My Predictable Clinical Life

In the past week, I have started to work on an inpatient psychiatry unit for youth. It is not easy being a psychiatrist for an inpatient program, but it is interesting and more predictable than outpatient psychiatry. In an outpatient program, emergencies arrive with little notice, often disrupting one’s schedule on days when there is no room for disruption. On an inpatient unit, the emergencies are right there in front of you all the time. This is predictable unpredictability and I find this more manageable than the frenzied calls that can disrupt an entire afternoon’s clinic.

For the past week, I have arrived on the unit to calls of, “Can I speak with you now?” or “What time are you meeting with me? I have stuff to do.” With a much smaller overall caseload than outpatient psychiatry, and patients who need to be seen daily, there is an opportunity to get to know the youth I am working with so well that their needs can be more thoroughly addressed.

The most common reason for psychiatric hospitalization for youth is to stabilize acute symptoms of psychiatric illnesses but case formulation and diagnosis and treatment plan development are becoming even more critical in youth psychiatric care. The reasons for this are embedded in the shortage of Child Psychiatrists and of youth mental health resources in general. Outpatient child psychiatry programs everywhere are stretched to the limit, to the point where the World Health Organization found that many mental health needs of youth around the world were not being addressed directly but rather through programs addressing other concerns. For example, street-involved youth often get more mental health support through housing agencies than from mental health agencies or hospital or clinic mental health programs.

Inpatient psychiatry programs and their function and purpose are not always well-understood, mostly because evidence often supports community treatment for some patients who would prefer hospitalization and hospitalization for patients who find the restrictions of psychiatric units too difficult to tolerate. This concept was summarized best by a patient I saw many years who asked me, “Dr. Beck, how come the people who want to stay in hospital can’t but the people who want to leave aren’t allowed?” When I responded, “I don’t really have a good answer for that question,” I was met with, “You don’t have any good answers.” I wish I thought that wasn’t true.

The WHO report emphasizes the need for greater collaboration between inpatient programs and the community. The social advocate in me loves the idea of working with schools, shelters, food banks and public health to develop the partnerships that will improve collaboration. The best outcomes for the clinical conditions where psychiatric hospitalization is indicated can be predicted based on social conditions. This means that those of us in who work in youth mental health must work with community partners if we are to have any success at all.

It also means that I will be diagnosing and treating conditions that go well beyond mental health into personal and social well-being. Hence, on my first day back, it was predictable that I would find myself gowned and gloved, hair covered, combing through a young person’s hair looking for nits. I can answer most questions about lice, in case anyone is interested.

How to Legalize Marijuana

My interview on CBC’s The House had such a positive reception that I wanted to follow up with a short essay summarizing most physicians’ recommendations for legalizing marijuana. My own perspective is that of a psychiatrist whose patients are all adolescents and young adults. This means I am concerned about the short-term impact of marijuana intoxication in the young people that I see, but I am even more worried about the long-term impact of cannabis on the developing brain as well as the links between cannabis use and psychotic illnesses.

Most physicians hope that the federal government will approach the legalization of marijuana emphasizing public health concerns as the most important consideration in the drafting of legislation. There are also law enforcement and government revenue aspects of the legislation but in jurisdictions where these considerations were emphasized, health outcomes were affected. Doctors in Canada – and Canadians in general – will find that negative health outcomes will eliminate any possible benefits to legalizing and regulating marijuana.

The government’s vision is to have marijuana legally available for non-medicinal purposes by Canada Day 2018. For the implementation to fully consider the public health implications, the government can look to its experience with the legalization and regulation of tobacco and alcohol. There are lessons to be learned from this experience from a public health perspective and I hope Canadians can benefit from that experience. We can also learn from those countries and jurisdictions that have already legalized marijuana. Also, now is the time to set up an evaluation and research agenda to ensure that we continue to learn from our experience with legalizing marijuana.

Some of the main health concerns with marijuana are related to its impact on the developing brain. The brain continues to develop until age 25 and there is significant evidence that cannabis use interferes with brain development. While it would be ideal if the minimum age to purchase marijuana could be 25, Young Canadians are already using twice as much marijuana as any other age group in Canada. Young Canadians also have a higher rate of cannabis use than youth in any other G8 country. With use being this high (20% of Canadians aged 16-24), it is more realistic to focus on reducing cannabis use to the extent that is possible. The Canadian Medical Association recommends setting a national standard where minimum legal age for purchasing marijuana would be 21, but with restricted strength and purchasing limits until age 25.

