From Bedside to Bench

During all my years of practicing medicine, I have been close to research in the institutions where I worked. I have admired and assisted clinical researchers, but I had never felt inclined to join their ranks. When I became the Clinical Director of the Youth Program two years ago, however, that changed. With this new role came the task to promote research and to become more personally involved in the research being conducted in my program and institution.

It is remarkable how much research is conducted in a university teaching hospital, with little funding and most research being conducted off the corner of people’s desks. Most of these researchers are earning their living from their clinical work, with next to no additional funding. Often the only additional funding they receive covers costs related to materials for research and a few hours from a research assistant. It is not unusual for physician researchers to be self-supporting, receiving no direct compensation for this work. This is my experience in psychiatry, but I suspect that it is not much different in other medical specialties.

Much of the research conducted in the clinical programs in which I work is to benefit our programs and our patients, first and foremost. We ask each patient to complete surveys and simple diagnostic measures before and after all programs, in some cases after each session, so that we can be sure that there is value to the programs and therapies we have developed and that we use. In many programs that we are developing, we ask for feedback after each session. For example, if we are starting each session with a mindfulness exercise that no one finds helpful, then we change exercises. All this data provides us with valuable information about the profile of the patients we are treating. It also indicates the type and severity of the conditions being treated in a tertiary care treatment facility.

As I began to consider all the data we have available that patients have given permission for us to use and analyze, I began to consider that, even when I worked as a psychiatrist in private practice, I had a great deal of patient data at my disposal. Occasionally, when a situation I had managed was very unusual, I would discuss with a patient and their family the possibility of sending a short communication about the case to a journal. I had no one to advise me on the process. I had to negotiate and consider the ethics of the situation on my own with the patient and their family. Often the patient and the family had considered their situation to be unique. They were eager to participate in this minimal research process as a specific case discussion to benefit other patients and families who might find themselves in a similar situation.

The minimal level of funding available in universities and the complete lack of funding available to physicians in private practice to pursue limited clinical research underlines the shortsightedness of our single payor. Imagine if research were promoted by Provincial Ministries of Health in Canada, to the extent that expertise and funding were readily available to Primary Care and other specialists in the community, what we might learn to improve best practices in Canada. Imagine if the funding in Alternate Funding Plans was sufficient that every physician in our teaching hospitals could be involved in research without financial penalty, what we might learn about secondary and tertiary care.

An example of the kind of research that is possible when the payor supports it is the study conducted by the United States Center for Disease Control, supported by Kaiser Permanente, is the Adverse Childhood Experiences Study. I learned about this study when I was researching (unfunded, of course) other data we might like to collect in programs. It is “one of the largest investigations of childhood abuse and neglect and later-life health and well-being”.

This is the kind of work we could be doing across Canada. I could not find any evidence of this research, although I would be relieved to know that I was wrong.

 

Life and Death Reporting – A Book Review

André Picard has been reporting on health and healthcare for The Globe for over thirty years. His book Matters of Life and Death: Public Health Issues in Canada is a collection of oeuvre from that period, focusing on some of the most important heath issues of that period and for Canada today. Apart from being a practicing psychiatrist, I did work for a time in health policy for the Canadian Medical Association and I haven’t quite shaken the habit. Mr. Picard’s book has become a reference for me and I am referring to it time and again when discussing or considering healthcare.

The book is organized into fourteen sections on what are arguably the most important topics in Canadian Healthcare. Picard cites fourteen areas of healthcare that deserve immediate attention because of their impact on Canadians’ health and our health care system. These are Medicare, Mental Health, Drugs, War on Drugs, Aging, End of Life, Children, Reproductive/Women’s Health, Disability/Inclusion, Indigenous Health, Cancer, Infectious Disease, Lifestyles, Social Determinants. Each topic has its own chapter and the book is very readable and understandable even if reading about health and healthcare is not easy for the reader. As someone who promotes health literacy to the sixteen year old adolescents in my practice, this is important. The short articles in each chapter are interesting and well-written. Members of my team and I used Sip on this: Like all drugs, alcohol isn’t Consequence free for a group about alcohol use in teens.

As I said before, this book has become a reference for me on Canadian Healthcare. I like to have good health policy information, to have the correct statistics and an impression of how others might be considering a health policy topic. Matters of Life and Death was accurate from these perspectives in those areas of health care where I have very good knowledge, which was always reassuring. Also, even when I don’t agree with his opinion, I can always see Mr. Picard’s point of view. This is the essence of good science journalism to me: that it stimulates dialogue and further consideration.

I feel that Matters of Life and Death is a book that every Canadian who wants to understand the problems our healthcare system should read, but I also think they would enjoy it. I will also say that the most valuable information provided was found in the Introduction. Mr. Picard compiles a list of the shortcomings of health reporting. He cites a list developed by Gary Schwitzer, a well-known American health journalist, and then develops the list further. That list is a lens against which one can evaluate journalism on healthcare, a good tool to have when you’re trying to decide whether an article is worth consideration.

(Note: I read the 2017 Douglas & McIntyre paperback edition of Matters of Life and Death: Public Health Issues in Canada.)

