal framework for gender equality that member states agree to support by the end of the Commission on the Status of Women.

What are the issues facing rural women and girls in their quest for equality? Think of the impact of climate change and unsustainable farming practices on rural life. Think of the barriers to women owning land in some parts of the world. Think of the financial barriers women face even in our own country. The issues of migrancy are particularly problematic for rural women. Rural women and girls do not have the access to adequate health and reproductive health support. They do not have access to legal support when required. For all these difficulties, there is overlap with the issues faced by women and girls in an urban setting, but the remedies are more difficult to establish and maintain for rural women.

One of the most amazing aspects of this meeting is that there are always women attending who have never been to New York City or the United Nations. It is always inspiring to speak with them about their experience of the city and the institution. Over the years I have attended this meeting, and in all the years I have come to New York, I find that my faith in the city grows, while my faith in the organization diminishes.

The United Nations was built on lofty goals and tremendous idealism, but countries that deny women basic rights sit on the UN Human Rights Council. The treatment of the State of Israel by the United Nations has been worrisome at best. It is the Church Center for the United Nations that has most inspired me; its chaplains and its mission exemplify the spirit I wish I could find in all of the institutions of the UN.

The city, however, and the spirit of its people, have emerged stronger through the challenges they have faced. New York City lives and breathes and invigorates. I learn something every time I visit New York. I am like Tom Wolfe who said, “One belongs to New York instantly, one belongs to it as much in five minutes, as in five years.”

At the end of my time at the Commission on the Status of Women, I expect I will feel discouraged about my United Nations experience, but I will leave New York longing to hold on to a New York state of mind.

Book Review: The Undoing Project: A Friendship That Changed Our Minds

The story of the friendship between Daniel Kahneman and Amos Tversky is the story of how our minds lead us to make mistakes. The Undoing Project: A friendship That Changed Our Minds by Michael Lewis focuses on the relationship between two extraordinary psychologists. However, in telling the story of that relationship, Lewis educates the reader about behavioural economics, discipline that arose out of the work of Kahneman and Tversky.

Lewis is a prolific American non-fiction writer, probably best know for his book Moneyball: The Art of Winning an Unfair Game. He is a remarkable storyteller – in fact, even after I had read The Undoing Project, I couldn’t quite figure out whether Lewis had meant to write about a friendship or behavioural economics. Even in the introduction to the book, Lewis hints at this dilemma himself:

“What possessed two guys in the Middle East to sit down and figure out what the mind was doing when it tried to judge a baseball player, or an investment, or a presidential candidate? And how on earth does a psychologist win a Nobel Prize in Economics? In the answers to those questions, it emerged, there was another story to tell.” (p.19)

With this beginning, Lewis tells the story of Tversky and Kahneman and their friendship – and the tale is compelling. Most people would find that they cannot stop reading. Two clever men, both Israeli, with very different personalities are intellectually attracted and out of their collaboration they make discoveries about how we think that will ultimately change how we think.

Those of us who practice medicine are certainly aware of Kahneman’s and Tversky’s work. Their work, as extrapolated in to medicine by Dr. Don Redelmeier, working with Tversky. They examined how errors in medical judgment occurred, and particularly in the case of expert physicians who sometimes ignored the data in favour of their own intuition. Most often, in these cases, the doctor will be wrong. This important work has helped physicians to check their thinking, to confirm that they are basing decisions on facts and not impressions.

Because Lewis uses the history of a friendship to help describe important discoveries about how we think, I found that I learned about Tversky’s and Kahneman’s work without having to think about it. I think most readers would have the same experience.

(I read the hardcover W. W. Norton edition of The Undoing Project: A friendship That Changed Our Minds, published in 2017.)

Guest Blog: Dr. Cargill and Dan’s Law

For the past nine months, I have been visiting my sister who is dying in Nova Scotia. This experience has truly sensitized me to the needs of those who need palliative care, and I now appreciate how much I will want to be able to control how and where my life ends. But this is not always possible, as Palliative Care physician Dr. Darren Cargill found out while caring for Dan, a patient who had moved to Ontario from Alberta. Dan’s story is very moving, and it underlines some of the inhumanity in our disjointed healthcare system. Dr. Cargill confronted this inhumanity on his patient’s behalf, and that is an even more inspiring story.