As well as brain development, child psychiatrists have also noticed increased prevalence of psychotic symptoms in young people using marijuana. We notice that psychotic symptoms emerge at a younger age for those with a predisposition for these conditions who use marijuana. We also notice that cannabis use is associated with the more serious chronic symptoms of schizophrenia.

Many physicians are also concerned that that rigorous research has never been applied to whether marijuana has any medicinal value. Marijuana has been available for medicinal purposes in Canada for many years, but there are few, if any, studies confirming its efficacy. Given the health risks, is it not time to insist on research to determine whether medicinal marijuana is effective?

Finally, one of the most important public health impacts will be related to the consequences of driving while intoxicated.  One’s capacity to safely operate a motor vehicle after using marijuana can be affected for as long as 6 hours after use. There is no currently no adequate way to identify or evaluate whether a driver is under the influence of cannabis. A method to evaluate intoxication must be developed before legalization. In this regard, the experience of Colorado should inform Canadian legislators. This excellent review outlines the increase in traffic accidents and Emergency Room visits since marijuana was legalized. Traffic accidents are one concerns but there are others. Colorado legislation was focused primarily on the revenue generating aspects of marijuana legalization. The negative health outcomes should be a cautionary tale for Canadians.

I have focused on those aspects of marijuana legalization that are most important in my practice but the Canadian Medical Association prepared a detailed submission for the Government of Canada Task Force on Marijuana Legalization and Regulation. Canadian doctors and the Canadian Medical Association are extremely concerned about this legislation. Great effort has been taken to alert the federal government to the risks involved in legalizing marijuana. I mentioned earlier that I wished the legal age to purchase marijuana could be 25. I can see how unrealistic this is, given how much marijuana young Canadians use right now, when it is not legal. After the fact of negative health outcomes from legal tobacco and alcohol, Canadian governments have had to launch massive public health and education campaigns. It would be good to roll these out now, in the hope that we can avoid some of the negative health outcomes doctors know are coming.

Benjamin Franklin made what must be one of the first public health statements in America. We can remember this as marijuana legislation moves forward, even if Colorado didn’t:

“An ounce of prevention is worth a pound of cure.”

Does Ontario Have A Gun Problem?

Adolescents have been the focus of my practice in Psychiatry for more than twenty years.  Adolescent boys have a complicated relationship with violence and anger and it is not unusual to see that erupt, especially when they are struggling with symptoms of mental illness. It almost seems as though, at some point in adolescence, men must work through what their relationship with violence will be. As they do this work, the entire course of their lives can be affected by the lethality of the weapons they have at hand. A gun is never a helpful accessory for a young man struggling to understand and cope with violent urges toward himself or others.

Why am I thinking about guns? I have just returned from Boston and early in March I spent a week in New York City for the Commission on the Status of Women. As a Canadian, I am always more cautious when walking by myself, especially at night, in American cities. This is because, as a Canadian, I believe that there are many more guns in these American cities than in Canada. Public health research has shown that guns are a health risk.

Having said this, both Boston and New York are managing gun violence while Toronto, a city where I spend much more time, has seen spikes in gun violence in 2016 and increasing gun violence in 2017. Even in Ottawa, the capital city known for its general safety, had a higher than normal number of shootings in 2016 and 2017 is showing the same worrying trend.

Canadians often smugly think that gun control manages gun violence and, while all evidence supports this, these recent trends need to be considered. These increasing numbers mostly reflect violence involving the young men under 25 I mentioned at the outset. We know that young men’s brains continue to develop into their twenties and most parents of young men certainly notice this. This is true even though, by age 21, most young men have undertaken significant responsibilities related to education and work, and often families or relationships.

During the period of late adolescence and early adulthood, young men are at higher risk of being perpetrators and victims of violence. Over many years, there has been much speculation on why this is the case. Research cites adaptive advantages from our past to the economic disparity and racial tension that is believed to fuel violence around the world.

