Ongoing Discrimination Against Women Doctors

An article that I read recently emphasized how long and how unsuccessfully women physicians have been struggling to improve their working conditions to the point where they might be able to find some time with families along the road to career success. It is over 40 years since I was a fresh-faced seventeen year old starting medical school and it can be disheartening at times to realize how little real progress has been made. Articles like Krause et al’s Impact of Pregnancy and Gender on Internal Medicine Resident Evaluations: A Retrospective Cohort Study make this all too clear. The sophistication of the study techniques adds credibility to women physicians’ and learners’ own reported experiences but, at some level, I think it’s unfortunate that years of reporting have never been enough to force change upon our hospitals and our medical schools.

My consideration of this study, which examined the evaluation of internal medicine residents after their own pregnancy or a partner’s pregnancy, led me to ask how (or whether) Canada’s medical educational colleges, the Royal College of Physicians and Surgeons of Canada or the College of Family Physicians of Canada, ensure that there is no gender-based discrimination in their own evaluation of trainees.

Neither College makes a statement that the organization is aware that there is gender discrimination in medicine, although this is no different from other professional credentialing bodies whose websites I examined. I also reviewed the website of the Association of Faculties of Medicine of Canada (AFMC). The AFMC does have an award, the May Cohen Award, for “outstanding effort or achievement in improving the gender equity environment in academic medicine in Canada.” However, there is nothing to indicate any work they are doing to ensure that there is no gender discrimination in the evaluation of trainees.

Most faculties of medicine in Canada do now have a person of reasonably high rank within a medical school tasked with addressing this gender-based discrimination and this is important to all women faculty, and even many men. I am beginning to think, however, that the problem is not bad intentions but rather implementing measures that have been proven to improve gender balance and reduce gender discrimination, and then tracking progress.

What could one do? Well, for one thing, both educational colleges could begin by recognizing that family life can really mess up a schedule. Both colleges have extensive details on how it manages accommodations for those candidates with special needs, but neither one makes any mention of whether family needs, e.g. the due date of your child’s birth coincides with the date of your examination, can be accommodated. At least half of medical graduates in the country would be significantly affected by this situation and the other half will likely also consider their child’s birth as the event they must attend.

This 2003 study on gender differences in academic advancement did offer some insight into the background of gender discrimination in medicine. The study also indicated some of the differences between the concrete treatment of men and women faculty that could be mitigated if departments and faculties of medicine undertook to implement change.

For example, from the study in question, women faculty were routinely paid less – they could be paid the same. Women faculty more often shared lab space – everyone could have their own lab space. Leadership positions were more often offered to men – departments could make a concerted effort to find leadership positions for capable women. These are all results that could be tracked for improved performance, and evidence of improved performance would certainly be welcomed and noticed by women. Also, while many medical faculties are working on these issues, it is evident from the article mentioned at the outset that there is still a long way to go.

But what could the educational colleges do about these issues? They could, in my view, acknowledge that they are aware of the gender discrimination that occurs in medicine. They could evaluate their own examination practices to ensure that the gender bias in these has been eliminated. They could emphasize to the Faculties of Medicine training their members that every candidate ought to have an equal opportunity to train and accredit programs accordingly. If they have taken any of these measures already, as a member and physician, I wish I could find that information on their website.

As someone who has spent over forty years working for gender equity in medicine, it would be reassuring to know that my efforts, and those of my colleagues, have not been for nothing.

Youth and Cannabis: Does Legalization Set Them Up?

The legalization of cannabis is of great interest to many Canadians, including my patients, most of whom are under 19. Here’s a typical conversation in my practice lately:

Youth: “Hey, Dr. Beck, what do you think it’s going to mean now that marijuana is going to be legal?”

Me: “Actually, it probably won’t be legal for you. You’re still under 19.”

Youth: “But, seriously, Dr. Beck, what does it mean?”

Seriously, my concern is that my young patients will now be the focus of anyone involved in illegal drug activity once marijuana goes mainstream with liquor and tobacco. My only contact with this world of illegal drugs has been via youth. Their stories of dealers and dealers’ expectations are frightening and open up possibilities for youth that are very difficult to solve without a much more in depth dialogue than we are currently having.

For many years, I have been asking my patients to help me develop ways of speaking with them about drugs and alcohol so that I am effectively communicating the concerns about using these at their age and at any age. There is significant evidence that public health campaigns that effectively communicate the risks of a behaviour can help to deter that behavior. I want to be an effective communicator.

