The Other Side of the Bed Shortage

I am spending my day on the other side of the hospital bed shortage. I am sitting with my sister in the nursing home where she is spending the final days of her life. She waited seven months in a hospital bed for this space to become available.
Around us, all is peaceful. People down the hall are playing BINGO. The lady across the corridor has visitors for her birthday. It’s a far cry from the hospital because it’s quiet.

A hospital is a noisy place, day and night. During the day, there are so many people: nurses, doctors, technicians, dieticians. There is all the activity that comes with them. There are also announcements: codes, visiting hours, when the coffee shop is open. There are serious conversations at bedsides and few private spaces. Everyone seems to be hooked up to at least one machine. There are, however, about 12 – 20% percent of patients who are not hooked up and who do not have conversations. These are the people waiting for a quiet space in a nursing home or palliative care or long term care.

Reading articles about Emergency Room wait times or hospital bed shortages, one is given the impression that patients do not want to leave their hospital bed. However, this is not true. Most of them, much like my sister, are relieved to have been moved to a quieter setting. “I’m glad not to be a bed blocker anymore,” my sister says when I first see her in her new home, “I don’t need all the bells and whistles.”

My sister likes this setting in many other ways. She has a view of the Nova Scotia countryside outside her window. There are sitting rooms throughout the residence, with televisions and plants and books – quiet, cozy corners of a type not seen in hospitals. There is a full recreational program and food my sister enjoys. There are two cats.

“The cats are good,” my sister says, “They keep down the mice. You can’t have cats in a hospital.”

“Don’t tell me there are mice in hospitals,” I reply.

“Okay, I won’t,” says my sister who was a nurse, “but you know that’s the kind of thing the doctors never want to hear.”

She goes on to speak about the guilt she had felt when she was “taking up a bed”. She considered that maybe it was because she had been a nurse. She remembered how exasperated she and her colleagues had felt about long term care patients in acute care beds. She hopes she was not too much trouble to the staff when she was still in hospital.

As a child psychiatrist, I have not had to wrestle with bed shortages as other doctors have. Everyone agrees that there is a significant need for long term care beds, but it does seem as though much of the advocacy for these beds comes from the acute care side of the occasion. It comes from the concern that patients are receiving their care not from the relative comfort of a hospital room, but from such places as the corridor of the Emergency Room or closets or any space that can be found. We would all agree that these are not good places to receive acute medical care.

But there is a need for us to be aware that there is also better care available to those patients like my sister who don’t need an acute care bed, but who cannot be comfortably cared for without significant nursing and home care support. People like my sister do not have a lot of energy for advocacy, nor do their families, but it’s important to remember them.

Our lives are important at every stage.

(These are the 2 cats who live at the nursing home. This picture is from Facebook.)

#MeToo

Over the past week, the systematic victimization of women in Hollywood by a serial sexual predator has caused many women to look at their own life experience and consider whether they have also been the victims of sexual harassment, or worse, in their workplace. Today I have been watching the intensity of the #MeToo campaign build and I have been thinking of the experience with sexual harassment of most women physicians and medical students, including myself.

The essence of the #MeToo campaign is that a woman who has been sexually harassed copies a prepared text onto their Facebook page, or Instagram, or Twitter with the hash tag #MeToo to indicate that she has also been a victim of sexual harassment. This is the screen shot from my Facebook page:

 

As a physician who trained in the 1970’s at McGill University in Quebec, I studied medicine in my late teens and early twenties. When I applied to medical school, I was asked by one interviewer, “Are you interested in getting married?” Having always been a little too smart-mouthed for my own good, I answered, “I’ve only just met you. Can I have some time to think about it?” But over the years of repeating that story, no one was ever surprised that someone (a man) asked me this question.

My women colleagues and I became used to professors and staff physicians and senior residents enquiring about our menstrual cycles, our marriage plans and commenting on our suitability for senior leadership roles. At the time, I suspect that most women medical trainees were like me. We took for granted that this treatment was typical in medicine. All trainees were subjected to humiliation, verbal abuse and a work load that was essentially equivalent to slavery. The sexual harassment that woman trainees experienced was influenced by a medical environment, but women were mistreated in all work environments. In fact, the term sexual harassment may have been coined at Cornell University in 1975, but that was not the literature medical professors considered valuable.

