Earlier this week, I joined colleagues from 20 nations in London, England to discuss the social determinants of health and health inequity in our societies. Specifically, we wanted to explore the role of doctors and their national associations in addressing these gaps by viewing socioeconomic issues through a health lens.
Why should doctors care about things like poverty, housing, nutrition insecurity, education status and early childhood development? Well, the answer is that, more than anything else, these and other social determinants contribute significantly to the health of our patients. In fact, these factors constitute about 50% of what makes people sick.
This graphic always surprises doctors at first. We live, for the most part, in a world where we treat disease. Even when we talk about prevention, we usually mean things like managing risk factors for disease like high cholesterol, hypertension, smoking and alcohol consumption.
But to truly get upstream in the trajectory of human disease, one must consider the “causes of the causes” of disease. This leads us directly and squarely to the social determinants of health; the socioeconomic circumstances in which our patients live. And so, even if this is not our traditional area of expertise, we must as doctors be at least aware of these associations and consider, I would argue, what role we might play in addressing these issues both in our individual clinical practices as well as at a macro level through organized advocacy.
The evidence for a “social gradient” of disease is overwhelming. Incoming World Medical Association President Sir Michael Marmot – a British epidemiologist who established the UCL Institute of Health Equity has assembled an impressive, international body of evidence showing clear correlations between social determinants and important health and wellness metrics.
Sir Michael Marmot
It is well worth browsing the Institute’s list of presentations to get a sense of the consistency of the findings. Since I am a cardiologist, I will reproduce one of his slides here on the prevalence of circulatory disease death rates to illustrate the power of this work:
Age standardised circulatory disease death rates at ages under 75, by local ward deprivation level, 1999 and 2001-2003 : England
A self-described optimist, Sir Michael steadfastly rejects any suggestion that change cannot be achieved rapidly. He cites post-conflict Colombia, where some attention to the social determinants has seen a reduction in the percentage of citizens living below the poverty line over the past 10 years:
At this unique two-day conference (co-sponsored by the British and Canadian Medical Associations (shout-out to CMA’s Jenny Buckley and Karen Clark for their great work in organizing the meeting!)) there were many lessons shared from countries around the world. The meeting itself was also shared with the world, as several physician social media enthusiasts were tweeting the proceedings under the hashtag #doctors4healthequity. At one point, it was trending in fourth place on Twitter in Canada, just behind #angelinajolie.
Australian Medical Association President Dr. Brian Owler and a past CMA President, Dr. Anna Reid, reviewed how their countries’ colonial histories have inflicted upon First Nations and Aboriginal Peoples a multi-generational trauma that very much persists to this day. Hungary’s Dr. Istvan Szilard described persistent systematic racism against the Roma People and the negative impact this has had on their health. Their eloquent presentations demonstrated vividly that health inequities are largely socially engineered.
Dr. Anna Reid recalls Canada’s racist beginnings and the lasting legacy of Canada’s residential schools.
American Medical Association Past-President Dr. Ardis Dee Hoven reported that minorities make up 35% of America, but only 6% of doctors. Health inequities are striking in the world’s richest country, and they closely mirror race and socioeconomic status. “(We) have a history of not making healthcare available to minorities”, she said, while also reflecting on the fact that minorities are more affected by obesity, diabetes and hypertension.
Dr. Ardis Dee Hoven, Past President of the American Medical Association
Dr. David Pencheon, Director of the Sustainable Development Unit (SDU) at NHS England, made a very compelling case for the impact of climate change on health, and in particular, the stark truth that the biggest producers of carbon emissions suffer the fewest health consequences – illustrating a consistent pattern of international (as opposed to intranational) health inequities driven by socioeconomic and political imbalances.