To help prepare myself for this new world, I am reading everything I can about the impact of cannabis legalization in other jurisdictions. Besides a public health education campaign, what other measures can I use to increase awareness of the risks of cannabis use in youth?

I was very intrigued by some of the ideas in this CBC story, and particularly the notion that the legalization of cannabis may help to “normalize” conversations about it. With young Canadians smoking more cannabis than their same age peers anywhere else in the world, we likely should have “normalized” this conversation long ago. I want to extend my conversations to the point where we’re discussing what “normal” substance use is. I want to discuss a better approach to the mental health problems associated with cannabis use disorder and cannabis dependence.

I also think that we need to consider how knowledge about cannabis use in Canadian youth can better inform lawmakers so that Canada’s youth are not caught as the focus of trafficking schemes, since law enforcement has been clear that illegal activity related to cannabis will not just disappear on July 1, 2018. Once adults can all head over the neighbourhood Cannabis Control Board of Ontario, dealers may turn to the markets that are left and youth are one of those markets.

Keeping young people safe from every possible negative outcome is my main concern with the legalization of cannabis. I know what my concerns are but there are no measures proposed that will address these concerns.

Here is what I am asking:
1. Once cannabis is legal and regulated in Canada, how will we adapt public health education to include youth?
2. How will we prevent Canada’s youth from becoming the focus of illegal activity related to cannabis?
3. In the midst of our new “openness” about cannabis, will we talk about mental health, about cannabis use disorder and cannabis dependence, any more effectively than we are now?

Learning Disabilities

I was twenty-one years old when I first truly understood learning disabilities. I was in my clinical clerkship at McGill University in a psychiatry rotation. One of the patients I was following had dyslexia. Like every good medical student, I read everything I could about the condition. But it was the definition that was personal for me: “the general term for disorders that involve difficulty in learning to read or interpret words, letters, and other symbols, but that do not affect intelligence.” I am not sure where the definition is from because I have copied it today from the journal I kept at the time.

This disorder was important because of how my mother had always described her own academic abilities. My mother always told us that she “could never spell” and was “a slow reader” and that her younger sister was “the smart one”. My brother and sisters and I were given very easy to spell names because my mother had struggled to spell her own beautiful given name, which was Othelia. She didn’t like this name, I suspect because it always made her feel “stupid”.

“I can’t even write my own name,” she’d say.

But, on the other hand, she could talk your ear off and no one could recount family stories as wonderfully as she could. Her vocabulary was sophisticated, her grammar perfect and, if she could have written them down, she would have produced some of the best stories about life on a small Ontario farm in the Ottawa Valley during the Great Depression. She also got the best marks in math in her family and, for many years, made her living as a bookkeeper.

The more I read about this condition, the more I realized that this was exactly my mother’s problem. Educational institutions were just beginning to accommodate for learning disabilities in the 1970’s and I astounded my supervisor with the amount of work I did to get those accommodations for my patient, who was struggling to complete the mandatory English credits to get her Architecture degree. This young woman had been discouraged from studying architecture because “it’s a difficult job for a woman”. That’s another quote taken from my journal.

Female medical students were just as rare as female architecture students in the 1970’s, which was another factor that kept me engaged. Not to mention enraged, when a senior resident at rounds suggested that part of the management plan ought to be for my patient to switch to a “woman’s career”, like “teaching”. I had a great supervisor at the time, a former Associate Dean of Admissions at McGill University’s Faculty of Medicine who was committed to bringing more women into medicine. He said to me, “I can tell by the look on your face what’s about to come out of your mouth, but don’t say it.”

With my supervisor’s assistance, I appeared with my patient in front of the School of Architecture’s Examinations Appeal Board. I provided clinical records that proved that her mental health had been affected by an Acute Depressive Episode, a well-recognized medical condition. Then I brought documentation on Dyslexia and requested that she be able to have accommodations to allow for this condition. Universities weren’t used to providing accommodations at the time, but a Professor of Medicine and former Associate Dean is hard to argue with and so we were successful.

Fresh from this success, I went home, thinking to convince my mother, who had just started Community College, to get accommodations for her own education. She had decided to go back to school to get a postsecondary education, which was a dream for her. She was failing all her essay assignments and exams for reasons that were now completely obvious to me. I tried to explain dyslexia to my mother, all my articles and research in my hands. Of course, those articles were meaningless to her because she couldn’t read a word.