The one factor that has kept this violence from becoming lethal has been access to a weapon, usually firearms, that immediately make an attacker much more dangerous. In fact, countries that implemented gun control saw the number of multiple murders significantly decrease. This fact alone is the number one reason to implement gun control. Gun control is the perfect example of a public health measure based on the number of deaths and injuries it prevents. With this in mind, we need to ask, is there now increased access to firearms in Ontario to account for these spikes in gun violence?

There has not yet been an analysis that allows us to answer this question. In a country with gun control, a policy that has helped maintain public safety for so long, we need to be certain that we take this increase in gun violence seriously. Experience has taught us that gun control measures can make a difference in preventing injury and death.

Those of us who are the parents of young men, or who have been young men, or have been the caregivers of young men in distress know what can happen when frustration takes over from a youth’s better nature. A young man with a gun can do much more harm with a firearm than with his fists, or a knife. We know from the crime statistics that more and more guns are aimed at others, but many of these young men also aim at themselves.

The point is that there are more victims. We often decry that police are not attuned to the mental health problems of those they arrest. However, those of us who are concerned with health need to provide some support to the police and other agents of the law with respect to the increasing number of guns in Canada. The health impact is increasing along with the crime rate. Those of us who specialize in adolescent health must begin to understand the law as it relates to our patients.

A Children’s March for Ontario

The youth in my practice with the most complex mental health problems are those who have grown up “in care”. The expression “in care” refers to the fact that a child or youth is not living at home but rather with a foster family or in a residential care facility, usually called a “group home”. These young people are victims of assault and neglect in their families of origin, but they are also victims of a system of residential care that shuffles them around from home to home, caregiver to caregiver – a system that is no more supportive than their own family.

In late 2016, the Government of Ontario undertook to improve the lot of these youth. On the usual road, paved with the usual good intentions, the Government introduced Bill 89: An Act to Enact the Child, Youth and Family Services Act, 2016, to amend and repeal the Child and Family Services Act and to make related amendments to other acts. In many respects, the young people in this province who are living in care played a large role in ensuring that such an act is even before the Ontario legislature.

In November 2011, with the support of the Provincial Advocate for Children and Youth of Ontario, youth volunteers from across Ontario convened the Youth Leaving Care Hearings at Queen’s Park in Toronto. This was the first time youth had organized public hearings at Queen’s Park. The reason for the hearings was to address the concerns of the over 8,000 children and youth who are Crown Wards in Ontario – children and youth whose guardian is the Crown, through the Children’s Aid Societies in Ontario. There is a Report on the Hearings, My Real Life Book, and You tube videos. These will help you to understand how many youth live in care in Ontario and how they feel about this experience. I felt very honoured to be one of the adult contributors to the hearings. I remember an interview after my presentation and how emotional I felt during the interview. I had met three youth I had cared for at the hearings and I was so glad to see them doing well after everything they had gone through.

After the hearings, the youth continued to be involved. They participated in the inquests for Jeffrey Baldwin and for Katelynn Sampson, two children who died at the hands of their caregivers while living as wards, even though both these experiences must have been extraordinarily difficult personally. Their work and participation and enthusiasm finally convinced the Government that it had to act to change the existing Child and Family Services Act to better serve the children and youth it was meant to help.

The best part of Bill 89 are the principles it sets out as guidelines:

“The Government of Ontario is committed to the following principles:

Services provided to children and families should be child-centred.

Children and families have better outcomes when services build on their strengths.  Prevention services, early intervention services and community support services build on a family’s strengths and are invaluable in reducing the need for more disruptive services and interventions.

Services provided to children and families should respect their diversity and the principle of inclusion, consistent with the Human Rights Code and the Canadian Charter of Rights and Freedoms.

Systemic racism and the barriers it creates for children and families receiving services must continue to be addressed. All children should have the opportunity to meet their full potential.  Awareness of systemic biases and racism and the need to address these barriers should inform the delivery of all services for children and families.

Services to children and families should, wherever possible, help maintain connections to their communities.”