Over the past forty years, with both male and female colleagues, many of us are working to change this culture in medicine and we even have days when we believe we have been somewhat successful. We can say that there is now excellent evidence that respectful medical workplace behavior is still a problem and that every physician or medical student or resident should now be aware of the principles of medical professionalism and disruptive behavior. That’s it, however. That’s the extent of our progress: that we should know better. Medical students and residents continue to tell us that there is a problem and women doctors and medical students on Social Medial today are recording their #MeToo’s along with women in every other profession.
Many women in medicine will say that this misogynistic treatment occurred mainly when we were students and residents, but it is just not true. Women are still being passed over for academic promotion, hospital leadership roles, association leadership roles and even association awards. If you look through this list of winners of the Canadian Medical Association’s Frederic Newton Gisborne Starr Award, you will find the name of one woman. Even if you don’t count all the early years of the CMA when women couldn’t be doctors in Canada – not one of the best reasons for this low number of women award winners, mind you – it is still a sad statement about how women are regarded in the profession. Finally, and probably most telling, the specialties in medicine with the lowest fees are those dominated by women.

From the moment in an admission interview that I gave that sarcastic answer to an inappropriate question, I have been working for medicine to be a more positive profession for women. The number of women in medicine has grown, but we still work harder for recognition than our male colleagues. We still do not call out sexual harassment in medicine to the extent that we should. For all my women colleagues who think I am exaggerating, I suggest that you have a conversation with some work friends about your own experiences in Medicine.

This is what you’ll learn after thinking about most medical workplaces: #YouToo

 

Opioids and Social Capital

Over the weekend, I read the first article about the opioid crisis that made any sense to me. It was published in Scientific American last week and explained why so many of the strategies that we are using to combat the rising rates of opioid overdose have been ineffective in curbing the rate of overdose to any great degree.

The article summarizes the research that suggests that the best ways to address the abuse and dependence on opioids is to help communities strengthen the social ties between people. The author opines that the emotional reasons that we become dependent on any substance are factors that communities should seek to address in to reduce the morbidity and mortality related to opioids.

In one study published in the Journal of Health Economics, researchers looked at the impact of macroeconomic changes on opioid use in specific counties and states in the United States. For the region studied, researchers found that, when the county unemployment rate rose 1%, the opioid death rate per 100,000 rose by 3.6% and the opioid overdose Emergency Department visit rate rose by 7%. These statistics held throughout the state.

The article summarizes the science related to the body’s naturally occurring opioids – endorphins and enkephalins – these help us to moderate both physical and emotional pain. The science is outlined concisely and briefly and reminds the reader of those factors which increase the levels of these naturally occurring opioids. It also reminds us how this hormonal system insulates us from emotional pain in our lives.
I have never prescribed opioid medication myself, and most of the doctors I know are similar in practice to me so I have been bewildered about who all the doctors prescribing them could possibly be. I’ve seen the numbers, however, and I certainly know of physicians who have gotten into difficulties because of the way they prescribe opioids. I understand that physician regulatory bodies have sought to address the increasing rate of opioid abuse and overdose by offering courses on prescribing these medications.

To address this dangerously increasing use of opioids, communities have been distributing naloxone kits, setting up safe injection sites and running health prevention campaigns. I support these measures as urgent action must be taken in the moment to do what we can to prevent harm to those already at risk because of opioid use.
Having said this, it’s time to think about what can be done to address those social capital deficits. The OECD defines social capital as “networks together with shared norms, values and understandings that facilitate co-operation within or among groups”. These networks include such networks as family, friends, groups we belong to, or organizations that support us. According to the research, the loss of social capital is linked to increasing opioid use and all its attendant risks.

I’ve been thinking of social capital lately as I’ve worked to find supports in their communities for youth in my practice, supports such as groups where families might learn to cook or spend time with other families. As I did this research, I realized that some Ottawa communities are better at this work than others. It makes sense from this that communities might consider supporting community development as well as safe injection sites and naloxone kits.