I asked him as a guest blogger to speak about his advocacy on behalf of Dan, advocacy that has resulted in the introduction of Bill 54 into the Ontario Legislature. Here is what he had to say:

“Bill 54, introduced by MPP Lisa Gretzky and which was debated and passed second reading on November 17th, 2016, provides much needed support for patients and their families. Canadians who move or return to Ontario and require palliative care or home care should not be subject to the typical three-month wait to be eligible for OHIP services.
The Bill carries the support of the Ontario Medical Association on behalf of its 34,000 physicians and medical students.
The issue came to light for me when a patient, Dan Duma, was denied home care services upon returning to Ontario from Alberta. Dan was dying of cancer with a life expectancy of less than three-months. Dan’s Law prevents future patients, families and caregivers from experiencing unnecessary hardship as a result of this lack of access to needed care.
As a doctor, I know that there is no medical justification for the wait period and I believe that, especially in these circumstances, we should afford Canadians and permanent residents the right to die with dignity. The benefits of home and palliative care are not only medical – they serve to support family members and caregivers.
The benefits of timely care include avoiding potential medical complications of delayed care and the associated significant human and financial costs arising from these complications.
Bill 54 has passed second reading and was sent to the Standing Committee on Justice Policy. This bill needs to be passed before the provincial election. I am asking that you write to your MPP and ask that Dan’s law be passed.”

Why would a person have to move from one Canadian province to another if they were dying? We all know the answer to this. They would move to be closer to family members. Why should they be denied the benefits of palliative care or home care? Please send an email or letter to your MPP and ask them to move Bill 54 forward. No one should ever be denied care in Canada because they moved from one province to another to be closer to family.

You can contact your MPP in Ontario using this list. If you are a physician in Ontario, please support this work. You can find a template letter under Advocacy on the OMA website. You do not have to say much, just tell them to get Dan’s Law passed before the election.

You can tell from how he wrote those few words above that Dr. Cargill is a doctor who feels that part of his work is getting all the support his patients need, even when that requires changing the law. Think about yourself or your own family. If you, or a loved one was very ill and had to move to be closer to the people who love you, so that they could be with you and look after you, is it reasonable that your health care would be compromised? Of course not! Thank you to Dr. Darren Cargill of Windsor for working so hard to change an unreasonable situation.

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I am feeling disappointed with the voting process for the Canadian Medical Association President-Elect Nominee from Ontario. A few people on Twitter are saying it only took them 5 minutes, but they clearly had all the right numbers and user names and passwords together at exactly the moment that they decided to vote. I had a spare ten minutes on a Wednesday evening before a teleconference started, clearly had none of the right details and ended up having to vote last Saturday when I could go through the information more carefully.

Some of the information that was most helpful came from a Past Ontario Medical Association President who had sent an email encouraging people to vote and from a friend I called incidentally about something completely different. I did vote but it took about half an hour, not including any time on the phone with friends. I did hear from two candidates that relatively few people had voted and so I started calling the list of people I had been encouraging to vote. I coached five people through the process as they were keen and I think every vote is really going to count in this election. I did have to coach them around the pitfalls I had encountered, and did return to the former OMA President’s email for the solution to a problem different from the one I had encountered.

I will be very interested to know what the turnout is in both the OMA and CMA elections that are currently underway. I know from the personal experience of having run in both OMA and CMA elections that the turnout is usually under 20% in both, less than the turnout in most Canadian municipal elections. Turnout in Canadian municipal elections varies although this work from the University of Waterloo outlines a rate of 35% in Vancouver, which is the lowest among several Canadian cities. The turnout in the last federal election was high – 68.49%.

The University of Waterloo article does mention that online and telephone voting usually increases voter turnout. This is the Canadian Medical Association’s first completely online election for President-Elect Nominee in Ontario so it will be interesting to see whether the voter turnout is increased. After my experience, I am guessing that this will not be the case. If I am correct, and the voter turnout is very low, I will be interested to learn from CMA how close they came to the target they set for voter turnout. By the same token, I will also be interested in seeing whether, in its second year of primarily electronic balloting, the OMA is managing better turnout rates. I have found the OMA system to be more straightforward, but this is not everyone’s experience.

I am going through this long, likely boring story of voting in the CMA election to stress that we must hold all entities accountable when they claim loftily that they are democratic without ever establishing exactly how they ensure that anyone who is eligible to vote can easily do so. Turnouts under 30% don’t suggest great accessibility to one’s franchise, but I could not find any target for acceptable voter turnout by any association or elected jurisdiction. Which suggests…what? They don’t care?? They think that low turnout is mostly the electorate’s problem??

Even countries as proud of their democracy as the United States have had to implement laws to ensure that African-Americans have fair access to their franchise, but not everyone follows these laws as the American Civil Liberties Union will attest.

