Return to Weeneebayko- a proposal by Dr. Bikrampal Sidhu that respects the local community and its people.
When I was a medical student at Queen’s University (1977-81) I did a rotation as a clinical clerk in Moose Factory. It was my first exposure to the life of people in the true North and it was an eye opener. Queen’s students and faculty provided local care and even travelled further north by helicopter to pick up patients to transport south. We were in the community (not integrated but present). The realities of implementing a care plan or making a diagnosis were very clear. As in many global health postings, I left humbled and reminded that modern medicine is hard to practice without certain tools and medicines, which are not universally available. Over the years some doctors have continued to travel to Moose Factory but there has been an erosion in this and an increase in the reverse travel (patients coming to Kingston). A recent Medical Grand Rounds by one of our new endocrinologists, Dr. Bikram Sidhu, transported me back to the shores of James Bay and made me rethink our approach to providing specialist care for the people of Weeneebayko. This blog includes an introduction by me followed by Bikram’s ideas for reinvigorating our longstanding relationship with Weeneebayko.
Dr. Sidhu’s piece is very consistent with the Truth and Reconciliation Commission’s (TRC) report. The TRC essentially noted that lack of historical knowledge about the injustices of our treatment of First Nations, Inuit, and Métis peoples has had adverse consequences and requires an active remedy. As TRC Chair Justice Murray Sinclair stated, “Education, or what passed for it, got us into this situation, and education is what will lead us out.In this case we need to be educated about the lack of a patient centered approach to care in the north.This blog is a humbling reminder we have work to do!
First, a little cartography for those who have not journeyed north and may wonder where is Moose Factory and how does one get there. It is telling when I asked Apple Maps the distance between Kingston and Moose Factory it returns a message “Directions are not available between these locations”…and that seems to be the problem!
Guest blog by Dr. Bikrampal Sidhu MD FRCPC, an Assistant Professor and specialist in Endocrinology and Diabetes at Kingston Health Sciences Centre and Queen’s University.
Bikram completed his bachelor’s degree in mathematics and a master’s degree in physiology at the University of Toronto before attending medical school at the University of Calgary. He subsequently completed Internal Medicine and Endocrinology residency programs at the University of Toronto prior to starting practice. Bikram has strong interests in teaching and education, having recently completed a Master’s in Health Professions Education through Maastricht University in the Netherlands. His clinical interests are in all areas of Endocrinology with a focus on diabetes in pregnancy and transgender health. He is passionate about these and other special populations and reducing healthcare-related inequity.
In society as a whole, the topics of inequity and systemic discrimination have been gradually increasing in importance. Over the past few weeks and months, these topics have exploded and become front page news and dinner time conversation. As a microcosm of society, we in healthcare have been gradually increasing in our own discussion of the very same topics, and I would hope that it explodes in the same way. When I presented Medical Grand Rounds on ‘Using Old and New Care Models to Address Inequity’, I had no way of knowing the events that were about to unfold in broader society. We should seize this opportunity to make these issues front page news in healthcare as well. What follows is a summary of one part of that presentation that I think is especially pertinent today.
In medicine, we take for granted that our underlying purpose in everything we do is to improve the health of our patients in some way. We deploy evidence-based tests, and prescribe our best medicines. We educate new generations of doctors about our methods. We research to improve our tools. We innovate continuously and patients get better.
However, if we look closely at who we serve, we find that not everyone has the same outcomes or fits the curve nicely. We have groups of patients who do well, and groups that don’t do as well. And when we look closely at why there are ‘have-nots’, we often find barriers preventing them from accessing the standard of care. When innovations improve the outcomes of society, they often respect those same barriers – they improve the outcomes of those that were already doing well, and remain inaccessible to those that were doing poorly. Innovation can worsen inequity.
Figure. We often act as though our population of patients are distributed as a bell-curve as in panel A. As we innovate, the curve shifts to the right. However, the curve is often shaped like panel B, and innovations can sometimes only be accessible to those who are already in the ‘better-off’ group. Panel C showsa major finding of the LEADER trial, a15% reduction in all-cause mortality with liraglutide, a drug used to treat type II diabetes.Butliraglutide(Victoza)costs over $3500 per year in Canada, and many times more than that in the US.Applying this innovation to our population in panel B will likely worsen inequity(i.e. the left population group would not improve and the right population group wouldfurtherimprove, widening the chasm).
If we want to address inequity in medicine, we need to examine in depth the care of people who aren’t achieving optimal outcomes, and find out what the barriers in that population are. We then need to make sure that we target innovations and solutions directly at those barriers. In Canada such an examination turns our eyes northward.
In diabetes (and many other diseases), one population that frequently is identified as having poor health outcomes is Indigenous people. The First Nations and Diabetes in Ontario atlas produced by ICES provides robust data on the deficits in access to primary care, specialist care, glycemic control, complication screening, and vascular outcomes across Indigenous populations in Ontario (see Figure below).
Figure. Health care disparities for First Nation people in Ontario. Theabove charts from the ICES atlas provide a small sample of the differences in outcomes. InPanel A,there is an 123% increase in probability of end stage renal disease (ESRD) in First Nations people vs all other people in Ontario. ESRD;Panel Bshows a 350% increase in rates of limb amputation; Panel Cshows that First Nations people worse glycemic control (more people with hemoglobin A1C levels over 7.1) than other people in Ontario.Panel Dshows that First Nations people have decreased access to medical specialists, which is just one of many probable contributors to the outcome disparity (and one area in which Queen’s Department of Medicine can help)..
