UWOMJ
the university of western
ontario medical journal
Volume 86, Issue 2, Fall 2017
www.uwomj.com
The University of Western Ontar-
io Medical Journal (UWOMJ) is a
student-run journal and publish-
es themed issues biannually as
well as an online issue focused on
case reports. Established in 1930,
the UWOMJ provides a forum for
original articles, review articles,
and commentaries on topics relat-
ed to medicine and healthcare. All
articles are authored by clinical or
healthcare-research trainees, re-
viewed for accuracy by faculty that
specialize in the relevant areas, and
peer reviewed by a team of students.
Our interdisciplinary readership in-
cludes students, medical residents,
and faculty members.
We are financed & managed inde-
pendently. Any opinions expressed
in this journal represent the opinions
of the authors and do not necessarily
reflect the views of the editorial team
or the Schulich School of Medicine &
Dentistry, our affiliated institution.
The UWOMJ is published in London,
Ontario, Canada. Please visit us on-
line at www.uwomj.ca or contact us at
uwomj@meds.uwo.ca
UWOMJ 86:2 | Fall 2017 Page 1
table of contents
op-ed
5 Letter from the dean
Michael J Strong, MD, FRCPC, FAAN, FCAHS
original articles
6 Indigenous access barriers to health care services in London, Ontario: The Engaging for
Change Improving Health Services for Indigenous Peoples qualitative study
Stephanie McConkey
Faculty Reviewer: Lloy Wylie, PhD, MA (Department of Psychiatry)
9 Collegiality and career success: How one’s medical school learning environment can affect
one’s sense of personal and professional fulfillment decades after graduation
Dr Gerald Schneiderman, MD (Class of 1958), PsychD, FRCPC, DLFAPA, DFCPA
13 Collaborative care models for integrating mental health and primary care: A policy overview
Rachelle Maskell, Anna Rudkovska, Marisa Kfrerer, Shannon Sibbald
Faculty Reviewer: Gerald McKinley, PhD (Pathology and Laboratory Medicine)
commentary
16 Racing for accessibility of a life-saving drug: A timeline of naloxone’s changing status in the
midst of the opioid crisis
Sandra Botros
Faculty Reviewer: Amardeep Thind MD, PhD (Epidemiology and Biostatistics)
18 Doctors without bricks (and mortar): Akira and the emergence of mobile health services
Alistair D Scott
Faculty Reviewer: Robert John Petrella, MD, PhD, FACSM, FCFP (Department of Famil Med-
icine)
20 Availability of novel contraceptive methods in Canada
Polly Tsybina, Kyle Canton
Faculty Reviewer: Shannon Arntfield, MD, MSc, FRCSC (Department of Obstetrics and Gyne-
cology)
feature articles
22 Applying health promotion theories to improve depressive symptoms through exercise
Dor David Abelman, Andrew Daniel Hanna
Faculty Reviewer: Jennifer D Irwin, PhD, MA, BA (School of Health Studies)
25 What does ‘holism’ mean in Indigenous mental health? A review of the literature and sugges-
tions for healthcare professionals
Ranjana Bhattacharjee, Alana Maltby
Faculty Reviewer: Piotr Wilk (Department of Epidemiology & Biostatistics), Martin Cooke
(Department of Sociology & Legal Studies, University of Waterloo)
28 The detrimental effects of obstetric evacuation on Aboriginal women’s health
Ann Marie Corrado
Faculty Reviewer: Debbie Laliberte Rudman, PhD, OT Reg. (Ont.) (School of Occupational
Therapy)
table of contents UWOMJ
the university of western
30 The ethical concerns of physician recruitment from Africa to the global North
Ann Marie Corrado ontario medical journal
Faculty Reviewer: Ken Kirkwood, PhD (School of Health Studies)
Volume 86, Issue 2, Fall 2017
www.uwomj.com
32 Moral distress in health care professionals
Ann Marie Corrado, Monica L. Molinaro
Faculty Reviewer: Sandy DeLuca, PhD, RN (Arthur Labatt Family School of Nursing)

35 Healthcare systems within the Middle East

Elizabeth Dent, Damilola Toki, Natalie Dupuis, Josiah Marquis, Tharmitha Suyeshkumar,
Meriem Benlamri
Faculty Reviewer: Lloy Wylie, PhD, MA (Department of Psychiatry)

37 The application of quality improvement methodologies in surgery

Stephanie Fong
Faculty Reviewer: Sayra Cristancho, PhD (Centre for Education Research & Innovation)

40 Why can’t patients last the wait? Decreasing substance abuse treatment waiting list attrition
Nicole A. Guitar
Faculty Reviewer: John Campbell, PhD (Department of Psychology)

42 Vicarious trauma and secondary traumatic stress in health care professionals

Nicole A. Guitar, Monica L. Molinaro
Faculty Reviewer: Paul Frewen, PhD (Department of Psychology)

44 Parsing Anhedonia: a reverse-translational strategy for treatment of anhedonia in clinical

populations and potential implications of conditioned motivators
Roger Hudson
Faculty Reviewer: Steven Laviolette, PhD, (Department of Anatomy and Cell Biology)

