Tag Archives: family medicine

Barefoot to White Coat

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Having returned from my three months of out-of-province electives, I settled back into the swing of things at home… at least for the next two months 😉 I was at home just long enough to do some CaRMS interviews for my upcoming residency specialty training, complete my final undergraduate OSCE (a lengthy clinical exam with actors pretending to be patients suffering from a variety of weird and wonderful ailments), and spend an incredible month working with the Program of Assertive Community Treatment (aka PACT), a service provided at home to individuals with severe and persistent mental illness, helping them stay out of hospital and maintain their independence in the community.

March 1 was Match Day, the day where medical students all across the country are informed which specialty program they have been accepted into; or in other words, the day we find out what type of medicine we will be practicing for the rest of our careers. I was beyond thrilled to match to my first choice of Family Medicine – Northern-Remote stream, a specialized Family Med program designed to address inequities in access and quality of healthcare for Canadians living in rural and remote areas, particularly those of Indigenous descent. While every Family Med program across Canada offers excellent medical training, I was drawn to the Northern-Remote stream for its unique decolonizing vision and immense scope of practice. And now, as of July 1, I will be a member of its team!!

“Plan B” theme party on Match Day Eve – Joshua and I showed up as WWOOFers, to nobody’s surprise!

Match Day!!

Even after some epic Match Day celebrations, the adventures were not over! Two days after the Match, I boarded a plane along with three other med students, and two days after that, we landed in Shantou, China, a “small town” of only 5 million people in the Guangdong province, nestled on the coast of the South China Sea.

Our apartment complex and view from my window

Seven minute walk from my apartment to the harbour!

The four of us had the immense privilege of being chosen to participate in an international medical exchange with one of our sister universities. Every day for three weeks, we toured two different hospital wards, ranging from Neonatology to Hepatobiliary to Orthopedic surgery. An English-speaking physician was assigned to us on each ward and would accompany us on bedside rounds of their patients.

The brain tumour research hospital… appropriately shaped.

Shantou “Hospital #1”

Bedside rounds & teaching


There were a number of striking differences in the Shantou hospital wards compared to our Canadian wards, but the most notable by far was the organization of care. In North America, family physicians (known in the past as “GPs”) are the first stop for the vast majority of patients. Sore throats, earaches, slipped discs, period problems, prostate problems, depression, pregnancy… most health concerns can be treated directly by a family doc, but if need be, the patient is then referred to the appropriate specialist for more unusual and complicated health conditions.

This type of healthcare organization, aka with a “primary care” focus, is rare in China, and the vast majority of individuals in China bypass primary care physicians and attempt to access specialists directly for all healthcare concerns. In other words, if you have a headache, you try to see a neurologist. A cough and sore throat? You hope to somehow snag an appointment with a respirologist. Partly this is due to cost: with China’s three-tiered system, individuals are required to pay for most services out of pocket, so patients do not want to risk having to pay a family physician and subsequently pay another fee to a specialist. Furthermore, there is a strong historical component that has cultivated a sense of mistrust towards the idea of primary care.

Several decades ago, the concept of “primary care” referred to farmers in rural areas who received a mere 3 months of training by urban medical professionals, in an attempt to address healthcare access issues for the enormous rural Chinese population (which represented 80% of the total Chinese population during the 1970s and 1980s). While these “barefoot doctors,” as they came to be known, provided some relief to the healthcare crisis, their training and medical expertise was understandably unequal to that provided in tertiary care centres staffed by fully trained physicians. The barefoot doctor system eventually collapsed under economic policies introduced during the Cultural Revolution.

Family Medicine was only introduced as an official specialty in Chinese medical schools in 1999. In 2009, new health reforms were put in place in response to rising public frustrations over difficulties in accessing professional medical care, as well as the steep prices associated with healthcare. The Chinese government instituted a goal of training 300 000 family physicians by 2020; even this impressive number, however, would still only provide 0.2 family doctors for every 1000 citizens (in comparison, consider that there are 1.17 family docs per 1000 Canadians – ~6x more than in China – and that is still woefully inadequate!!)