The worst part of Bill 89 is that, in fact, it may not, in fact, adhere to these principles and it is not at all clear in the text what the measures are to ensure that Children’s Aid Societies and group homes or foster parents will comply with the new measures of the act. Legislation is always complex, and difficult for people to understand. I am very well-educated – 11 years of postsecondary education – and I have trouble completely understanding the bill. Can you imagine how difficult it is for those who have not yet completed their education to understand it? Youth in care in Ontario have worked for many years to bring changes to the Child and Family Services Act. They made submissions to hearings and inquests, telling their stories of being cut off from their families, from those who loved them and from services that would have helped them heal. They told these stories even when it brought back horrible memories of what happened to them. They told these stories even if their mental health deteriorated.

They are, in fact, getting ready to do this again. Bill 89 is now in Committee and the Youth in Ontario want it to meet their needs. There are over 8,000 Crown Wards in Ontario, but there are almost 20,000 living in Children’s Aid Society Care. These are Ontario’s children – literally.

This Act – in fact, every legislative act – needs to be accessible. In simple language, citizens must be able to understand what an Act is saying to ensure that it does what it means to do. No one is blaming the legislators – the lofty goals and language set out in Bill 89 make it clear that the intent is to improve the situation for Children and Youth and Families in Ontario who need support. If the Act is made understandable for the Youth who have worked to get Bill 89 onto the legislative agenda, they will know whether it can be effective.

The Government has also made it clear that these changes are needed quickly and so, as is often their habit, the Committee process is being truncated. This is not fair to the youth who have been working for these changes. Until every submission is heard, from every youth who wants or needs to provide their input, the Committee process should not stop.

Our Voice, Our Turn, My Real Life Book, and the inquests for Jeffrey Baldwin and Katelyn Sampson showed us that the current Child and Family Services Act silenced children and youth and allowed their suffering, even their deaths, to be institutionalized. Let us honour these young people and their heroic actions to make Ontario a better place to grow up. Let us urge the Government to wait, and make Bill 89 as effective as it can be. Let’s match their courage with our own.

(Note: The Children’s March refers to incidents in Birmingham Alabama in 1963 when African American children left school to march downtown to meet the Mayor and speak about their experience of segregation. They were arrested, sprayed with hoses, but kept on marching, causing legislators, and especially President John F. Kennedy, to finally move forward on Civil Rights legislation. Photo is from a Biography documentary.)

Finale

In my last moments as Chair of the Ontario Medical Association Board, I thought of the five remarkable doctors, my former colleagues on the Executive Committee ,who have been my inspiration for the past six months. They embody the compassion, devotion and civility that epitomize physician leadership. I have learned so much from them.

Like my colleagues, despite having Council’s confidence to continue personally, I found the vote of nonconfidence in the Executive Committee in general to be extremely troubling.  As much as I want to assist in mending the divisions within the Ontario Medical Association, I believe that the best thing I can do is to assist as a Board member for a few more months.  The past six months have also taken a toll on those who care most about me and my clinical work so I feel it is important to attend to the interests of my family and my patients.

I am first and foremost a doctor and nothing is more satisfying to me than watching the life come back into a young person’s face as their depression lifts. I am inspired by the clinicians that I work with in my hospital and my community. The doctors and nurses, psychologists, social workers and other clinicians in my hospital keep me grounded in what is most important in medicine. They are amazing.

In ten years of medical politics, I have learned that I am not a politician. I can’t learn the lines or follow the cues. As too many people tell me, I cannot keep my facial expressions under control. If I have had any success, it is because I am persistent. It is because my efforts to be tolerant and gracious and kind have occasionally been successful. It is because, having always worked with youth, I have learned not to take my self too seriously.

The picture below is my favourite picture of me in OMA service. This was taken last November with Ontario’s medical student leaders. On the days when I have the most worries about where we are headed, I think about these doctors-in-training and I am reassured. If the work I have done for the Ontario Medical Student Bursary Fund and Physician Human Resources have had an impact for one young doctor, then my time at the OMA Board has been well spent and I leave with a light heart.

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(Photo credit: OMSBF)

Ministers

I am getting pretty fed up with Health Ministers. Ontario’s Minister of Health and Long Term Care, Eric Hoskins, dumped a “deal” on the table for Ontario doctors at 8 a.m. last Wednesday morning. He was in a press conference by 9 a.m. letting the public know that he had offered Ontario doctors more money than he had in August 2016. Not mentioning that the doctors had rejected that August deal, the Minister also neglected to say that he had decided to pit groups of doctors against each other with his most recent offer. His latest “deal” seems to give family physicians an increase at the same time as it cuts the highest paid specialists.

