Journalism and the Scientific Method

Three years ago, I reviewed Seth Mnookin’s book The Panic Virus. In that review, I noted the importance of science reporting in assisting the public’s understanding of scientific research and science in general. Keeping this in mind, I want to highlight an article from the Ottawa Citizen by Elizabeth Payne, a Postmedia health reporter. The article addresses the question, “Could infections cause Alzheimer’s?”

In her article, Payne considers the controversy about the link between microbes and Alzheimer’s disease. She reports that those scientists who favour the microbe hypothesis have made a widespread plea that the public “embrace” their hypothesis.

Payne’s reporting is factual and clear. It leaves the reader with the opportunity to consider whether the microbe hypothesis research supporters or the plague hypothesis supporters are more credible. It calls upon us implicitly to consider both theories, but to remain open to the results of the ongoing research on Alzheimer’s disease. To be open to possibility, to be able to assess alternatives as revealed by rigorous study, is the essence of science. Through her reporting, which points out the conundrum of a controversy in scientific research, Ms. Payne makes it clear why the public should not, in fact, “embrace” a hypothesis until the research and much more consideration yield a clear result.

I am a clinician, not a researcher, but I work in a university teaching hospital affiliated with a research institute and so I have participated in clinical studies. When focused on one’s own research study, it is easy for a researcher to become attached to trends that one believes are emerging from one’s research. I have done enough research to realize how dangerous this is. I have learned that one must be faithful to the scientific method that has fostered the real breakthroughs.

The scientific method is systematic and allows for the modification of the hypothesis. Learning the scientific method is one of the first lessons in science class in elementary school. I remember having to devise experiments in Grade 3, not for a science fair project or research but to demonstrate that I understood the scientific method. That same lesson was repeated at the beginning of many grade school science classes for years to come. The scientific method is fundamental but, like all fundamentals, it is more easily expressed than understood. Ms. Payne’s excellent article reported some news from medical science and reminded us of how difficult it is to learn the scientific method.

(Note: The excellent graphic depicting the Scientific Method included here comes from the Science Buddies Website. Science Buddies is an award-winning, not-for-profit organization dedicated to building scientific literacy.)

The Patient’s Medical Home and Me

Last week, after I posted my blog on my concerns regarding “Primary Care Pediatrics”, Shereen Miller responded thoughtfully, asking, “Who is the quarterback of each person’s health care?…Should someone be in charge, connecting all the dots…”

This question is immediately answered for me by the Patient’s Medical Home, as described by the College of Family Physicians of Canada in their position paper A Vision for Canada: Family Practice: The Patient’s Medical Home. (http://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/PMH_A_Vision_for_Canada.pdf)

This paper defines the Patient’s Medical Home as “a family practice defined by its patients as the place they feel most comfortable – most at home – to present and discuss their personal and family health and medical concerns. It is the central hub for the timely provision and coordination of a comprehensive menu of health and medical services patients need. ” Does this not sound exactly like the service Shereen is seeking, as a patient?

As a specialist physician providing mental health care, I also like the idea of a family physician trained to coordinate my patient’s personal health care so that my team can attend to mental health concerns. All too often, it is necessary for the multidisciplinary mental health team to attempt to piece together a patient’s health status ourselves, without the longitudinal view of a personal  family physician who has monitored someone’s health over many years.

While the introduction of primary care models in the past decade in Ontario has given more patients access to a hub for their primary care, there is not yet a system in place for specialists like me to easily plug into the central team. To some extent, this is because many specialists are in hospitals, physically and virtually disconnected from patients’ family physicians. I can see the value of better connections between specialists like me, who are experts with difficult to manage chronic illnesses, and family physicians and their teams. Right now in Ontario, many family physicians’ teams have the services of allied health professionals, e.g. social workers, pharmacists, nurses, directly on the team but this collaboration does not yet completely extend to specialist physicians such as psychiatrists, internists or pediatricians. Some of the large university family health teams do have these “shared care” services but, as far as I know, none of the community-based family physician groups have access to specialists as I have described above.

In my view, such a system offers tremendous advantages to patients. First of all, because of the ready access, collaboration regarding which patients’ conditions need a consultation versus therapy could be undertaken quickly, eliminating some of the time usually spent waiting. Another consideration mentioned by Shereen was the notion that the doctor is not always required in a patient’s assessment and diagnosis. Certainly psychiatrists are very used to working with allied health professionals – I have worked on multidisciplinary teams since my residency and, like all of my psychiatric colleagues, team-based care for patients with psychiatric conditions has the best outcomes. This system eliminates another layer of inefficiency, allowing patients better, quicker access to specialty care.

I have been sold on the idea of the Patient’s Medical Home since I first read about it and heard it described. To extend this care to include specialists requires some changes to our current funding models, but different funding and not more funding is required.

Having said this, I am sure there are disadvantages to the model I have begun to describe.   I would like to hear about them to see if they can be overcome. I am also taking the advice from my readers by examining some of the models in place in other countries to see how they would refine this concept of specialty care being a “room” in a Patient’s Medical Home.

It is important for all of us to consider how the developments in primary care can more fully exploited for every patient’s benefit. How would this work for you?

Is there a Need for “Primary Care Pediatrics”?

I have spent the past week covering most of my colleagues for March Break, including four out of eight nights on call for psychiatry at the Children’s Hospital of Eastern Ontario. For reasons that are not entirely clear to me, whenever I spend a lot of time at CHEO, I find myself thinking about the degree to which I do not believe that pediatricians should be engaged in the primary medical care of healthy children and adolescents. I hesitate to speak about this since “primary care pediatrics” is very popular among parents and pediatricians in my community.