Some may think that China’s approach to healthcare is actually more effective; after all, cutting out the middle step of a family physician should likely result in faster and better service, right? On the contrary. Since 2009, primary care use in China has decreased, while visits to hospitals and specialist services have increased significantly. And sadly, death from all causes, money spent on healthcare, and inequity between rural and urban health measures have also increased in China. Multiple studies have shown that regular primary care improves health outcomes and reduces time spent in hospital. But unfortunately, in China, people with multiple different health concerns tend to use specialist and hospitalist care over regularly seeing a family physician. Moreover, people with lower incomes tend to have poorer access to primary care services, and therefore are at a higher risk for poorer health outcomes in general.

The partnership between our university and Shantou has been an exciting adjunct in addressing the primary care gap in China. While in Shantou, Canadian Family Medicine faculty and residents were very involved in giving lectures to and leading discussion groups with Shantou medical students and residents.

It was fascinating to discuss both the differences in clinical approaches between China and Canada, but also realize just how many similarities existed between our sites. As one preceptor stated, “We are all just trying to provide the best care possible to our patients.”

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The Revolutionary Practitioner Manifesto

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My electives adventure all started by securing a spot with the University of Toronto’s Health of the Homeless elective, and building the rest of my schedule around it. Even knowing what we do about the connection between social determinants (such as income, housing, race, and gender) and health, I had never seen another medical elective specifically designed to address the populations most in need of medical services.

Inner City Health Associates (ICHA) is a group of over sixty physicians dedicated to providing care to those who truly need it most – those without housing, without income, without identification, and often with complex health struggles for which they have been repeatedly refused care. Our existing system has been carefully built to ensure that those who could stand to benefit most from health care are effectively barred from accessing it. For example, even in our “free” Canadian healthcare system, care is extremely difficult to access if you do not have proper identification, like a provincial health card. However, in order to access a health card, you need proper identification… Hang on a second. Something isn’t adding up…

ICHA docs see this paradox and work to correct it through education and advocacy at all levels of the system (the public, policy makers, and other healthcare professionals), reminding people of the undeniable connections between things like income, housing, and health.

Higher income and social status are linked to better health. The greater the gap between the richest and poorest people, the greater the differences in health.
World Health Organization

I say “remind” because we first learn about the social determinants of health as early as UNICEF Halloween presentations back in Grade 1 (or if you’re evangelical by trade, then World Vision sermons before you were even out of the womb), where we are taught that poor kids are sick and need our help. Crude and incomplete, but built around an important truth: Poverty contributes to a lack of health. And many factors contribute to poverty. “The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power, and resources at global, national, and local levels” (World Health Organization, 2017).

When I am one of the privileged wealthy (and by that, I mean I can read, have stable housing, food in the fridge, safe drinking water, and a physician who won’t refuse to see me because of my housing/sexual orientation/age/illness), I need to look at how I am contributing to – or at the very least, not working to change – those factors contributing to other people living in poverty.

And this is what moved me most about the ICHA docs. Their ultimate goal is for public perspective and the Canadian healthcare system as a whole to shift towards a system that is truly equitable, accessible, universal, portable, and comprehensive (hmmm… sound familiar?) So ICHA docs are dynamic teachers in the hospital, devoted mentors of medical students, passionate advocates on Parliament Hill, and constantly working with policy makers to encourage systems level change (I myself had the privilege of attending a breakfast meeting with the Law Commissioner of Ontario to discuss a new policy of palliative care). But in the meantime, if they cannot convince others to join them in providing quality care to those who need it most, they just go out and do it themselves.