48 Wait times for psychiatric care in Ontario

Rachel Loebach, Sasha Ayoubzadeh
Faculty Reviewer: Javeed Sukhera, MD, FRCPC (Department of Psychiatry)

51 Medical smartphone applications: A new and innovative way to manage health conditions
from the palm of your hand
Marcello G Masciantonio, Aneta A Surmanski
Faculty Reviewer: Christopher J Licskai, BSc, MD, FRCPC (Department of Medicine, Division
of Respirology)

54 The current state of Health Links

Rachelle Maskell, Connor Cleary, Keri Selkirk, Shannon Sibbald
Faculty Reviewer: Amanda Terry, PhD (Department of Family Medicine)

57 Approaches to incorporating indigenous health into the Canadian medical school curriculum
Danielle Robinson, Chowdhury Anika Saiva, Purathani Shanmuganathan
Faculty Reviewer: Lloy Wylie PhD, MA (Department of Psychiatry)

60 Conservative management strategies to mitigate the increasing burden of osteoarthritis on

the healthcare system
James J Young
Faculty Reviewer: Bert M Chesworth, BA, BScPT, MClScPT, PhD (School of Physiotherapy)

UWOMJ 86:2 | Fall 2017 Page 2
UWOMJ
the university of western
ontario medical journal
Volume 86, Issue 2, Fall 2017
www.uwomj.com
UWOMJ 86:2 | Fall 2017 Page 3
table of contents
departmental articles
62 Poverty: A clinical instrument for family physicians
Gayathri Sivakumar, Brandon Chau
Faculty Reviewer: Thomas Freeman, MD, MClSc, CCFP, FCFP (Department of Family Medi-
cine)
65 Radiology wait times: Impact on patient care and potential solutions
Logan Van Nynatten, Ariel Gershon
Faculty Reviewer: Ilanit Ben-Nachum, MD (Department of Medical Imaging)
67 Evaluation of supervised injection facilities as an ethically sound approach to treatment of
injection drug abuse
Katherine Fleshner, Matthew Greenacre
Faculty Reviewer: Jacob Shelley, LLB, LLM, SJD(c) (Faculty of Law)
70 An analysis of the French healthcare system in the context of geriatric care: how does Canada
compare and what can we learn
Hong Yu (Andrew) Su, Lilian Jade Robinson
Faculty Reviewer: Monidipa Dasgupta, MD, FRCPC (Division of Geriatric Medicine)
73 ECT: examining a controversial therapy in the armamentarium of psychiatry
Nirushan Puvanenthirarajah, Asma Amir Ali
Faculty Reviewer: Shelley McKellar PhD (Department of History)
76 Machine Learning in Medicine
Chloe Gui , Victoria Chan
Faculty Reviewer: Daniel J. Lizotte, MSc, PhD (Department of Computer Science)
79 The complexity of cross-sector healthcare teams: An interview with Dr Shannon Sibbald
Alice Yi, Dino D’Andrea
Faculty Reviewer: Shannon L Sibbald, PhD (Department of Family Medicine)
81 A series of unfortunate events: How should a health system react after preventable medical
errors?
Jamie Riggs, Carlos Muzlera
Faculty Reviewer: Merrick Zwarenstein, MBBCh, Msc, PhD (Department of Family Medicine)
84 OECD single-payer policy review
Adam Beswick
Faculty Reviewer: Kelly K Anderson, PhD (Department of Epidemiology and Biostatistics)
86 Chikungunya virus in Canada: A case report highlighting the need for increased global health
education
Herman Bami, Jason L Elzinga
Faculty Reviewer: Javeed Sukhera, HBSc, MD, DABPN, FRCSC (Department of Psychiatry)
editorial team
executive team
UWOMJ
the university of western
ontario medical journal
editor in chief Craig Olmstead (Meds 2017)
Volume 86, Issue 2, Fall 2017
www.uwomj.com
Ramona Neferu (Meds 2018)
senior associate editors Alexander Levit (MD/PhD 2020)

Amanda Oakie (PhD 2018)

junior associate editors Andrew Namasivayam (Meds 2019)
Charles Yin (MD/PhD 2021)

senior blog editor Robert Bobotsis (Meds 2018)

junior blog editor Zarina Markova (Meds 2019)
senior financial officer Robbie Sparrow (Meds 2019)
junior financial officer Dino D’Andrea (Meds 2020)
Alice Yi (Meds 2019)
layout managers Mark Krongold (Meds 2019)
Sarah Cocco (Meds 2021)
Claire Browne (Meds 2020)
it director Meagan Wiederman (MSc 2019)
departmental editors
Brandon Chau (Meds 2018)
clinical procedures Gaya Sivakumar (Meds 2020)
Ariel Gershion (Meds 2019)
diagnostic review Logan Van Nynatten (Meds 2020)
Cover Art: Canadian Healthcare
System Symptoms by Richard
Ying Yu
Description: The Canadian Health-
care system is an efficient system
that provides care for its patients.
However, there are still many as-
pects of it that need to be addressed
and improved, including Indigenous
health, mental health, long wait
times, and the current ongoing opi-
oid crisis. I wanted to draw a cartoon
that could encapsulate these broad
aspects that need to be improved
in a simple picture with minimal
clutter. I decided that a sick Can-
ada could represent that and the
Schulich stethoscope represents our
important role in addressing these
heath care disparities.

