The Pharmacare Monument

The image I have of how universal pharmacare is being added to the resources Canadians have for healthcare is a building, a specific kind of public building that can be found in most Canadian cites: a hospital. Think about a hospital in your city that was originally built sometime in the twentieth century. The original building may even be a heritage building, a monument to how health care was delivered in its era.

Adjacent to this building, and attached to it is another building, perhaps even another heritage building, but at least another edifice that is a testimony to the health services of its era, or the research conducted in that time. A particular element of these hospital structures is the way in which they are attached to each other. On occasion, the means of getting from one of these buildings to the other is an above ground passageway, often an overpass over a road. Think of the overpass between the Former Royal Victoria Hospital in Montreal and the Montreal Neurological institute. At other times, buildings are connected by a series of tunnels. Tunnels, in fact, seem to be a common feature of psychiatric hospitals. I was trying to find an image of the tunnels underneath my hospital’s former buildings and found that many older psychiatric hospitals have a series of tunnels between buildings. If that’s not a metaphor, I don’t know what is!

(Photo credit: This image of the overpass between the Royal Victoria Hospital and the Montreal Neurological Institute is from the Wilder Penfield Digital Collection of the Osler Library at McGill University.)

I am sure many healthcare providers are so familiar with these hospital images, that when I say that the new pharmacare measures being undertaken by federal and provincial governments across Canada are much like our hospitals, they will see immediately what I’m getting at. All these new pharmacare programs are add-ons. There is no vision of a whole structure being contemplated, bringing together all the stakeholders currently involved in assisting Canadians’ access to medications. There are, instead, add-ons, connected to existing plans and measures such as some Canadians’ insurance benefits, other vulnerable Canadians’ existing coverage and all Canadians’ own money. Except that, since all the money being used for all these plans is our money, we’re all going to have to deal with a series of tunnels and passageways to determine exactly how to get coverage for the latest, greatest drug our doctor has ordered. As someone who sees mostly people under 18 in Ontario where “universal” pharmacare has now been introduced for everyone under 25, I can assure you that “universal” has developed several new meanings over the past few months.

There has been tremendous progress in healthcare over the past two hundred years, and many of our older hospitals which have only gotten add-ons and not a completely new building are monuments to that progress. It is likely that, in time, the new hospital buildings that are being built will also become monuments. Unfortunately, it seems that humans struggle to build a structure, either a building or a policy, so that it can easily change and this is what is needed in healthcare. We need a new pharmacare policy that takes over from all existing drug coverage, one plan that has the same elements, no matter your age or health condition.

Wouldn’t it be great if the investment in pharmacare came with a new plan for Medicare and Canadian healthcare itself? That would be building for the future.

(This is Timmerhaus a modular building in the Netherlands built completely of sustainable materials.)

Recovering from Child Abuse

The prevalence of child abuse in Canada is approximately 1%. This may seem not to be very high but the impact child abuse has on those affected has far reaching consequences. This is best illustrated by more statistics, so I am going to summarize these over the next few paragraphs. While you review them, I suspect that, like me, you will find yourself asking how any of these children ever recover and, when they do, you will wonder how they managed.

Thirty percent of children who are abused do not finish high school (Lansford, Miller-Johnson, Berlin, Dodge, Bates, & Petit – 2007). They are 26 times more likely to be homeless (Herman et al, 1997), 4 times more likely to be arrested as a young offender and twice as likely to be arrested as an adult (Lansford et al, ibid.). They are 3 times more likely to have an unplanned pregnancy (Irish, Kobayashi, & Delahunty, 2009). All these circumstances interfere tremendously with becoming a productive adult and so the gifts these children might have brought to the world may be lost forever.

The impact of the trauma they have suffered does result in serious mental illness in these children and youth. They are 4 times more likely to experience suicidal ideation and self-harm (Irish et al, ibid.) Not surprisingly, some studies show that as many as 100% of these children suffer from some symptoms of Posttraumatic Stress Disorder and 37-50% develop Posttraumatic Stress Disorder (Trask, Walsh, & Dilillo, 2011). They have 4 times as many contacts with mental health services as adults than the rest of the population (Spataro, Mullen, Burgess, Wells & Moss, 2004).