NHS England’s Dr. David Pencheon
And there was so much more. We heard from France, Finland, Zambia and Slovenia. We heard from Portugal and Denmark and Spain. Sweden’s Dr. Asa Wetterqvist delivered a passionate speech on her country’s ambitious health promotion plan – including a tobacco end-game strategy – in which thoughtful incorporation of the social determinants was clearly evident. Trinidad and Tobago’s Dr. Lianne Conyette discussed the rise in obesity paralleling the social gradient and her country’s efforts to get people more active. Advocate Leah Wapner, Secretary General of the Israeli Medical Association, addressed head-on her country’s political and ethnic struggles. “All of our patients are equal”, she said, while acknowledging the impact of income inequity on the health of Israelis, including Jews, Arabs and other ethnic groups. Dr. Wunna Tun, from the Myanmar Medical Association, told a story of how the cost of a motorcycle ride for an injured man was enough to dissuade him from traveling to a hospital following a serious injury.
Dr. Lianne Conyette – President of the Trinidad & Tobago Medical Association
Canadian Physicians and the CMA on the Social Determinants of Health
Canada’s Dr. Gary Bloch, a family doctor working out of St. Michael’s Hospital in Toronto, spoke of the development and implementation of a clinical tool to help assess and “treat” poverty. Treating poverty like a disease, he argues, is the way to bring physician skills directly in touch with the social determinants of health. Helping a low-income patient fill in their income tax form, for example, so that they can be eligible for a refund, puts money in their pocket, he argues. (See Dr. Bloch’s TEDx talk here). His clinical tool for poverty in primary care has been adopted by the Ontario College of Family Physicians and can be found here.
Ritika Goel and Dan Raza (who weren’t at the conference but whose work was cited) have also taken the position that screening for poverty is an important role that doctors can play in their everyday practice. The simple question, “Do you have difficulty making ends meet at the end of the month?” is highly sensitive and specific for the detection (diagnosis?) of poverty.
Canada’s work on the social determinants of health stands out on the international stage, although we have much more work to do. Physician champions like Drs. Gary Bloch, Ryan Meili, Monika Dutt, Ritika Goel, Dan Raza, Cory Neudorf, Elizabeth Lee Ford Jones, Norah Duggan, Vanessa Brcic, Jeff Turnbull and so many others are “walking the talk” and showing how clinical and political interventions can make a real difference. In Saskatchewan, for example, Ryan Meili’s Upstream organization has persuaded the Government of Saskatchewan to pursue a poverty-reduction strategy, and Canadian Doctors for Refugee Care were instrumental in the federal court’s recent ruling overturning federal government cuts to refugee health care.
At the national and organizational levels, the CMA stands tall with its historic work on the social determinants. During Dr. Anna Reid’s presidency, the CMA conducted a series of national town halls which raised the profile of the issue and culminated in a widely-lauded report, Health Care in Canada: What Makes us Sick? We’ve also developed educational modules for physicians on how to treat poverty in practice and on early childhood development. Our CMA representative to the WMA, Dr. Andre Bernard from Halifax, is an articulate and internationally-respected advocate at the policy and political levels. He will be joined by CMA Past President Dr. Louis Francescutti at the next WMA meeting in Oslo later this year.
“Why should I get involved in the social determinants of health of my patients,” you ask? Because everything that affects the health of our patients should concern us. It’s not a left-wing or right-wing thing, it’s a healthy society thing. We have only just begun to explore the positive influence doctors can have at the bedside, in the boardrooms, in academic health policy circles, and at the political level (locally, nationally and internationally). The CMA is proud of Canada’s physician leaders in bringing these issues to the fore and we will continue to make this a core strategic priority for the organization.
Over the Christmas and New Year’s Holiday this year, I had the privilege of serving as the attending physician in the Cardiac Sciences Unit (CSU) at my hospital – Kingston General – a regional academic tertiary care hospital in Southeastern Ontario. The CSU is a cardiac intensive care unit where we care for seriously ill patients with acute cardiac problems like heart attacks as well as those recovering from cardiac surgery.
I always enjoy working clinically. It is a great privilege to be allowed into the lives of patients and their families – particularly at times when they are vulnerable and scared. It is a responsibility that I take very seriously. We all do. There is no better job in the world.