My first reason for this belief is that I believe that a family gets better care when a family physician has the care of everyone in the family. As a family therapist, I like to see as many members of a family in sessions as I can – it provides access to more information and the more information a family therapist has, the better care he or she can provide.  I suspect this is true in family medicine also. My own family doctor cared for three generations of my family and I believe that this gave him an advantage since he knew very well what the family history of illness was.

The second reason that I question the value of pediatricians doing primary care is that I feel that their skills as a consultant and caregiver to children with complex and chronic illnesses is too vital and that as much of their time as possible should be devoted to ensuring the best management of children with illnesses that will affect them all of their lives.

Finally, as someone who spends many days caring for children who are living outside of their own families, or whose families are struggling to manage being a family, I would like to find a way that pediatricians could be a resource to these parents and families. The evidence tells us that the children in these families are at much higher risk of illness and here there might be a role for the assistance of a pediatrician providing additional care to what would normally be provided by a family doctor.

I have worked with many parents and, even when they are poor and struggling to parent, they want to do what’s best for their children. Childhood is when we are most likely to develop habits: of what we eat, how much we exercise, how we spend our recreational time. Pediatricians are often the best advocates for early intervention in chronic illness and children and parents are eager learners and usually keen to do what is right.   More pediatricians involved in public health might well ensure that marginalized children grow up healthier than is predicted by virtue of their socioeconomic status and the educational level of their parents.

Now that I’ve said what I thought pediatricians should do, perhaps they have some comments about child psychiatrists!

A Reflection on Rural Medicine

I was in Perth, Ontario on Thursday evening for the Lanark County Medical Society Annual General Meeting and will be in Renfrew County Monday evening for that AGM. These meetings allow me a chance to catch up with the way of life of small town doctors, struggling with the disadvantages of rural medicine.

I grew up in a small town much the same size as Perth and was actually born in Pembroke where Monday’s meeting will be held. What I recall the most about the plight of doctors when I was very young was that, in pre-medicare days, many of them struggled to make a living in small towns. It is not a myth that, in farming communities, they often received payment in the form of produce and that many relied on payments from their wealthier patients because poorer patients had nothing to pay. I recall the doctor who lived near us in Joliette borrowing money from my father. I also remember that, at times, no matter how tired he was, there was no one else to go out to see his patient, suddenly requiring urgent attention.

While medicare changed the financial situation, it did not change the fact that most doctors still prefer to practice in cities and, at these small town meetings, a topic of conversation is recruitment. These communities have relied upon international medical graduates, a few thousand dollars worth of CME funding and one or two people returning to practice at home after their training is completed. On Thursday evening, they told me that a problem seems to be that “No one wants to practice this way anymore.” Practising this way means having a full service family practice including obstetrics and nursing home care as well as house calls. It means ER shifts – finding balance would certainly be problematic at times.

This kind of practice also means a loss of anonymity. Imagine if, whenever you went shopping or on a date, everyone in town knew what you were doing. I recall a time when I was travelling to Pembroke for the day to do some consultations at the Children’s Aid Society. I arrived at the agency to learn that my aunt was having the workers and me over for lunch – I had not even told her I was going but word gets around in small towns. Everyone also knows you, whether they’re your patient or not. That cannot always be easy.

Only 10% of Canadian doctors practice in these settings while 20% of Canadians live in these communities. Those numbers have not changed in at least ten years. Most people would agree that recruitment is necessary, but is there anything you can learn from a physician like me, born and raised in small towns, who does not go back to work in one.

If you were to ask me what the main reason is that I do not live in a small town, the answer would be that my husband prefers to live in the city. I suspect that this is true of many of us who started medical school with an intention to go home. I do travel outside of Ottawa to work with agencies in the countryside around Ottawa but it is not the same investment as being the member of a community and I know it.  When you live in a community, the people matter. They are your friends and neighbours, your children’s teacher and the local reeve. What you give to them they give you back, in a way that is not known in a larger, much more anonymous city. People do know more of your business than you might like but they also help when something comes up.

I remember being home from medical school one Easter. The doctor called me because my family’s neighbor was failing and was going to have to be transferred to Montreal for more care. He needed me to watch her for several hours while he was tending to the delivery room. He had not been able to reach any of the other local doctors and he wanted me to do this. I thought this was pretty much illegal but I also knew that many people knew I might be able to help and they would know if I hadn’t. Between a rock and a hard place, I stayed with my neighbor for several agonizing hours. It was not different from care I had given in my internal medicine rotation but I was on my own and I felt the responsibility of knowing that my decisions about what care she should have were the final ones. The bulk of the care I provided was comfort: I talked about where she was going in Montreal, since I knew the hospital well, and told her that I would visit her. She thanked me afterwards and I remember how her face would light up when I did visit her on the ward at the Royal Victoria Hospital.

Afterwards she always told people that I had saved her life, which I know was not true.  No one was ever convinced, however, and so my reputation as “a good doctor” was established in the town where I grew up. While I certainly thought of working there, in my last year of medical school, my mother moved to Montreal when my younger sister and brother were to start university. Everyone in town knew that I would stay near my family, because that is what people do and they would have thought less of me if I had not done that.

In the end, I do think that the place to find doctors to work in small towns is in those towns, among the children there who can grow up to study medicine. The evidence supports that and I hope the Society of Rural Physicians of Canada has a program in place to encourage the youth of their communities to undertake a medical career. That is the best hope to find doctors for these towns.