When I contemplate the histories of the young people that I see in the tertiary care psychiatric hospital where I work, these numbers – other than the 100% – seem low. I suspect, however, that this is because the youth we see have usually had significant mental health services even before they were seen in our programs and so those who are eventually seen in tertiary care likely have a higher prevalence of child abuse.
The young people who have been victims of child abuse also have more contact with the general medical system as 90% of them have worse health than the general population (Springer, Sheridan, Kuo & Karnes, 2007).

I am looking up these statistics for the purposes of determining to what degree mental health programs must consider their impact as they design programming for conditions beyond trauma. For example, to what degree must a program for youth with psychotic disorders allow for a history of childhood trauma? In fact, this is likely the wrong question.

The question that must be asked is: how do mental health programs ensure that the specific needs of those children and youth who are victims of child abuse get services that will also address their psychological trauma, as well as the other programs they require?

The traits that ensure that a young person can recover from the impact of child abuse, based on numerous studies examining longer term outcomes, focus on the development of resilience. You don’t have to do more than scrape the surface of the resilience literature to determine that remaining positive about one’s talents, about one’s ability to recover and about the future are the keys that unlock the development of resilience. As mental health care providers, it is our task to ensure that everyone can feel positive about themselves and their future., no matter which mental health condition they suffer from.

What I like best about this is that it is a simple lens through which to examine programming. You examine each facet of a mental health program asking: Does this foster the development of a positive attitude toward the patient, their recovery and their future? If the answer to the question in any circumstance is “no”, then changes are needed until the answers and the approach is positive.

I do find it personally helpful to be mindful of this when I see a young person who has been the victim of child abuse. If I can focus on helping them to be positive about the future, we can usually figure out what services they need to move forward.

“Note to self: Every time you were convinced you couldn’t go on, you did.” (Anon.)

When Children Die

Like many other people from Ottawa, I have been very much affected over many years by the courage of Jonathan Pitre, who passed away on Wednesday evening. He was 17 years old and suffered from epidermolysis bullosa. There have been tributes for Jonathan from so many, including hockey players and civic leaders and journalists, as well as Moms and Dads and all the rest of us. One of the most moving tributes came from the journalist, Andrew Duffy, who has followed Jonathan’s story over many years.

Hard upon this story came the news of an accident in Saskatchewan that resulted in the death of 15 members of the Humboldt Broncos of the Saskatchewan Junior Hockey League. Most who died were under 20.

When I read through the tributes to Jonathan Pitre and his mother, or those for the Humboldt Broncos and their families, I feel so grateful that I have never had to cope with such a difficult event in my life. I wanted to write about this, but I wanted not to focus on advice on how to manage such tragedies.

I’ll give some references, in case some readers were hoping for advice. This is a great article from The Guardian considering one woman’s experience with the death of her child. I found that this article really helped me to contemplate how to be a comfort to someone facing this tragedy. I also found this article addressing what not to say to a parent whose child has died very helpful. The only guidance I would add to this list is: Be extra cautious about social media – it can catch people unawares, causing additional, unnecessary hurt.

I learned all I ever need to know about what it would be like for a child to die from the two women in my life from whom I have loved the most: my mother and my daughter.

My mother had two children who died very young. My oldest brother died of influenza in 1955 at age 2. This was 18 years before the World Health Organization first introduced flu vaccine recommendations for general use. A second brother died in 1956 of RhD hemolytic disease of the newborn. This is a condition that occurs when a mother who has an Rh negative blood type develops antibodies after being exposed to her child’s Rh positive blood during pregnancy. These antibodies may affect Rh positive children in subsequent pregnancies. The antibodies can cause severe illness, including death. In 1968, anti-RhD immune globulin (Rhogam) was introduced. By injecting inject mothers who were Rh negative with Rhogam, RhD hemolytic disease could be prevented. My brothers died too young to benefit from these medical discoveries.

As a child, and even as an adult, I could never completely understand my mother’s ongoing sadness over my brothers. However, in the hour after my daughter’s birth, having held her for not more than twenty minutes, I understood what every new parent also quickly understands: I could not bear it if I lost this child. I ceased to wonder about my mother’s sadness. I no longer wonder at any parent’s sadness. I know I would be inconsolable if I lost any of my children and that is what Jonathan’s mother and the families of Humboldt are going through today. Are we not all with them in spirit?

I also have one piece of advice that I can give. It is contained in this blog I wrote for The Scientific Parent. Sadly, it is one of the most popular blogs I have ever written. It provides advice on how to help children cope with difficult news. The Scientific Parent used the blog so much that they developed a graphic to go with it. I would like nothing more than for its circulation to end, but more realistically, I am glad if it is helpful.