(My own photo)

Mental Health Measures Anyone Can Do

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

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

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

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

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

Hunger For Justice

About once every month, I buy a patient or a patient and their family a meal. This is always embarrassing for them. Parents especially struggle when I insist that they must also pick something for themselves. I understand this. No one likes to admit that they’re struggling to feed their family. I did learn, however, that when I didn’t insist that parents eat themselves that food was often saved for other children at home. At the same time as I would feed people, I would call the food bank closest to their home to arrange for the family to pick up food on the way home. Another embarrassment for them, but I insist, telling the family that they can volunteer at the food bank once they are managing themselves.

As a doctor, I find it discouraging that there is so much food insecurity in a country like Canada. Food Secure Canada estimates that 4 million Canadians are food-insecure – 1.15 million of these Canadians are children. In northern and remote communities, the situation is even worse. It is estimated that 2/3 of indigenous children are food insecure. Given how unlikely it is that families are volunteering this information, I am confident that these numbers are low. I have met teenagers who are not even aware that they are not getting enough to eat. They are told that adolescents are “always hungry” and they believe that their own hunger is a normal state. I advise residents and medical students to find out in detail what their patients are eating so that they can truly assess whether their patients are getting enough to eat. Adolescents need a lot of nourishment, especially adolescent boys. We have known this since the time of Plato who said, “A boy is an appetite with a skin pulled over it”.

Food Secure Canada works to advance food security and food sovereignty through 3 goals: zero hunger; safe, healthy food; a sustainable food system. To help the youth that I see, I encourage schools to support breakfast and lunch programs. Snacks and meals are available in many of our Outpatient and Day programs. In my neighbourhood, the Parkdale Food Centre works with restaurants, schools and even the local theatre to grow food all year long and to help young people learn to cook. Community meals are a part of the social support network across Canada, often run by faith groups but also by food banks and restaurants and other agencies. Despite all these efforts, people still go hungry. The Ottawa Mission serves 1300 meals per day and food banks estimate that over 40,000 people in Ottawa are food insecure. Last year in Toronto, 136,000 children needed school lunches.

There are just over one hundred youth seen in our outpatient program at my hospital every week. These youth and their families are already managing at least one family member’s chronic health condition. Given how many of these are from marginalized groups, it’s likely that as many as 40% are not getting enough to eat, leading to even more health problems. We have not been able to figure out who most of them are. I don’t know if food banks and social agencies could manage to help everyone if we did.

The lesson from my experience is that every doctor in Canada, no matter where we practice, no matter how prosperous our community, needs to ask their patients if they are getting enough to eat. Once we have asked, we then need to accept that many, many people will not be truthful about this. They are too ashamed.

Our patients are hungry, and we must be hungry also…for justice.

(Note: This is a picture of one of the Parkdale Food Centre’s growing towers.)

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.)

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.

Seria Una Cruz Verde?

I am watching the news from the Venezuelan election and wondering what I would do if I were a doctor in Venezuela today. The election is the most recent assault on the people of Venezuela by their President, Nicolas Maduro. By the end of the day, or within a few more days, he will become the dictator of Venezuela. The making of a dictator is the undoing of security in a country and many young Venezuelans have seen their country go from being the richest country in South America in the 1980’s to having an 86% poverty rate in 2017.
Since April, over 100 young people have died in protests in Venezuela. That total increased by 19 this weekend as protests over the election intensified. Venezuela’s neighbours, Brazil and Colombia are bracing for a refugee crisis. The country is experiencing a food security crisis and medicines are not at all available.
The scale of the humanitarian crisis was confirmed by Dr. Douglas Leon Natera, President of the Medical Federation of Venezuela. Natera is reaching out to colleagues in the region. This is a communication to Dr. Maite Sevillano, Vice President of the South American Region of Medical Women’s International Association:
“To the friends: The health sector being headed by the doctors is only attending emergencies, trying to continue to give priority to children, pregnant women and the elderly. These resolutions are being followed by 96% of doctors in public services and 85% in private.” (Personal Communication to dra Sevillano)
Venezuelan physicians are especially concerned about the impact on children, who have been most affected by the food insecurity. Also, youth have been the majority killed in protests against the Maduro regime, according to Dr. Natera.
In Venezuela, however, some of the heroes are also young. Medical students and recent graduates of the Central University of Venezuela have banded together as volunteers to provide first aid and whatever care they can to those injured in protests, on both sides. However, despite the group’s impartiality, government forces usually see them as part of the protest. As they help, some have been injured and one of the volunteers was killed. To identify themselves, the volunteers wear white helmets with a green medical cross and carry white flags bearing the same green cross. Cruz Verde (Green Cross) is what they are called and those injured in protests call out for them, and pray for them.
As most of the volunteers are in their twenties, they were born when their country was still wealthy. They have witnessed its disintegration. They are studying – and learning – the basics of public health, emergency medicine and the impact on health of a humanitarian crisis in the most unfortunate way. Their older colleagues, led by Dr. Natera, are also working to provide basic medical care to starving and desperate Venezuelans. When I read about their work and watch youtube videos of their working conditions, my own first world medical concerns dissolve into this philosophical question:
“Seria una Cruz Verde?”

(Photo credit: Christian Science Monitor)