Many reading this will believe that this is all about the social determinants of health but this is a reflection on the need for all of us to consider how we personally build communities. Do we go to groups? Do we initiate support activities? Do we go to community events? All things considered, cities can support communities but they can’t provide them the way they can buy naloxone kits or new services. They can’t make your neighbours neighbourly. That takes individual people getting out of their chairs, turning off the TV or their devices, and talking to people or working with people. While it does build a community to have skype meetings or online chats, this research is telling us that, if we truly want to have communities, then we must have some that we can walk to when we’re caught in a snowstorm or hurricane, or the power goes out. Perhaps if we volunteered at the food bank, it wouldn’t be so hard to go there for food, or even just company, when the need arose. Having community meals or parties or street events, bringing disparate parts of communities together, can help you find out what services you can have or help in your neighbourhood.

Last weekend, the Wellington West Community held an event on Wellington Street. As I walked along running my errands, I stopped off at a few services. I learned that one agency, Ottawa West Community Support, has a range of services to help seniors continue to live in their own homes. They told me that volunteering with them has helped many older people make the transition to using their services. That is social capital. I learned that the library helps anyone learn how to navigate the internet safely, from kids to seniors to newcomers. The library has an English Conversation Group. These are examples of building social capital.

This research and consideration has me thinking about how I could invest in social capital in my hospital practice and so I have been thinking about the kinds of groups that could most help youth in my community. I have a few ideas but would be interested in others’ ideas also. Please tell me. It seems a long way from the opioid crisis to me, but the research suggests that I am wrong. How do you build social capital? How do you think we could help?

(This photo has been in multiple places on the internet. I found it in Lawrence Wall’s twitter feed.)

Just Ask

I consider myself to be a very fortunate doctor because I do not often have to deal with the death of my patients. My patients usually recover from their illnesses and, because they are young, I am often able to see them live out the promise of their lives.
The deaths in my practice, however, always continue to haunt me because they are deaths by suicide and suicide is such an insidious outcome that even those of us who see it most often can forget that suicidal ideation and attempts are serious symptoms of a severe illness. We should know better, but we still forget that this severe illness is very difficult to recognize.

Severe illnesses in youth are so difficult for all of us to comprehend. Depression and suicide are even more difficult because they are symptoms that often occur in young people who can present a cheerful countenance to the world – who have a gift of helping others to feel happy. Have you not heard this? Do you not know of a situation in which this was exactly the case?

On the weekend, I read J. Kelly Nestruck’s article in the Globe and Mail about Jonah McIntosh, a young actor at the Shaw Festival who died by suicide in July. He recorded how the Artistic Director at the Shaw Festival saw Mr. McIntosh: “always smiling and making everyone around him smile”. Mr. Nestruk also documented that a death such as the young actor’s suicide was not one the theatre company had experienced, which seemed surprising to me. There is a suicide every forty seconds in the world and artists and actors have a suicide rate of 24 per 100,000, higher than physicians or teachers or nurses.

The article underlined for me once again that those of us who work in mental health fail to educate the public about how difficult it is to predict the course of depression – we have not communicated how a smiling face cannot be assumed to be an accurate reflection of mood. Many people with depression leave their friends and family, leave their doctors’ offices, with a smiling face even when they are plagued by persistent suicidal thoughts, with plans to act on their troubling symptoms. Most of these people have brought joy to their families and friends, but have never found it for themselves.
At this stage in my career, I no longer think about whether I am asking the question sensitively. I just ask, “Are you thinking of suicide?” “Do you have a plan to kill yourself?” People ask all the time if these questions could cause a person to think of suicide but this is not the case.

Just ask, I tell people. If the person you ask seems shocked, or makes some protest, just say,”I am so worried about you and I do not want to make the mistake of not asking about suicide.” We would not hesitate to ask about the serious symptoms of heart disease. We must begin to do the same for depression and suicide. We can save these wonderful lives if we ask. We can prevent suicide.

(On September 10 at 8 pm I put a candle in my window to show my support for suicide prevention and for those who die by suicide and for those who survive.)

A Public Health Campaign for Legal Marijuana

When I first reviewed the Government of Ontario’s approach to legal marijuana, I was disappointed. I was hoping for an approach with a strong foundation in public health. I feel strongly about this and wrote about my concerns for the Ottawa Citizen.