Invisible and Unrepresented

In between the celebrating and resting of a long holiday weekend, I have found myself doing research on the Canadian Medical Protective Association(CMPA). On Friday, I found this tweet of the candidates for a position on the CMPA Council and was incredulous at the fact that no women were running:

(CMPA Promoted tweet)

The Canadian Medical Protective Association is a “a not-for-profit, mutual defence association which is governed by a council of physicians representing members from across Canada”. Women members, however, might well take issue with the idea that this is a representative organization when the Council, the governing body of the CMPA is comprised of 29 Council members, only 7 of whom are women.

What are the implications for women physicians when their representation on the CMPA Council is so limited? Consider this in two broad areas.

The CMPA is in the business of risk. There are negative outcomes in healthcare and in some of those outcomes, physicians might have acted differently. While some will take issue with this view, often a negative outcome cannot be accurately predicted and this is where the risk comes in.

The CMPA, in its fee structure over a number of years has taken risk into consideration. For example, the risk that a surgeon will have a successful action taken against them is higher than the risk that a psychiatrist will be in this position. Hence, surgeons pay higher CMPA fees than psychiatrists. Also, the financial awards to successful claimants is higher in Ontario than in Quebec. Therefore, Ontario physicians have higher fees than Quebec physicians.

Consider then that there is evidence that women physicians have fewer complaints against them than male physicians. This being the case, why is this not taken into consideration into the fee structure? This seems like a clear case of gender bias.

My second concern is that women physicians do practice differently than their male colleagues and yet the CMPA does not seem to have done any research into the implications of this in terms of risk. The bias against women physicians by the public, other allied health care providers and even by the profession itself is well-established. New research continues to confirm this bias and yet there is no evidence on their website that this has even been considered by the CMPA.

An organization like the CMPA cannot completely be faulted when its elected Council does not have the number of women on it that might be optimal. However, one begins to be suspicious about gender bias when there has not ever been a woman President of the CMPA. If that is not enough to have members questioning whether women physicians have a strong enough voice in CMPA, a review of their committees will show that not many women are represented here either. Surely CMPA Council has some say over the number of women on committees?

When I raised similar questions about gender bias within the educational colleges last February, the Royal College did reach out to me, although unofficially, and not with any answer that I was given permission to publish.

I will be interested to see whether the Canadian Medical Protective Association has any response. My real goal in writing this, however, is to remind women everywhere that, in organizations, professional and otherwise, there is still a need for us to demand our due from our representatives. There is still a need for us to support the work of women colleagues whose presence will eventually change organizations. This is true in all areas of work – woman are still invisible, even in those professions where we are equal in numbers.

Violence in Mental Health

My work is full of violent actions – my violent actions against others.
I have chased youth. I have called codes to have others restrain them. I have completed paperwork so that they can be picked up by the police.

Many times, because of documents I have written, young people have been picked up by the police and brought to a hospital in a police car, often handcuffed, although that is changing as police become more knowledgeable about mental illness.
I have ordered that young people be observed on a one-to-one basis, not allowing them even to go to the bathroom without having a Mental Health Worker’s foot held in the door to keep it open.

Many psychiatric inpatient units have a double door locking system, much like a prison.
Medication is sometimes used to restrain patients who become violent – not all of them are suffering from delusions.

These actions are taken to keep people safe, both from themselves, and so that others are not hurt. Each of these actions requires specific documentation on my part. But, make no mistake, these are violent actions.

These violent acts are the most overbearing tools available to keep people safe. But, whenever I am obliged to use them, it is a failure. It is a failure because these violent actions, carried out to keep people safe, delay healing and recovery.

People do not always understand how violent these measures truly are, but, if you have ever experienced them, you know. You know these are violent actions. You may understand why I have had to take these measures but I will always see these as a failure, in some way.

One of the most important results of early intervention in strong outpatient programs in psychiatry is that we can avoid hospitalization, as well as these violent measures. That is always the goal. Hospitalization itself is a failure and the less time a person spends in inpatient psychiatric treatment, the better.

Psychiatric hospitalization is sometimes necessary, but it is usually best to avoid this measure, if at all possible.

Think about the measures I have described. How would you like it if these happened to you?

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.