” I’m not as smart as you,” she said. I felt like I was being mean to her when I convinced her to let me try to get accommodations for her. She came with me to the student advisor at the College, who was more enlightened about learning disabilities than Professors in the School of Architecture had been. From then on, my mother was allowed to complete her exams and assignments orally. She graduated with honours, of course.

Today, when I am working with a youth with a learning disability, what I remember most vividly is how “stupid” my patient and my mother felt all those years ago. Working with my patients now, I can always find skills they have that demonstrate how they intelligent they are. There is much more information now about learning disabilities, including this web site which shows what text can look like to someone with dyslexia.

After my psychiatry rotation, my supervisor stayed in touch with me. Medical school exams were difficult for me because they were multiple choice. I have failed every multiple choice exam I have ever written the first time I wrote it. When I look at a multiple choice exam, I feel like a starving person with a menu and I feel stupid that I cannot pick out the correct answer. Ironic, isn’t it?

(Note: Dr. Alan Mann, Professor of Psychiatry at McGill University and Psychiatrist-in-Chief at the Montreal General Hospital, former Associate Dean of Admissions in the Faculty of Medicine, had the most influence in my career of any of my teachers. It was one of the greatest honours of my life to serve as Chief Resident at the Montreal General Hospital during his tenure.)

(Credit: This image is from Time Magazine.)

Let’s remember to Look After Mental Health Advocates

January 31, 2018 is Bell Let’s Talk Day. For the last month, a series of short video clips has been circulated by Bell to promote its important fundraising and awareness raising day. The video clips feature people who have experienced mental illness and they are worth watching because they are so inspiring. I can never listen to these stories without being moved. Everyone who knows me knows that I cannot help but be affected by these stories. I even become tearful, to my chagrin, because I am so amazed that there are people so willing to share their stories and their pain so that others can be helped. (Note: My daughter, who has this same affliction, has called this “the stupid, emotional gene”. We both find it embarrassing.)

I am privileged to know individuals who are, have been, or likely will become mental health advocates. In my experience, they are entirely motivated to prevent other people having to experience the degree of pain they have suffered. To do this, they tell their own story. They have stories of recovering from their own mental illness; to remind others that recovery is possible and not to give up. They have stories of a loved one who did not recover; they work to build the services their loved ones didn’t have and they remind us not to give up. They have stories that finding mental health can be an ongoing struggle but not to give up. That is the overwhelming message: Don’t Give Up!

What makes mental health advocacy successful? This study of how mental health advocacy was established in Sierra Leone considers the factors that led to its success and the barriers that it faced. Before this advocacy began, there was almost no consideration of mental health in this poor African country so this elegant study allows us to extrapolate from its prima facie case to our own situation in Canada, where mental health advocacy is not new. A review of the factors that helped and the barriers is striking in that there is little difference between Canada and Sierra Leone. Consider what this means: our mental health advocates in Canada must overcome the same barriers to achieve their goals as those in a country that most would consider to be far less sophisticated. If you talk to a Canadian Mental Health advocate for five minutes, you will find out how evident this is – and how discouraging.

Why do mental heal advocates do this work and what do you need to know if this is a path you’ve chosen? This article by Erin Hodgson, who leads the Jack Talks program at Jack.org addresses these two questions. My favourite part of this article are her six self-care strategies. These are important for everyone, but especially important for mental health advocates who, in my experience, give so much to their work. While you’re reading the article, you can find out about Jack.org itself and their important advocacy work with young people.

Mental illness comes close to all of us. It doesn’t take the usual six degrees of separation to find someone who has suffered from a mental illness – most of us know well someone who has had a mental illness and, often, we are that person. Personally, my father and two brothers died before I was twelve. My father’s death brought other losses and I am, in many ways, an expert at loss and grieving and they have been my window on mental illness. I consider myself lucky to have suffered no worse affliction. During my days of listening and watching others cope with the heartache and aftermath of mental illness, I am awestruck by people’s persistence and courage. I don’t know if I could manage as they do, I often don’t know how they manage and I consider it a privilege to help them do this. When these people decide that they must work for others, I am always blown away.

I have seen too many advocates become overwhelmed by their memories and the task they have chosen for themselves. I also know that the system offers little organized support and so I try to keep my door open for them. I am not trying to be their caregiver, unless it is clearly my job, but I will try to find them the help they need. My goal is to be an enabling factor as described in the Sierra Leone Study, or the nudge to remember the self-help strategies that Hodgson says advocates need.