Matthew Greenacre (Meds 2019)

ethics & law Katherine Fleshner (Meds 2020)

Cory Lefebvre (MD/PhD 2022)

health economics Adam Beswick (Meds 2020)

Andrew Su (Meds 2019)

health promotion Lily Robinson (Meds 2020)

Nirushan Puvanenthirarajah (Meds 2020)

history of medicine Asma Amir Ali (Meds 2019)

Victoria Chan (Meds 2019)

medicine & technology Chloe Gui (Meds 2020)

Alice Yi (Meds 2019)

profiles Dino D’Andrea (Meds 2020)

Carlos Muzlera (Meds 2019)

thinking on your feet Jamie Riggs (Meds 2020)

Jason Elzinga (Meds 2019)

zebra files Herman Bami (Meds 2020)

UWOMJ 86:2 | Fall 2017 Page 4

op-ed

Letter from the Dean

It is at times difficult to appreciate the full spectrum in a manner that ensures excellent healthcare for Canadians
of knowledge translation. The CIHR considers knowledge with cost containment. It would be fair to say that innova-
translation to reflect the iterative process that includes syn- tions brought into the healthcare arena today rarely are less
thesis, dissemination, exchange and the ethically sound ap- expensive than their predecessors and indeed many of the
plication of knowledge to improve the health of Canadians. more complex treatments for previously refractory diseases
Knowledge Translation Canada, a network of Canadian carry a tremendous financial cost. It will be up to this next
experts in knowledge translation, defines this as one of the generation of healthcare practitioners, including yourselves,
greatest challenges in healthcare. They have synthesized this to be able to critically appraise the literature of these advanc-
to reflect the gap in applying the results of health research to es and then help to influence not only their use at the bedside,
the patient bedside. This is often called the translational gap but how that are integrated into a much broader Canadian
and has been an area of great discourse over the last many healthcare milieu.
years. It is often suggested that the clinician scientist is criti- The UWO Medical Journal has a long and rich tradition
cal to the closing of this gap and as such, it is the gradual de- of helping to foster the development of this skill set. Written
cline in the number of clinician scientists being trained that and supported by students, often in the early stages of their
is viewed as one of the greatest risks for knowledge transla- career, this is an inspiring effort. I would encourage you to
tion. It is a gap that we as a medical school have taken a lead consider contributing to this journal by submitting articles
role in attempting to understand and then rectify, a role that which address this issue of knowledge translation. Not only is
has led to the generation of Canadian consensus recommen- this a great benefit to your colleagues, but the exercise of un-
dations for the training of clinician scientists. While these dergoing peer review of manuscripts can be richly rewarding.
recommendations cover a broad range of training paradigms, At a time when all aspects of science are under greater
the goal is clearly to improve the health of Canadians through scrutiny, your ability to defend your decisions and partic-
not only the genesis of new knowledge but its application at ularly those that lead to alterations in the therapy of your
the bedside. In this light, it truly is the responsibility of all patients, will be critical. The UWO Medical Journal is a key
clinicians to understand knowledge translation and to apply piece of this.
its principles in patient management.
Many would argue that the existing definitions of knowl-
edge translation may be somewhat restrictive. Increasingly, Michael J Strong, MD, FRCPC, FAAN, FCAHS
as we understand the complex relationship between health Dean, Schulich School of Medicine & Dentistry
outcomes and fundamental cellular or molecular mecha- Distinguished University Professor
nisms of disease, the ability to effectively communicate our
understanding of the disease process and then apply this to
the bedside has become equally as challenging and complex.
As we must move increasingly towards cost containment
across virtually all developed nations who expend a signif-
icant proportion of their gross national product on health
care, it is critical that the next generation of medical leaders
be understanding of the barriers to knowledge translation
and how overcoming these can improve health outcomes. As
individual clinicians and as members of health care teams, it
will fall increasingly to us to ensure that this knowledge is
used to ensure a sustainable healthcare system. Quite simply
put, the health care system in which we exist currently is not
sustainable in its current form. It will be for your generation
of health care providers to have a critical understanding of
not only disease processes but also to be able to critically ap-
praise biomedical innovations and emerging healthcare prac-
tices. It will fall to you to then integrate this understanding