As I walked around the hospital on Dec 26, from the CSU to the Emergency Department and up to the wards to consult on other patients, it occurred to me that the holiday period was a lot like a perpetual night shift.
Everyone who works in a hospital knows that there are two cultures: the daytime culture and the nighttime culture. At night, everything slows down. Most of the attending physicians are home. There are fewer nurses on the wards. Many of the techs, pharmacists, physiotherapists, dieticians, social workers, and others who help to care for patients are at home. Tests are harder to get. Consultations are on an urgent basis only. Everyone hunkers down for the night.
Now, this isn’t necessarily a bad thing. Not too many patients want to have their scheduled ultrasound at 2 in the morning, or have an elective gall bladder surgery in the middle of the night. The CT of the head to investigate seizures that have been happening intermittently for a few months can probably wait until the morning. And let’s not forget, patients need to sleep.
But what happens when we stay in nighttime mode for a week? What about when this night shift-like state lasts for several days in a row, as it does over the Christmas and New Year period?
In the hospital world, we talk a lot about patient flow. I’m not a big fan of the term, because I find it de-personalizes patients’ health care journeys. It seems somehow to reduce a profoundly important life experience to a bland and mechanical series of events; the efficiency of and speed at which all the therapeutic and diagnostic events that comprise a health care experience occur. Starkness of the term aside, it is useful to understand because it is precisely the impairment of patient flow that leads to suboptimal experiences for patients who are hospitalized over the holidays.
What does all this mean? What does slower patient flow over the holidays mean to patient care?
Well, if you have an emergent or urgent problem, you will be well cared for. If you have a heart attack, a gastrointestinal or cerebral bleed, a ruptured aorta or acute respiratory failure, you will be treated promptly and treated well, with all the best that modern medicine has to offer. This is the case all the time – night or day; regular day or holiday.
The patients most affected by the holiday slowdown, predictably, are those who are most vulnerable – our seniors with multiple chronic conditions who don’t really need to be in hospital anymore but are waiting to go home or to a long term care facility.
Over the holidays, family doctors’ offices close or have reduced hours. Home care scales down. Partner community hospitals – themselves in holiday mode – are less able to repatriate patients and in some cases even close beds. Social workers and physiotherapists are less available. Unionized employees from nurses to techs are entitled to 5 consecutive days at either Christmas or New Year’s, making staffing a challenge for managers. Not as many doctors are around. In the world of patient flow, there is push and pull. Over the holidays, the pull grinds to a halt. There is only push. All the usual barriers to getting patients to the next step in their journey get higher and thicker.
And so, patient flow slows. And when patient flow slows, bad things happen. Patients fall. They get hospital-acquired infections. They get sundowning and muscle wasting. They experience depression and despair. They languish.
None of this is readily apparent at first glance. Everyone is doing their job. Caregivers are compassionate and capable and I saw them do their jobs admirably. The diminished quality of the patient experience over the holidays is very hard to see when looking at sequenced events individually. It is the totality of the experience; the sum total of the subtle underperformance of patient flow that leads to the collective suboptimal outcomes.
Health care should be a 24/7, 365 day-a-year enterprise. A truly patient-centred system that was designed to serve patients optimally would never take a 7-day vacation.
It’s been a busy few weeks and I have had the great privilege to travel a lot across the country and speak to a lot of people about seniors care. The CMA’s message – that we need a national seniors strategy with Ottawa taking a leading role – is resonating with patients, their families, ordinary people, citizens’ organizations, and the press.
I think that if we can fix seniors care, we will go a long way toward fixing the health care system in this country. And our health care system needs some fixing. According to the latest Commonwealth Fund Report, we rank next to last among 11 leading nations – only the US is worse. Many believe that with the introduction of Obamacare in the US, their value-for-dollar proposition will improve sufficiently to vault them above us.