Mental Health Advocates need our support, and by that I don’t mean professional help. I mean they need all of us to remember that they are doing something we could all do if we wanted to, if we had their courage. I am not that brave and so I will support mental health advocacy by supporting them. On Bell Let’s Talk Day, I will be one of the best tweeters and Facebook posters. It’s the least I can do.

(Note: Image from Sydney.edu.org)

It’s Not Your Fault

I am thinking about families today, and especially the families of those who have attempted or completed suicide. Suicide is the most serious consequence of having a mental illness and a suicide attempt and suicidal thoughts are always reminders of how dangerous a mental illness can be.

When someone dies of a suicide attempt, those who know and loved them suddenly become victims of the stigma that continues to plague mental illness. How does that stigma manifest itself?

The stigma is evident in the fact that most family members and friends will ask themselves, “Was there something more I should have done?” For the most part, if your mother or your sister or your child dies of cardiac arrest or cancer, you do not ponder the circumstances, concerned that you were neglectful or remiss. But suicide and suicide attempts are different in that there are always lingering doubts about what signs we might have missed. We go over final statements and conversations, finding meanings that we believe we should have caught.

I want very much for everyone reading this, who has had someone close to them lose their life because of suicide, to read the next sentence carefully, knowing it is the most important thing to remember about suicide and suicide attempts.

It’s not your fault. It’s no one’s fault. The problem is that suicide and suicide attempts are symptoms of a serious mental illness.

I wanted to emphasize those sentences and that paragraph above, but I mean this plea to be gentle, a reminder of how insidious mental illness can be. Mental illness has a different contagion. It is as if we can catch the guilt and low self esteem of our loved one from their suicide or suicide attempt. No other illness does this.

Next week, January 31, is Bell Let’s Talk Day. Already the Commercials are playing, raising awareness about mental illness more effectively than any other campaign. During the campaign, we will hear from people with great courage who speak about their mental illness, in voices that systematically work against the stigma that still marks the afflicted.

The suicide rate in Canada is 11.5 people per 100,000. The number of family members and friends affected by these deaths is too extensive to capture. Probably about one third of us have been affected by a suicide or a serious suicide attempt.

I am thinking about those of us who have been affected by a death by suicide or a suicide attempt. I am writing this so that we remind ourselves not to be infected by the contagion of stigma, not to fall into the trap of thinking that we were at fault for a death by suicide or a suicide attempt. I want us to remind each other, because I find it hard to remember this on my own.

(Note: Tabitha Suzuma is a British author of fiction for young adults. This image is from Pinterest.)

Seasonal Affective Disorder? Or a Bad Winter?

In Eastern Ontario, this has been a winter for the record books: long periods of deep cold alternating with difficult periods of precipitation and very few days of temperatures that make for a pleasant walk. Just this past week the temperature fell 30 degrees within 12 hours and the precipitation turned from rain, to freezing rain to snow. I find that whenever there is a difficult period of winter weather, more patients will ask, “Do you think I have Seasonal Affective Disorder?” Because of the weather, there are many more people asking that question this year so a brief primer and some references might be helpful for some of you.

Norman Rosenthal is the psychiatrist who, with his research team, first described Seasonal Affective Disorder (SAD) and his book, Winter Blues: Everything You Need To Know To Beat Seasonal Affective Disorder, is still one of the best references on the condition. It is available now in its fourth edition. The book is easy to read and still provides some of the most authoritative information with respect to SAD. He even has a blog and short video about what you need to know about SAD.

Since I see youth and young adults in my practice, I should point out that this group has a higher rate of Seasonal Affective Disorder. It is interesting that, in his blog about SAD in college students, Rosenthal suggests that parents can have a protective effect on youth vulnerable to SAD since they will remind them to get enough sleep and to care for themselves. When one is away from home for the first time, it takes awhile to learn selfcare and so these students might be more vulnerable to a condition that causes decreased energy and a sleep disturbance. This is Rosenthal’s contention so it follows from this that if you, or a family member, suffers from Seasonal Affective Disorder, a good way to support them is by helping them to maintain a reasonable schedule, especially with respect to getting enough sleep.