UWOMJ 86:2 | Fall 2017 Page 5

original article
Indigenous access barriers to health
care services in London, Ontario
The Engaging for Change Improving Health Services for Indigenous Peoples qualitative study
Stephanie McConkey
Faculty Reviewer: Lloy Wylie, PhD, MA (Department of Psychiatry)
abstract
Introduction: Indigenous peoples in Canada suffer higher
rates of health inequalities and encounter a number of health
services access barriers when compared to their non-Indige-
nous counterparts. Indigenous peoples experience social and
economic challenges, cultural barriers, and discrimination when
accessing mainstream health services.
Methods: In London, Ontario, 21 interviews and 2 focus
groups (n = 25) with service providers were completed, each
session spanning approximately 1 to 1.5 hours. Interviews were
voice recorded and transcribed verbatim. Themes were identi-
fied using NVIVO 10 software.
Findings: Approximately 2 to 5% of clients are Indigenous
in hospital-based services. There are a number of social factors
that influence whether Indigenous peoples access health ser-
vices. Indigenous peoples do not have access to adequate pain
medications because physicians are reluctant to provide Indige-
nous patients with pain medications due to common perceptions
of addiction. Indigenous peoples also have barriers accessing a
family physician because physicians are reluctant to take on new
patients with complex health needs.
Conclusion: Systemic discrimination is still alive in the
health care system; therefore, there is a need for cultural safety
training among physicians to increase awareness of access bar-
riers and challenges that many Indigenous patients face when
seeking health care.
introduction
Indigenous peoples (First Nations, Inuit and Métis) face high-
er rates of adverse health issues than non-Indigenous people in
Canada. Despite the high prevalence of respiratory and circulatory
diseases, infectious diseases, injuries, obesity, diabetes, and some
cancers,1 Indigenous peoples do not receive adequate health care
and/or do not like to access conventional medical services because
of common experiences of discrimination and racism, delivery of
poor quality health care, and other access barriers.2-9
Research has shown that Indigenous peoples do use tradition-
al Indigenous approaches to medicine, however, most Indigenous
peoples have to seek conventional medicine because that is all that
they have access to due to issues of funding and availability of these
types of services.7,10
With the increase in urbanization among Canada’s Indige-
nous population, these issues have been more rapidly affecting the
UWOMJ 86:2 | Fall 2017 Page 6
urban Indigenous population. This is problematic because today
more than half of Canada’s Indigenous population live in urban set-
tings.11 A main explanation for the increase in urbanization among
this population is the need to relocate in order to access a range of
health and social services.12 Those that do not relocate into the city
often have to travel far distances to access health and social services
in an urban area.8,13 Unfortunately, there are a number of challenges
that Indigenous peoples face as a result of accessing mainstream
services. Some of these challenges include financial challenges,
transportation barriers, housing, racism and cultural barriers.13 The
primary goal of this study was to identify the main health service
inequalities that Indigenous peoples experience in an urban setting
through exploring the attitudes, knowledge and skills of health care
providers that work in hospital and/or community-based health
centres.
methods
The Engaging for Change: Improving Health Services for Indig-
enous Peoples project received research ethics approval from both
Western University and Lawson Health Research Ethics Boards.
A literature review and discussions with local Indigenous health
leaders were carried out to determine priority health research
areas for the Indigenous population in London, Ontario prior to
commencement of qualitative interviews with health care practi-
tioners. From August 2015 to June 2016, 21 one-on-one interviews
and 2 focus group interviews (2 participants per focus group) were
completed, each interview session spanning approximately 1 to 1.5
hours. Interviewees included physicians, nurses, social workers,
patient navigators, patient experience specialists and individuals in
a leadership position (eg Department Director) working in a range
of health care settings, such as hospitals, community health cen-
tres and specialized clinics. Inclusion criteria for participants were
those working in a health care setting in one of the five priority
services areas (emergency, mental health, maternity, diabetes and
cancer) within the London and surrounding area.
Written consent was obtained prior to commencement of a
structured interview or focus group. All participants were asked
20 in-depth questions regarding their experiences working with
or providing health care to Indigenous peoples. Focus group par-
ticipants would take turns responding to the interview questions.
Questions touched on topics including access barriers, positive and
negative experiences, policies and protocols surrounding Indige-
nous health, and communication, coordination and collaboration
with other local community health and social services. A full-list of
original article
interview questions can be found in Appendix A. Qualitative inter-
views were voice recorded and transcribed verbatim by qualified
research assistants. Afterwards, coding was completed using NVI-