As a citizen, I have volunteered in elections of every kind, in the belief that by doing so, I am doing everything I can to promote the democracies that govern me. I do this in all kinds of uncomfortable circumstances grateful that I do not face censure or death as many do around the world in jurisdictions where democracy is less secure. I even consider this expression of concern regarding the CMA’s election process to be part and parcel of my duty as a member of that organization. So I will ask my CMA representatives: Do you care that the voter turnout was so low and what specifically are you doing about it? I just hope the response does not leave me feeling like P. J. O’Rourke, who famously said: “Don’t Vote. It Just Encourages the Bastards.”

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We Should All Be Feminists

As International Women’s Day approaches, I wanted to mention a short book, adopted from a TEDx talk that you could read to reflect on what feminism means in this #MeToo age. Chimamanda Ngozi Adichie is an award-winning novelist from Nigeria and she wrote We Should All Be Feminists.

Adichie argues that “Boys and girls are undeniably different biologically, but socialization exaggerates the differences.” (p. 35) If socialization exaggerates the differences in North America, this experience is even more extreme in Africa and this has clearly shaped Adichie’s narrative.

In fifty brief pages, we can review some of the most important challenges facing the gender equity movement and contemplate how to continue to move forward. Of all her messages, the strongest is that we must continue to raise both men and women differently. I believe that we are all trying to do this, and the evidence is that we are mostly successful.

Feminists, female and male, are not the only people trying to raise our children, however. There are many individuals and organizations around the world, with access to our children via media and social media, who are also influencing our youth. Many of these are seeking to maintain the status quo. Why even our culture, as Adichie points out, gravitates to the status quo all around the world.

In this week leading up to International Women’s Day, find Adichie’s text or TEDx talk. Contemplate the role you have played in improving women’s lives, and then keep going. There’s still a lot of work to do, but I hope this little book will renew your energy as it did mine.

(Note: I read the February 2015 Anchor Books edition of We Should All Be Feminists.)

Will More Beds Make A Difference in Youth Mental Health?

It is almost one month since Ontario Health Minister Eric Hoskins announced that the provincial government would be investing in increased hospital beds to improve access, especially during flu season.

The investment includes 61 new mental health beds and, while I don’t want to sound ungrateful, or discourage investment in mental health, if I had a choice of how the money will be spent, I would not want inpatients beds, I would want outpatient services.

Most youth with mental health problems do not need hospitalization. They need outpatient treatment, perhaps including medication and often a treatment proven to have a positive outcome, like cognitive behavior therapy or dialectical behavior therapy, treatments that have been tested in controlled trials.

Since none of the treatments are long term, the Minister would not have had to worry about people being in therapy for years. Research demonstrates that the number of CBT sessions needed is between 5 and 20 sessions, lasting 30 minutes to one hour in length, and usually spaced every other week. Neither a referring physician nor a family should expect a youth to be followed long term unless they have a condition like Schizophrenia, or Bipolar Disorder. Even with these conditions, most of the treatment occurs in an outpatient setting. Most hospital psychiatry programs take accountability very seriously. The measures we use at my hospital to ensure satisfactory care include careful monitoring of symptoms using standardized scales; goal completion questionnaires completed by youth at least every other session; and less frequent focus groups with youth and families to ensure the best quality treatment.

If Minister Hoskins had asked me what I wanted, I’d have asked for nurses and social workers, maybe one psychologist or two. If there happened to be enough cash to make a longer term investment, I’d have suggested that we really need more psychiatrists. Based on the number of psychiatric residents training right now in Ontario, there will be a shortage of psychiatrists for at least 30 years. That’s as far out as the projections have been calculated, but I don’t expect the numbers would improve moving forward unless some action is taken.

Another measure that would serve many more youth would be to empower Psychiatrists to work more closely with colleagues in Primary Care or Paediatrics by facilitating the development of teams in the community, or by finding a way to include them in existing teams. If these teams could have access to nurses, social workers or psychologists, they would reach even more youth.

Minister Hoskins might also consider services for a few groups of youth who have complex needs and for whom services are very inadequate, including:
1. Children and youth with Autism Spectrum Disorder
2. Children and youth with developmental disabilities.

What I’ve just set down is not the best articulated, or most comprehensive approach that might be taken to youth mental health, but it does reflect what many groups have been considering and what the people I work with have wanted. The Ontario Psychiatric Association did provide this advice, related to Youth Suicide. Many of their recommendations overlap with mine.

There are some regions in Ontario with a greater need than Eastern Ontario for mental health beds for youth, but I suspect they also need access to outpatient resources to follow patients once they are discharged from an inpatient program.

My greatest frustration is that, like so many health measures undertaken in recent years, this seems like an isolated measure undertaken in a crisis. We need a well-conceived plan, and accountability. If my patients and I are completing scales and questionnaires regularly to establish our efficacy, why should governments not have to do the same? Shouldn’t the Health Minister have to prove that his “treatment” is “effective”?

(Photo credit)