As I read the views of other health stakeholders in legal marijuana, I could not help but notice that many of these felt that the government had addressed many of their concerns. Both Ontario Public Health and the Canadian Medical Association reported being satisfied with a legal age of 19 for marijuana, even though both had advocated for a higher age. The article I read said these organizations described the government’s approach as “pragmatic”. Why am I not satisfied?

This pragmatic approach focuses on regulations and where marijuana will be sold and the public health relies on regulation to manage the age of use. However, as all clinicians working in youth mental health and addiction, I know that the key to changes in behavior and attitude lie in education, specifically public education through health communication campaigns. In mental health, we are very familiar with how successful these campaigns can be. In the past ten years, vigorous health communication campaigns have  been able to neutralize the stigma that existed for centuries against mental illness and persons with a mental illness. I had hoped that, right from the beginning, the Health Minister would have pledged the funding for a sophisticated health communication campaign to ensure that all citizens understood the health risks of marijuana, especially youth for whom the impact on the developing brain can be significant. There was the promise that such a campaign would be developed, but no firm details were provided as to what steps have been taken to implement the campaign.

The campaign I wanted would include persuasive communications informed by social marketing strategies, with messaging designed for different target groups. The public health messages must be accurate, interesting and stimulating so that different communications might be needed for different groups and especially different age groups. I know that the Ministry of Health and Long Term Care can manage this level of sophistication. In fact, I even found a presentation entitled Developing health communication campaigns on the Public Health Ontario website.

The campaign I wanted would start now so that awareness of the risks of cannabis use and information about safe practices for using legal marijuana would be known by the time legalization comes into effect  in July 2018.

The campaign I wanted for youth would reflect the reality that Canadian young people are already the highest users of marijuana in Canada by age group. It would recognize that rules and regulations cannot be the only tools we use to prevent marijuana overuse and addiction.

Another public health element that I was seeking was the commitment of support for further research to evaluate the impact of legal marijuana. This will help us to understand how the Government’s approach might be improved in the future. It will reassure the public, including mental health professionals, that the Government is prepared to be prudent in ensuring that legal marijuana is introduced safely.

Finally, with the growing demand for mental health services, another element that I had hoped to see was a commitment to improved funding for services for addiction. While I do not believe that the legalization of marijuana will necessarily lead to higher rates of marijuana addiction, we know that the province’s coffers will benefit from increased tax revenues. Many groups were hoping for a commitment to improved services, services that are already much needed.

The legalization of marijuana is an opportunity for the Government of Ontario to demonstrate understanding that addiction is a mental health problem and that those people with an addiction should be assisted and not shunned. The young people that I see with marijuana addiction have higher rates of many psychiatric symptoms including psychosis and suicidal ideation and attempt. Many of the young people I see who are now in recovery would provide great advice on how the public health approach to legal marijuana could engage youth in its safe introduction. I hope the Government will seek the advice of those most at risk – people under 25.

Normal and Bored

There are six million young Canadians starting school this week. From busy, excited little kindergartners to oh, so bored almost adults in their finally final year, yellow buses and slower streets will signal the end of summer as nothing else does.
At the psychiatric hospital where I work, we have four classrooms, all part of the M. F. McHugh Education Centre, and the young people who are receiving treatment for their mental health conditions will continue to have access to education, even though they are not all well enough to benefit from that educational experience as much as we would like or hope.
As a clinician, one of the elements I value most about the McHugh classrooms is that they are a constant reminder to my young patients that there is a normal life waiting for them once they are feeling well. The very presence of these classrooms and their teachers is a reminder that everyone working with these patients has every intention of helping them get back into an academic life, a normal life.
Whatever age you are, becoming mentally ill turns your life upside down as no other life circumstance can. Often you cannot manage the very basics of getting up in the morning, or washing your face, or putting breakfast into your mouth. The idea that, on top of this, you’re expected to read Hamlet or learn about cell structure or get from classroom to classroom can be overwhelming. Imagine a classroom that supports you to manage exactly those studies while, fifty yards away, in another part of the same building, on an inpatient psychiatry unit, you are learning to cope with the voices telling you to kill yourself. It’s a lot to put together.
For a young person who is struggling with mental illness, or other difficulties, school can often be the most stabilizing influence in their life. If your dad left home on Tuesday, on Wednesday your class will still be reading Hamlet. If your grandmother passes away on Friday, and you saw your grandfather crying for the first time in your life, it really can help that cell structure does not shift in one week. If, all of a sudden, your mind is just not making sense, it helps to have a classroom where the teacher knows that this has not always been the case and that you will not feel this way forever. I think it especially helps to have a person who can bridge you back to the world where Hamlet and cell structure are important, and you can be a normal person again.When I was younger, I had wanted to be a teacher. The normality of life is one of the things I most miss about my life as a doctor. Like every physician, even when I focus on the person with me, I am often still focused on how well they are. Can they concentrate? Are they enjoying soccer once again? Is their mother back to nagging them about their room being a mess?
When you see a psychiatrist, and you’re sixteen years old, you know you don’t have a normal life. But, if every weekday morning you can sit in Mrs. Scott’s English class, listen to Mary Jo Jones be Ophelia and Sam Smith try to be Polonius, you can feel as though your life is as blessedly normal as everyone else’s. You can go back to being bored and everyone who knows you will think it’s a good thing to be normal and bored.