VO 10 Software to identify the main emerging themes.
results
Patient Population
Themes of qualitative interviews identified that hospital based
programs noted that only 2 to 5% of patients and clients were Indig-
enous peoples, however, respondents identified that the percentage
of Indigenous patients was higher in diabetes-related programs.
Additionally, physicians believe that Indigenous peoples do not
properly articulate their health issues to physicians, which could
play a role in the low percentage of Indigenous patients and clients
within the system.
Social Determinants of Health
Health care professionals understood that there are a num-
ber of reasons why Indigenous peoples may be reluctant to ac-
cess health care services. While some physicians did express the
need for patients to take individual responsibility, the majority of
respondents acknowledged the social determinants of health that
may hinder access to health care. Social determinants of health that
were discussed in the interviews included high levels of poverty
and unemployment, low education levels, and other social issues
that may influence an individual’s health and wellbeing. Transpor-
tation to health facilities was believed to be the main access barrier
among Indigenous peoples living in rural and/or remote communi-
ties, such as reserves. For example, one physician responded,
“I would say that people living in the community that don’t and access to follow-up care because there were difficulties
have the resources or the support to come to London. I think
they definitely struggle more with accessing services” (AB10P).
Another commonly emerging theme was that physicians be-
lieved that Indigenous peoples suffer from more co-morbidities
than their non-Indigenous counterparts and admitted that there
may be an issue with physicians being reluctant to take on patients
with complex health care needs. A physician noted,
“so there is a new doc who you know, is setting up a shingle in
town and a new office and they interview patients and they go ‘wow,
you are pretty complicated I don’t really want to get involved with
you’ and so that exacerbates the whole doctor shortage” (H23P).
This finding demonstrates the shortage of family doctors, but
highlights the particular challenges for people with complex health
needs, which is more common among Indigenous peoples.14-16
Racism and Discrimination
A number of participants shared that they were unaware of tra-
ditional Indigenous practices and perspectives of health and well-
being, however they acknowledged that these practices differed
UWOMJ 86:2 | Fall 2017 Page 7
from conventional approaches to medicine. It was also identified
that Indigenous practices and perspectives of health and wellbe-
ing were not valued in the health care system. Findings also sug-
gest that physicians are reluctant to prescribe pain medications to
Indigenous peoples because of common perceptions of addictions
and drug abuse. For example, one physician shared his beliefs about
systematic discrimination within the health care system as,
“I would think that there are, that on our side there are some
frequency of notions that they are all drug seekers. Which clear-
ly isn’t true, but I think that if you lined up 10 patients with
the same condition and how much pain meds would you give
this person if they were Aboriginal, I would bet less, because
the fear would be that they are there looking for pain meds to
abuse or sell, so I think that as a group they are linked” (A04P).
This response signifies that physicians are aware that there are
still discriminatory behaviours among physicians that may affect
how an Indigenous patient is cared for.
Physicians also raised the issue that many of their Indigenous
clients discontinue services. Physicians believe that this theme may
be correlated to poor follow-up and/or lack of appropriate referrals,
however, research has shown that it could be strongly related to the
experiences of discrimination and racism that Indigenous peoples
face within the system.3,7 Another explanation for lack of follow-up
could be jurisdictional challenges. For example,
“I had several unfortunate patient situations when I
worked in the emergency department specific to Aboriginal pa-
tients and that was around getting appropriate follow-up care
in having community care access get onto the reserve to pro-
vide care there. There were some barriers around that” (A03L).
This response provides evidence that there are jurisdictional
issues that Indigenous peoples living on-reserve face which neg-
atively influences the types of follow-up care they have access to.
discussion
The findings from this research show that there is a high need
for mandatory Indigenous cultural competency and safety training
among all providers working in the health care system so that they
will be able to provide more culturally relevant and safe care. Re-
search has shown that there is a lack of culturally appropriate health
services,4,17-18 and our findings align with research that suggests that
Indigenous peoples are still facing systemic discrimination when
accessing mainstream health care services and programs.3 Racial
misconceptions can strongly influence an individual’s health and
wellbeing, and make them reluctant to access health care as a re-
sult.3-7 Therefore, health provider training should take on the biases
and stereotypes that lead to the provision of poor standards of care
for Indigenous patients. Participation in cultural safety training
would be a means of reducing racist and discriminatory perceptions