For example, I worked with 2 physicians at a refugee health centre, a tiny room nestled within a shelter for newly arrived refugees. For many who have arrived in Canada fleeing persecution, there is a lag between when they arrive here and when they have their court hearing to actually receive their refugee status (ironic, because these individuals have been experiencing persecution for years, but are only recognized as a refugee once they are safe in a country defined as free from persecution). This lag, which can be many months, is a time of immense vulnerability for these folks, since they are not only fleeing immense trauma, not only adjusting to a new culture and climate, and not only trying to accomplish the daily tasks of living we all must do (families have to eat, kids have to get to school, spouses occasionally want to talk), but if they get sick, accessing healthcare can be immensely complicated (remember the ID/health card shenanigans described above??) Furthermore, it’s not just the usual pneumonias and UTIs that can get them down. Many come from countries where immunizations were unreliably accessible and where certain infectious diseases and genetic conditions are much more prevalent. When you are focused on daily survival in a refugee camp, screening for genetic blood conditions may not seem high on the list of priorities. But when you trying to live peacefully in Canada with hopes of surviving past age 45, suddenly that condition takes on a new importance.

In every new clinic I worked in (and I had the privilege of working in many… too many for a single blog post!), I made a point to ask the physician “How??” How did they end up here? How did they get the funding, the building, the equipment organized? How did they make it a reality to provide care to a population where literally no care existed? And their answer was almost always the same. They’d shrug and say something along the lines of, “Well, I knew it had to be done… so I just did it.” For the incredible docs at the refugee clinic, “just doing it” included rummaging in the basement of the major TO teaching hospital for discarded but still usable supplies. It meant 2 docs carrying each end of an old examination table to get it up the street from one clinic to this one. It meant these same 2 guys coming in at midnight after their workday to paint the new clinic room themselves. It meant them going to hospitals and administrative boards and other physicians and saying, “It would help so much if you could provide funding and staff. But if you can’t, we’re going to be doing this work anyways.” They continue to volunteer their time one day a week to provide healthcare to undocumented refugees who simply could not receive care anywhere else, and they also donate their money earned on other days to an emergency fund for their families who cannot afford their prescription medications.

I met psychiatrists who literally went into ditches and bus shelters to provide emergency mental health care where it is so desperately needed most. I worked with a palliative care doc who zips around Toronto in his little car, bringing comfort, dignity, and company to beautiful people who would otherwise be dying alone in back alleys and basements because they were refused care everywhere else. I carefully stepped around and over bodies jam-packed into a shelter common room to get to a woman so ill with uncontrolled diabetes that she could not come up to the clinic to be examined. On my first day working with one doc, they handed me a copy of their own personal Manifesto of a Revolutionary Practitioner.

“I only realised at age 60 that I needed to articulate my vision for practicing Medicine,” they told me. “I hope you will write your own much sooner than that.”

As a skilled professional, so much has come to me – opportunity, education, mentorship, social standing, income (one day!) Have I worked hard for it? Absolutely. But me working hard is not the point. We have put barriers in place to stop people who need care from coming to us. So the time has come for us to go to them.

What can we practically do? Most importantly, start to notice our own reactions to people who are homeless, poor, struggling with health problems. These are not the people we should be uncomfortable having in our hospitals – these are the people who most need care. Next, take the opportunity to start conversations with friends or families who may talk about the vulnerable people in our communities less than kindly. Heck, send them to read this blog! When you vote, look at how your representative talks about things like housing, access to clean water, autonomy for Indigenous populations. We know that upstream action ultimately is most profitable for all involved (sorry guys, “trickle down economics” isn’t a thing; actually, the opposite is true**), so make sure we’re supporting policies that will support all of us. And ultimately, I want to remember the ICHA docs: If something needs to be done, maybe we just need to do it.

In other words, if you find yourself painting a clinic at midnight, give me a call – I’d love to join you 🙂

Getting to a new clinic every day meant a LOT of public transit adventures…

A much needed evening of renewal at a BYOM Poetry Open Mic (Bring Your Own Mug for tea!)

** The IMF and the OECD have found that there is an inverse relationship between the increasing income share of the wealthiest and overall economic growth. If the income share of the top 20 percent increases by one percentage point, GDP growth is actually 0.08 percentage points lower in the following five years, suggesting that the benefits do not trickle down.
Shimman & Millar, 2017