(Note: As a new school year starts, I will be hoping for the best year for students and teachers and especially for those students and teachers in the McHugh classrooms around Ottawa.)

The Answer

I have not written much all summer because there is only one medical story on my mind. I have resisted publishing this story until I had something to say that might be helpful for others in a similar situation. Recently, one realization comes back to me again and again and for that reason I write about it now.
My beautiful baby sister is dying. I have been travelling to Halifax to spend time with her, knitting and talking while she lays in bed. I spend the days after these visits with a heartache that will not stop and I find now that I cannot stop thinking about her.
My sister has lived at least five years longer than her doctors thought she would. She has been able to see her daughter start and almost finish nursing school. She was happy to have been well enough to attend our mother’s funeral. If she has any pain, she minimizes it. If she has suffered any distress, she hides it behind her sense of humour. She is suffering from visual hallucinations, likely because of medication. Her thoughts on this: “At least it gives me something interesting to watch.” She is a true believer in positive thinking.
My sister is a great raconteur and she spends these Saturdays telling me the stories of her life. She talks of her friends from elementary school, high school and nursing school, most of whom she has found on Facebook. I am trying to write down what she tells me. When I read it back to her, she listens to my account and says, “Stick with quilting for a hobby.” She laughs at her own joke and then reminds me of how bad a baker I used to be. She tells me about patients she had cared for as a nurse and about how the most important parts of nursing involve “no science at all”. In the middle of one story, she stops and says to me, “I am so glad to see you. I don’t want you to be sad, you know.” I do not want to cry and the heartache inside me intensifies.
I have been contemplating how I will be a comfort to her. I want to be a welcome visitor regularly for as long as possible. It is easy for me to listen, as this is something I do most days at work. I only rarely struggle with people’s painful, emotional stories at work, but my sister is not my work. I have always been very good at separating work from family and, as much as I am diligent at work, I believe that my family needs me not to be a doctor, but someone better. Not that I don’t think being a doctor is important, but I really want to be a good sister in this time when she needs a sister.
This experience with my sister helps me to understand what it is like to be relying on doctors and nurses, how helpless one can feel, even when one has great knowledge. I find myself asking: “Do I remember how helpless a patient or their family member feels when I am speaking with them?” I know that my excessive emotional investment in a person’s care can lead me to errors – mostly sins of commission, rather than omission – but do I do what I can to help people feel at ease with being helpless?
I have been remembering the first time one of my patients died in my internal medicine rotation as a medical student. She was an older lady not expected to live. Her family took turns sitting at her bedside, day and night. I remember stopping to speak with them, day and night, getting them coffee or bringing them things to read or answering questions. I felt so badly because there was nothing I could do. I would sit with them and listen to their stories of their mother.
Thinking of my sister, I read through my journals of the six weeks I spent with this family and realized that I had the answer all those years ago, when I believed I had no answers at all. What on earth happens to doctors over the years that, as we become less helpless professionally, we seem to lose all the answers?

(Note: This is an image of Lawrencetown Beach, the Nova Scotia beach closest to my sister’s home.)