original article
about Indigenous peoples that are widespread within the health
care system. Additionally, cultural awareness will be beneficial for
care providers to support their understanding of the different per-
spectives of health and wellbeing among Indigenous peoples. Such
knowledge would facilitate improved patient support and better
communication and coordination with community-based services.
Supports need to be put in place to facilitate access to health
care services. It is clear that transportation is definitely a barrier
to those who do not reside in the city, because reserves do not have
the same structural support that any given city would in regards
to health care. Therefore, individuals need to travel to the city to
get adequate access to health care.8,13 Funding for transportation for
those living in rural settings would provide Indigenous patients and
families the ability to access health services within and out of their
community.
More awareness and communication between hospital pro-
grams and community supports (ie. Southwestern Ontario Aborig-
inal Health Access Centre, N’Amerind Friendship Centre, etc.) are
needed to ensure patients needs are being met and proper referrals
are being completed. Additionally, further research on continuity
of care needs to be done to understand why it is lacking among the
Indigenous population in London, Ontario.
Limitations of this study is that there was a small sample size
(n = 25) and only health care provider perspectives were included in
the research at this time. Additionally, ethnicity data is not collect-
ed in hospital-based services, therefore the number of Indigenous
patients was an estimation based on the respondents’ recollection.
conclusion
In order to improve health access for Indigenous peoples,
health care providers need to be aware of the issues and challeng-
es that many Indigenous peoples have surrounding primary health
care, most importantly the social determinants of health. Physicians
working in diabetes-related services should be aware of the high-
er percentage of Indigenous peoples in these services, and proper
training should take place to ensure cultural needs are being met. It
is evident that racism and discrimination are still alive in the health
care system and it has strong influences on the health and wellbeing
of Indigenous peoples. The next steps for this research is to under-
stand the impact of cultural safety training on health care workers
and to determine what other institutional supports are needed to
transform practice and patient experiences. In addition, the project
aims to understand patient perspectives and needs to identify how
to ensure appropriate care is provided when they access hospital
and community-based programs in London, Ontario.
UWOMJ 86:2 | Fall 2017 Page 8
Appendix A – Engaging For Change: Interview
Questions
1. What is your position in your organization/unit and what type of
services do you provide?
2. Approximately what percentage of your patients/clients are
Aboriginal? Has their numbers changed recently?
3. How would you describe the current condition of Aboriginal
access to health care in your service? Do all Aboriginal groups have
the same level of access? What are the differences?
4. Briefly describe an experience with an Aboriginal patient that
you feel was positive. Do your best to make clean and reflect upon
what you think made it a positive experience.
5. Briefly describe an experience with an Aboriginal patient that
you feel was negative. Do your best to make clean and reflect upon
what you think made it a negative experience.
6. What do you think are the greatest challenges in providing care
to Aboriginal patients?
7. What do you think are the greatest challenges facing Aboriginal
patients?
8. Are their specific services offered to Aboriginal people? Which?
Do you provide culturally appropriate resource materials? System
navigation supports?
9. How do you provide for Aboriginal specific needs (eg. Spiritual
practices etc.) in your institution (in the health care system)?
10. Are you aware of alternative healing practices that Aboriginal
people use? If yes, are systems in place to facilitate incorporation
of alternative practices into patient care plans?
11. What are some ways you think would ensure the provision of
culturally sensitive services for Aboriginal patients?
12. What supports would you need to help you provide more cul-
turally sensitive services for Aboriginal patients?
13. Are there Aboriginal employees in your organization?
14. Are your employees skilled in intercultural communication, Ab-
original cultural sensitivity? Do you provide on-the-job training in
cultural competence/sensitivity/safety? If yes, how often?
15. Are you aware of any policies/protocols for facilitating inclu-
sion of Aboriginal perspectives in or improving access to health
services?
16. What types of policies/protocols could improve access and
experiences of Aboriginal patients in the health care system?
17. Are you aware of community resources that could enhance both
understanding of and service delivery with Aboriginal patients?
18. Which organizations do you collaborate with around health
service provision for Aboriginal patients? Around referrals and
discharge?
19. Do you think there is a need for improving coordination be-
tween your program and other services? What are some concrete
examples of coordination that would improve continuity of care?
20. Does your institution engage the Aboriginal population for pro-
gram feedback? If so, how is this done?
original article