The symptoms of Seasonal Affective Disorder include:
1. Difficulty waking
2. Decreased energy
3. Difficulty concentrating
4. Increased appetite especially for sweets and starches
5. Weight gain
6. Anxiety
7. Decreased interest in socializing

These symptoms can interfere with a person’s capacity to manage their regular work or academic schedule and if you’re experiencing these, there are some things you can do that may be able to help.

First, look up the material I’ve included and consider whether you might have Seasonal Affective Disorder. Even if you’re not certain, there are some health measures you can take that have no risk and that could be helpful. Start with getting more light: go for a walk, especially a morning walk and find ways to let the sunshine into your home or workspace. You can use a timer or a dawn light at your bedside table to “start” the daylight a bit earlier. You can also get a specific light for Seasonal Affective Disorder. These are available in medical supply stores and some insurance plans even cover the cost.

You can also develop some basic Cognitive Behaviour Therapy techniques. Learn to recognize and manage negative thoughts and find some things to do that always help you to feel better. This last suggestion seems to be very hard for many people for whom depressed mood can be problematic. When there is a depressed young person on the inpatient unit, one of the most enjoyable and rewarding things to do is to help them find activities that always help them to feel better.

Finally, when should you see a doctor if you think you might have SAD? If your functioning at work or in school becomes affected, it’s time to discuss with your family doctor whether more treatment is required. Some cases of Seasonal Affective Disorder can be so severe that antidepressant medication will be needed.

All of this does not address whether a winter such as we’re having in Central Canada results in more cases of Seasonal Affective Disorder. Well, this does not seem to be supported by research. I cannot quite believe it myself. When I get ready to leave for work in the morning and I can’t quite face the 10-minute walk because it’s -30 degrees centigrade and there’s a wind chill factor on top, it would be great to feel justified in worrying about an increased risk of SAD. But it’s not the case. In fact, the short walk in the bright morning is likely just what I need to prevent the condition.

Mental Health Measures Anyone Can Do

There’s something about the Samaritan’s #LittleThings campaign that really appeals to me. Every time I see or read their suggestions and material, I am reminded that the best public health measures are simple and straightforward. They are also easy to remember and often easy to manage, so I decided to offer three suggestions, taken from the #LittleThings campaign, everyone can use in a medical or mental health practice that have been proven to be helpful in improving mental health. These would also be useful to anyone struggling with a mental health problem, or their family members.

My first suggestion is to do hospitable things. In our offices and at the reception desks in our program, we leave out water and glasses, snacks and interesting reading material. We keep the space clean and tidy and welcoming. Research shows that people react positively to welcoming situations so positive greetings and just very simple but special items can really help. When I had a private office, we would put out handknit slippers in the winter. People really liked these, especially that my mother had knit them in all sizes for the office. To consider how this works, imagine yourself going to a doctor’s office, and what these are usually like. Then think how it would seem if there were something to drink, a kind voice to greet you, anything that helped you to feel valued and welcomed. I don’t think it’s surprising that the evidence supports that it is good for our mental health when first encounters are positive.

The next suggestion is to learn to listen well. There is a great blog, Just Keep Swimming, written by a person “who uses the mental health service in Ireland”. One of their blogs, The delicate art of listening, contains some good suggestions on how to listen well. There is much being made today of the benefits of health care providers listening to their patients, but all those benefits apply to our personal conversations as well. Again, it seems simplistic but another proven way that we can promote mental health is by listening.

The third suggestion is a little more complicated, because it would involve some expense for a practice or office, but its value psychologically is well established. It is to send personal greetings by regular mail. This is a good suggestion if a family member or friend is living with depression – send them a card or letter from time to time and it will help them to manage the negative feelings. In my practice, at the end of a person’s hospital stay, I will often have patients send themselves a postcard or card to remind them of some fact about themselves or some advice that is positive that they often forget. People in general don’t get real mail any longer and it can be encouraging to receive something personal when you least expect it in the mail.

So that’s it! I imagine some readers are thinking, “Well, that’s just more wellness nonsense. Who bothered to prove that scientifically?” Well, you can find that out in the #LittleThings material also. I have not put the case for wellness activities as a part of healthcare deliveries especially well and maybe I will work on that from a Canadian perspective, but Harry Burns puts it very well in this short piece in New Scientist. Harry Burns is a Professor of global public health at the University of Strathclyde and a former Chief Medical Officer of Scotland. So consider the advice of a public health expert in this and consider some of these suggestions.