The “increase” to family physicians is very questionable since the terms and conditions to which extra funding is tied are so stringent that doctors would take a loss in order to meet the Minister’s demands. The timing of the offer is also suspect. It follows hard upon the passage of Bill 41, the so-called Patients First Act, which seeks to address problems in Ontario’s health care system with additional bureaucracy and a Command-and-Control approach that is totally unnecessary given the work ethic and devotion of most doctors. The Board of the Ontario Medical Association unanimously condemned the actions of the Government of Ontario and the Minister of Health and Long Term Care.

Hard upon this, now consider the federal government’s “Take it or leave it” offer to the provinces of an “increase” of $11.5 billion for home care and mental health. That’s meant to be an investment over the next TEN YEARS, for all Canadians. That’s an investment of about $300 for every Canadian. This is not more than a week’s worth of home care or 2 sessions with a clinical psychologist. Dr. Granger Avery, the President of the Canadian Medical Association, said, “The Groundhog Day-type discussions where political leaders bat around percentages and figures at meetings in hotels have to stop.”

Really, Ministers, doctors would like to be able to have a real discussion about a health care proposal that you introduce that does not require the use of quotation marks to alert the public to the fact that health ministers and doctors speak a different language, especially where money and patient needs are concerned.

As a physician, I would like to think that there is an opportunity to discuss why these proposals will not meet the needs of my practice. As a patient, I want analysis that demonstrates to me that the investment of my money has been careful and methodical and that investments are linked to outcomes that both my doctors and the government agree on. As a citizen, it is distressing to be a bystander to this grandstanding by legislators. This is people’s healthcare. You are governing. Please consider your proposals with the seriousness they deserve. Please talk with me, not at me.

Bleak Midwinter

The holiday season has officially started. I have begun to make a list of the families in my practice that should receive grocery vouchers so that they can afford food for the holidays. I also make a list for the teenagers who are living on their own. I confirm addresses and watch young people’s faces closely so that I can discern whether they are, in fact, housed. I ask them if their housing is safe, looking them right in the eye. I have a list of numbers on the corner of my desk for families or youth to call if they need housing. I have lists of where free holiday dinners are provided and where one can sign up to receive gifts. I am not trained for any of this. In fact, few doctors are trained for this work, but we all do it.  The hardest part of this work is finding a balance between the fear I have about how precarious my patients’ living situations can be and the realization that I have a responsibility to make that situation more secure.

I know there are many who will say that this is not a doctor’s job, but I cannot escape the knowledge that I have that says otherwise. Every doctor I know works for the best for their patients even when the best has nothing to do with pathology, physiology or medicines. Every doctor I know asks their patients questions about their income and work and family life.

The sharp contrast between the glittery mall displays and the realities of many lives is especially evident at this time of year.  While so many are focused on what they want the holiday to be, others are thinking of what they need so that the holiday is bearable. The impact of this contrast on mental health is significant.

At a time of year when family is glorified, the difficulties in one’s own family become highlighted. The support of family members is known to be a factor in good health, but how many people do you know who dread the “family” events that come with the holidays? How many of those events end much differently than sitcoms would have us think? Many of the youth I see live in care. Some will be preparing for a visit with family of one kind or another. Some will have days or even a week with their family. Helping youth stay realistic about these visits and the holidays is very difficult for those of us who care for these youth.

I am always most concerned about the youth who do not have a family to visit. Most people around them will be planning a visit and excitedly buying and wrapping gifts and planning travel. The youth without a family will be sharing their Christmas lists with a youth worker or social worker. You will receive gifts, often thoughtful gifts of things you want, but you will not have what you really want which is love, true affection from someone who has known you all your life and is happy for just being able to hang out with you. As a psychiatrist, I could point out the link between “hanging out” and endorphins but I think this just serves to distance us from the feelings. If you can understand what a young person with no family is feeling, you know that this feeling is not good for someone’s mental health.

As a physician, I always take some time off in November or early December to prepare emotionally for the holiday season, whose starkness is so evident in psychiatry. Then I come back to work ready to spend the next month social determinants of health.

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