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Chapter 1, The Urbanization of Aboriginal Populations in Canada; p.
32-43.
12. Newhouse D, Peters EJ. Not strangers in these parts: Urban Aboriginal
peoples. Policy Research Initiative; 2003.
13. Place J. The health of Aboriginal people residing in urban areas. Prince
George, BC: National Collaborating Centre for Aboriginal Health; 2012.
14. Gracey M, King M. Indigenous health part 1: determinants and disease
patterns. The Lancet. 2009 Jul 10;374(9683):65-75.
15. First Nations Information Governance Centre (FNIGC). First Nations
Regional Health Survey (RHS) 2008/10: National report on adults,
youth and children living in First Nations communities. Ottawa:
FNIGC; 2012.
16. Ring I, Brown N. The health status of indigenous peoples and others.
BMJ. 2003 Aug 23;327(7412):404-5.
17. Browne AJ, Smye V. A post-colonial analysis of healthcare discourses
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18. Browne AJ, Smye VL, Varcoe C. The relevance of postcolonial theoret-
ical perspectives to research in Aboriginal health. Canadian Journal of
Nursing Research. 2005 Dec;37(4):16-37.

UWOMJ 86:2 | Fall 2017 Page 9

original article
Collegiality and career success
How one’s medical school learning environment can affect one’s sense of personal and pro-
fessional fulfillment decades after graduation
Dr Gerald Schneiderman, MD (Class of 1958), PsychD, FRCPC, DLFAPA, DFCPA
abstract
Success in one’s career and life are subjectively deter-
mined. However, the presence or absence of regrets are good
indicia of one’s sense of fulfillment. In the context of profes-
sional education, “learning environment” is a key predictor of
one’s future sense of fulfillment. Collegiality, mutual support,
and decency towards one’s classmates were considered by the
author in this small-scale study to be important predictors of
one’s later success in life and medical practice.
introduction
Various large-scale retrospective studies have considered the
relationship between academic success and subsequent career suc-
cess. The opinion that success in one’s career is directly linked to
one’s academic achievement fails to account for a far more import-
ant predictor: the individual’s learning environment. Learning en-
vironments that foster collegiality and decency is a key predictor of
career success. In this small-scale study, the author surveyed 33 of
his classmates from the medical school class of 1958, The University
of Western Ontario. In the author’s own experience, his classmates
fostered a positive learning environment defined by decency, colle-
giality, and valuing the collective over the individual. More than five
decades later, the author surveyed his classmates, inquiring about
their life and career satisfaction, advice to the younger generation,
and also the presence or absence of regrets. 18 responses were re-
ceived. From the responses, the author illustrates how the collegi-
ality of his classmates continued throughout their lives, leading to
greater success personally and professionally.
background and methodology
Previous studies examining academic achievement and sub-
sequent career satisfaction have emphasized grades and academic
achievement. Wingard and Williamson state, “In medicine many
crucial decisions regarding the physician’s career development are
based on traditional grades that often reflect little other than an
ability to memorize isolated facts. The need to study both grades
and performance is self-evident; the need to rethink the use of
grades for crucial career decisions and training grant awards seems
to be equally evident.”1
The author conducted an email survey of his classmates from
the medical school of The University of Western Ontario more
than five decades after graduation. 33 questionnaires asked the
1958 class:
UWOMJ 86:2 | Fall 2017 Page 10
1. Please describe what your work after studying medicine at West-
ern was like. Did you remain in medicine? If so, did you practise?
Research? Write? What else did you do? Did you receive accolades
and/or awards? Are you willing to share a copy of your most up-to-
date curriculum vitae?
2. Please describe your personal life to the extent that you are
comfortable in doing so. Are you still working, fully retired, or
partially retired? Do you have any relationships or family you wish
to mention? What did you do that “defined” you beyond your work
life (hobbies, passions, pursuits of any kind)?
3. If you were to give advice to your younger self, prior to going to
med-school, what would you say? Would you want your younger
self to know what lay ahead? Or would you want it to remain an
unknown? Is there anything you would want to try to change,
looking back?
18 responses were received, either by email or in hardcopy. Of
those who responded, their answers were detailed, insightful, and
emphasized the value of meaning in life, not just within one’s own
aspirations, but also as a community.
the author’s impressions of the cohort
The author had regarded his classmates as having wanted the
best not just for themselves, but also each other. Collegiality was
at the core of their collective aims. Each of them was ambitious in
their own rights; despite everyone wanting to be singularly out-
standing, such ambitions never undermined the collegiality and
support that they provided one another throughout medical school.
survey results from the author’s medical school
class
The interactions amongst the author’s peers were defined by
sincerity and decency and were aimed at elevating the group as
a whole, rather than individuals at the expense of the group. The
author’s classmates’ values of good will, civility, and collegiality
were subsequently confirmed in their careers and personal lives.
His classmates’ collective answers to the questionnaire, as a whole,
pointed to a broader conclusion beyond any one individual re-
sponse: decency and humanity lead to more fulfilling careers than
selfishness and solitary ambition.
After excluding personal identifying information and person-
al anecdotes (such as shared memories and anecdotes), the author
extracted from the survey responses comments of a more gener-
original article
al nature that addressed each participants’ sense of life and career
success. Some of the responses were provided in response to each
question, but most were provided in the form of narrative respons-
es answering all questions globally. The author considered that
the paucity of regrets is particularly noteworthy. Extracts from the
questionnaire are presented below:
• “To start with, I would not change a thing in my life.”
• “I had a very busy medical and family life and I would
not change any of it. I would even keep my medical school
classmates.”
• “I did enjoy my 30 plus years in practice, but have to admit
I don’t miss it.”
• “I am happily engaged with family and community.”
• “I have no regrets about my career path.”
• “I have lived a happy and blessed life.”
• “I would change nothing about my past. I am satisfied,
happy, with moments of sadness about the passing of time,
and I loved practising medicine.”
• “Advice to the young: Have faith in God; don’t listen to your
agnostic professors. They know very little about life outside
of a university.”
• “Practice virtue; be prudent, be temperate; be just; have
courage; take prudent risks; love people, even the obnoxious
and ignorant. [T]each them to be prudent and loving.”
[complete quote]
• “Greatest virtue: patience – it conquers the world. And be
cause very few others have it, you win out of endurance!”
• “God and faith, with a touch of reason, are not contradictory.”
• “Choices made by current medical school students should be