I’m willing to bet that Canadians do not want to be at the bottom of any list that ranks national health care systems. Canadians highly value our health care system and the values upon which it was founded. It is an institution that is a big part of our national identity. So when a Commonwealth Fund Report measures quality (effective care, safe care, coordinated care and patient-centred care), access, efficiency, equity, and healthy lives and finds us next to the bottom of the pack, we need to take heed.
We need to spend smarter. We need to focus more on outcomes and quality, and less on volumes and activity. We need to serve and to be accountable to patients and their families rather than only to our institutions and structures.
Where to start? Well, let’s talk about how we can start to de-hospitalize the system.
Now, we will always need hospitals. Don’t get me wrong.
But increasingly, we need new ways to support seniors – so that they can age well at home, instead of as patients in hospitals. Today, between 15 and 20 percent of acute care hospital beds in Canada are occupied by patients – most of them seniors – who do not require acute care. We call them ALC (Alternate Level of Care) patients. They are in hospital simply because they have nowhere else to go. They are either on waiting lists for Long Term Care or they are waiting for a stretched home-care system to get the supports in place for them to be successful in their homes.
What are the consequences of this misalignment?
Well, first and foremost – seniors are not getting the care they need and deserve. Acute care hospitals are not designed or staffed to care for seniors with chronic disease. In hospitals, we put patients to bed – because that is what we do in acute care settings – we put sick people in bed. But these seniors are not acutely ill. They need a different kind of care environment. They need a care environment that lifts them up and restores them and helps them to live a dignified life. Not a small room with a bed and a chair, shared by 1-3 other people they don’t know, waiting for daily rounds by doctors and nurses who have nothing meaningful to contribute to them, warehoused while they wait for the next step in their care journey. What’s even worse is that we subject these seniors to a high risk of iatrogenesis. They fall. They develop hospital-acquired infections. They get deconditioned. They get depressed. Seniors with dementia suffer accelerated cognitive decline. The list goes on and on. It is a national embarrassment. Who wants to live in a hospital?
The other major consequence of this misalignment is that hospitals become full – and even overfull. Emergency Departments across the country are congested with long wait times for everyone. Elective surgeries get cancelled because there are no beds to put patients in afterwards. Tertiary care centres that offer highly specialized and complex care for regional populations can’t accept patients from smaller regional partner hospitals because they are full. Patients are put into “overcapacity” beds – hallways, alcoves, nooks and crannies and even closets sometimes. We call this situation and the slowdown in patient flow it causes, “Code Gridlock“. Increasingly, Code Gridlock is becoming the norm in hospitals across Canada.
Canadians are among the highest Emergency Department users in the industrialized world. (Osborn et al; 0.1377/hlthaff.2014.0947 HEALTH AFFAIRS 33, NO. 12 (2014)). At first glance, it might be tempting to say, “Hey, we just have to keep all these people with colds and minor ailments out of the ER – that will fix the overcrowding problem”. While it may be true that people with minor ailments should do their best to seek care elsewhere, doing so will not fix ER or hospital overcrowding nor will it fix what is wrong with seniors care. Having said that…. when seniors with multiple chronic illnesses come to the ER because there is nowhere else for them to go for their important but non-acute medical issue, they tend to be admitted to hospital more than they should. Why? Because that’s where the specialists are. Because that’s how you can get diagnostic testing fastest and easiest. One can understand the logic and the motivation. But that’s not what hospitals should be for. And when seniors get admitted to hospital, things often start to go wrong. Hospitals are toxic places for seniors who are not acutely ill. This is a tragically under appreciated fact.
We need to build a community-based infrastructure that provides access to teams that include primary care providers and specialists, rapid access to diagnostic testing and social services support. We need to reverse the trend of increasing poverty in seniors so that they don’t have to choose between their medications and food. We need to invest in affordable, safe housing for seniors. In short – we need to create a society that celebrates the triumph of aging – and that provides the care needed for seniors to age well at home. Chronic disease management doesn’t belong in the Emergency Department and on hospital wards. It belongs in the community where it can be delivered with higher quality, lower cost and better safety and efficacy.