At Queen’s University, we service a predominantly Indigenous population in the Weeneebayko Area (Moose Factory and surrounding communities), see map above. This relationship started with the Department of Pediatrics at Queen’s University and spread through the rest of the Faculty of Health Sciences. Over the years, the exact nature of the relationship has evolved, but at one time, it included a regular charter taking physicians from Kingston to Moose Factory to provide clinical care. Currently, the majority of our care is provided with the assistance of a daily charter bringing patients from there to our regularly scheduled clinics in Kingston.
A map of the Weeneebayko Health Region, with coastal (fly-in) communities of Fort Albany, Kashechewan, Attawapiskat, and Peawanuck labelled. Specialty care is provided in Kingston and Timmins primarily when services are not available in Moose Factory.
The original Moose Factory Indian Hospital in Moose Factory, Ontario.
In our care for the patients of the Weeneebayko area, we have gradually drifted from a patient-centered model to a physician centered one. As physicians in Kingston, we are now almost unburdened by patients from Moose Factory, because there exists a mechanism for them to be fit into our existing clinic schedules. We have created a system that requires the patient to bend to our needs, and implicitly, if unintentionally, values physician time as infinitely more valuable than patient time.
Using this one metric, we can even try to quantify exactly how “patient-centered” our current approach is. When I see 20 patients from Moose Factory in my clinic at Hotel Dieu Hospital, it requires about 10 hours of my time to provide that clinical care. Each individual patient on the other hand, takes perhaps 40 hours out of their life; this includes the time to fly down to Kingston the day before the appointment, and back the day after. Depending on how far they live from Moosonee, there may be up to a whole day more added on to that. That is 40 hours away from their home, family, livelihood, culture and friends. From the ‘time spent’ perspective, this model requires 10 physician-hours and 800 patient-hours for these 20 patient visits. If, on the other hand, I travel to Moose Factory for a day to see those same 20 patients, the math is substantially different. I would spend 36 hours away from my home, and each individual patient may spend about 4 hours on their appointment. For the same clinical care, my invested time has increased by 26 hours, but patient time is down 720 hours.
Going beyond this crude but objective metric, there are many other aspects of an on-site clinic which are beneficial to both us and the patient. Here at KHSC we have known clinical capacity issues, in part due to physical space. Every time a patient can be seen in a place that isn’t a “usual” clinic, we have decreased the demand on those limited spaces. There are measurable economic harms to having employed or employable persons missing 2-3 days for each specialist appointment. Related to that, there are real impacts on a person’s ability to maintain employment in those situations as well. For our obstetric patients, they may spend 2-3 weeks in Kingston over the course of their pregnancy for clinical care, and have to spend additional time here post-partum before they can return to their communities. At a time in their life that is difficult, we are asking pregnant and peripartum patients to spend days and weeks away from their support systems. Lastly, making the effort to travel to patients’ home communities is a gesture of genuine caring about the health of that community, a sign of respect for the community, as well as for the individual patient. Going there allows us to interact with and support the healthcare staff who are there. The trip north gives us the opportunity to generate capacity and expertise locally through education. In the long-term, this should decrease the demand on our services altogether.
A return to Weeneebayko is only one small step for each of our divisions. And we shouldn’t stop there because it is unlikely to completely solve the issue. As long as it is our responsibility to provide specialty care to this remote region, we should be continually re-evaluating disparities, inequities and barriers to access to care. That is why in the case of diabetes, we have developed a proposal for a complete remote diabetes program that includes on site clinics, conventional telehealth, text-based follow-up (using eConsult as a follow-up tool), education rounds, and case conferences. We hope that a model like this will have aspects that work for each individual patient, and aspects that improve local capacity and expertise. In the long-term, it may serve as a model for how a satellite multidisciplinary specialty clinic or division can be run for remote populations.
Figure. One example of a complete remote diabetes program leveraging multiple technologies to minimize patient travel time while improving local capacity and expertise through variable levels of support for different patients. In this model, the most complex patients may be seen in the on-site clinics, and then, in decreasing order of severity, by conventional telemedicine, virtual case conferences, or e-consultation.
The solutions and care models that we are working on for the Weeneebayko area are not necessarily going to be the optimal solution for other populations, or even other specialties. However, they do illustrate the importance of patient-centeredness in clinical care models. Closer to home, Dr. Appireddy has been doing great work in showing how direct to consumer telehealth saves money for both patients and the system, increases capacity, increases patient satisfaction, and doesn’t sacrifice quality care. Another clinical care model we are trying out is a Nurse Practitioner led diabetes clinic for patients without a primary care practitioner. This should remove pressure from walk-in clinics and urgent care centres, while improving timeliness of guideline-based diabetes care and hopefully decreasing admissions to hospital.
Fundamentally, the practice of medicine is meant to be in the service of our patients. I hope that readers will agree that the idea that clinical work requires a patient to come to a doctor to be assessed in some specific physical space is outdated. If we are to be patient-centered practitioners showing that we truly value our patients, we need to go to them. And for us at Queen’s University, that means returning to Weeneebayko.
Green ME, Jones CR, Walker JD, Shah BR, Jacklin K, Slater M, Frymire E, eds. First Nations and Diabetes in Ontario.Toronto, ON: ICES; 2019.
Marso SP, et al. Liraglutide and Cardiovascular Outcomes in Type 2 Diabetes. N Engl J Med. 2016;375:311-22.
Appireddy , Sana Khan , Chad Leaver , Cally Martin , Albert Jin , Bryce A Durafourt , Stephen L Archer Home Virtual Visits for Outpatient Follow-Up Stroke Care: Cross-Sectional Study J Med Internet Res. 2019 Oct 7;21(10):e13734. doi: 10.2196/13734.