In Canada right now, we have pockets of excellence and pockets of desperation. Only a national strategy that establishes a culture of relentless quality improvement through national standards and strategic, smart investments can get us where we need to go. How can we ever hope to improve without a plan? A national seniors strategy can leverage economy-of-scale efficiencies and help to share and scale-up successes. It can help to incorporate the social determinants of health and explore how tax policy and social programs can best be used to support seniors so they can age well at home.
Our partnerships with CARP, the Legion and The Canadian Labour Congress – among many others – reflects a growing consensus amongst a wide variety of stakeholders representing millions of Canadians. We need a national seniors strategy. All federal parties need to make this a key plank in their 2015 election platform.
I love CPAC like other people love the Weather Channel. To me, the discussions that happen behind the scenes – at the committee level and at other venues – is where opinions are formed and policy is generated.
Here are a couple of my recent CPAC “moments”.
The first is a media scrum at the Supreme Court – scroll ahead to 12:55. This was a piece on the landmark challenge to the law banning physician-assisted suicide.
The second is my appearance at the pre-budget consultations by the Parliamentary Committee on Finance (scroll ahead to 99:55 to hear my presentation and then you can see me field questions afterwards).
Do we actually influence policy makers? I like to hope so. Even if it is subtle. One must believe that they listen when we speak honestly and with authenticity on things that matter to Canadians.
One of the great things about this job is that I get to do a lot of travel across Canada and a chance to meet lots of fantastic people as we share ideas and experiences.
This week, it was Vancouver, and it was lovely. The sun was out, the weather was warm, and I had a blast.
My first stop was the University of British Columbia, where I met with Dr. Gavin Stuart, the Dean of Medicine.
Dr. Stuart is in his 11th year as Dean – he is well-seasoned, wise, and a highly respected leader in BC as well as nationally and internationally. We talked a lot about medical education – particularly the new distributive model in BC (70% of BC doctors are now on faculty!) and the collective effort to improve access to care in rural and remote communities. We also talked a lot about medical professionalism; how our professionalism must extend beyond advocacy for our individual patients and more into advocacy for the system, for our communities and our country.
My next stop was the Vancouver Sun, where I met with members of the editorial board.
We had a long, free-ranging discussion about seniors care. I told them the CMA intended to make seniors care a ballot issue in the next federal election. We need a plan, involving all levels of government, and with Ottawa taking the lead. The Sun was supportive, and published this editorial yesterday:
Osler said that the practice of medicine was an art, not a trade; a calling, not a business. Although Osler has made his mark in so many ways, what inspires me most from his teachings is the fact that he always sought to bring medical education to the bedside. He recognized the need to connect with patients at a human, personal level – to truly understand our patients and their lives so that we can contextualize their illnesses and therefore serve them best.
I spoke about our seniors strategy and about our civic duty, as professionals, to work toward a better system; to be leaders in society and to keep our patients at the centre of everything we do and everything we stand for.
One of the best parts of the evening was the chance to reconnect with my Dal Meds 1992 classmates, Drs. Scott MacDonald and Beata Byczko, who came out to hear the lecture!
Thanks to Vancouver Medical Association President Jim Busser and all who helped to make the evening so special!
The next morning, I was off to visit with the Board of Directors of Doctors of BC (formerly the British Columbia Medical Association).
We had a great discussion! Lots of alignments between Doctors of BC and the CMA. I emphasized how important the PTMAs are to CMA and that our strategy of engagement with the provincial and territorial medical associations meant a culture of continuous communication and feedback. Together, we are so much better than the sum of our parts.
Thank you, Vancouver!
Many thanks to Liberal Leader Justin Trudeau and his staff for sitting down with us to discuss the urgent need to improve seniors care in Canada. Mr. Trudeau has committed to calling a First Ministers’ conference should his party be elected to government, and he agreed that seniors care is too important not to be on the agenda.