their own, and not my rose-coloured recollections.”
• “I trust that I am defined as a decent human being, a good
husband, a good father, and a good grandfather.”
• “I try to keep promises that I make and wish to be known as
a reliable, educated and interesting person.”
• “I wish I had learned how to play golf and card games, and in
my academic career, I wish I had written more. Other than
these, I have had a rich life and would not have changed
anything.”
• “Physicians must be prepared to be parts of teams, to never
find the making of money the primary effort, to provide the
appropriate times required to satisfy patients, to easily accept
sending patients to other physicians when he or she is less
aware than others of management of the [patients’] illness, reer success”.2
etc.”
• “I certainly look back and wonder why the hell I didn’t
do more volunteering within the community, province, coun-
try, and the globe, etc.”
• “I have felt very strongly upset in not having joined ‘Doctors
Without Borders’ on the one hand.”
• “I wish I had worked more to help the healthcare in many of
the poor countries.”
• “If you can look out the window and truly enjoy nature, you
are really alive.”
UWOMJ 86:2 | Fall 2017 Page 11
The entirety of the survey pointed to the value that all of my
class placed on helping others. Decency and humanity at the core
of the individual and collective values. No regrets were expressed
regarding the participants’ values of decency, collegiality, and hu-
manity. Indeed, the only regrets expressed were that these doctors
could not have helped others as much as they had already done so.
Figure 1. Word cloud generated from survey response statements.
discussion and conclusion
One’s learning environment is central to his or her later career
satisfaction. In one study of 3,324 Dutch university graduates, the
authors observed that “… high-quality interactions between stu-
dents, their peers, and faculty around intellectually meaningful
subjects provides the most productive gains in terms of students’
learning outcomes.”2 The authors argued that the “… learning en-
vironment increases the motivation of students, which, in turn,
increases their learning outcomes. Learning outcomes show a sig-
nificant relationship with success in the initial phase of graduates’
careers. Furthermore, success in subsequent phases of one’s career
is influenced by experience gained by students during their involve-
ment in extra-curricular activities.”2 The authors concluded that
the “…learning environment is important for students’ learning as
well as their involvement in extra-curricular activities”, and “that
these two elements of university education are determinants of ca-
Each of the 18 responses obtained in the author’s survey
demonstrated the value that the author’s classmates had placed on
helping others. This corresponded with an absence of expressions
of regrets. Many of the author’s classmates had attained and sur-
passed their professional hopes and aspirations. Their work solved
problems in their communities. Many of the author’s classmates
also described deeply meaningful relationships with their fam-
ilies and loved ones. As noted by Schneiderman and Barrera, this
replacement of traditional values with egalitarian values has been
trending in the United States despite the apparent absence of struc-
original article
ture.3 Similarly, the author had previously stated, “choosing a career
in medicine is often rooted not only in a fascination with the human
body and with solving the problems presented by illness or injury
but also by a desire to help others.”4
In this much smaller scale study, the author was of the view
that his classmates went on to enjoy satisfying careers and enriched
lives. Although some expressed sadness over personal losses, none
had regrets about what they valued or how those values would en-
rich their lives in the years that passed.
As with Lee and Ryu, in this analysis, the author considers
pride and regrets to be self-conscious emotions only capable of
qualitatively subjective measurement.5 Despite that some of the au-
thor’s classmates had suffered familial tragedies, or difficult times
in their careers, not a single person expressed any serious regret
about their personal or professional choices.6 The absence of regret,
when considered in the context of the drive for meaning, suggests
to the author that all of his classmates lived lives of deep meaning
and value. A person’s survival in a career, family, or life in general, is
tied strongly to the durability of one’s sense of meaning. Meaning in
life revolves around one’s values.
The author’s view, as informed by his work on the Bereavement
Research Team at the Hospital for Sick Children, is that a person’s
moral values have a strong connection with that person’s sense of
self: when someone’s values are egocentric, failure to attain one’s
egocentric objectives will have a much more devastating effect on
that person’s core identity. This, in turn, can negatively affect one’s
resilience and ability to weather such defeats. On the other hand, as
Wu et al posited: “[t]he existence of a moral compass or an internal
belief system guiding values and ethics is commonly shared among
resilient individuals”.7 Wu et al also observed that, “a study of 121
outpatients diagnosed with depression and/or an anxiety disorder
showed that a low or lack of purpose in life and less frequent physi-
cal exercise were correlated with low resilience, but low spirituality
prevailed as a leading predictor of low resilience”; and “similarly,
purpose in life was a key factor linked to resilience in a study of 259
primary care patients with a history of exposure to a range of severe
traumatic events”.7
Following Wu et al, resilience in the face of difficulties re-
quires a strong sense of purpose, one which affirms itself regular-
ly by humanity and decency.7 In the author’s view, those who live
decently make decisions that are civilized, humane, and generous.
Our actions themselves, in turn, affirm our sense of values: by act-
ing decently, regardless of the outcome, we affirm rather than deny
that which we value; and when our values are affirmed, we grow
stronger and have a greater sense of purpose and accomplishment.
Conversely, when we act only in the interests of ourselves, failure
becomes much more intolerable, and growth is invariably stopped.
Regrets pile up and become shame, shame that we are unable to
part with unless we change our values.
Vermeulen and Schmidt argued that “the quality of the learn-
ing environment cannot express itself directly in the career success
of its graduates. In the final analysis, it must be the behaviour of the
students themselves, brought about by the learning environment,
UWOMJ 86:2 | Fall 2017 Page 12
which leads to superior academic performance and, through this,
to career success.”2 Defining career success is wholly subjective.
Regardless, expressing one’s “regrets” about career choices is a
good measure: a person who has no regrets feels that he or she has
achieved what they wanted to.
If we value decency over ambition, and civility over narcissism,
then events that affirm those values bolster us. It is, of course, im-
portant to one’s mental and emotional health to have ambition and
to enjoy one’s successes. However, if those are our only values, then
failure will not permit growth. Personal growth requires a stable
set of values, and when decency lies at the core of one’s values, one
grows with each act of decency. As we grow, we move away from
shame, away from regret. Like the author’s classmates commented,
people for whom decency and civility are key values, they have no
regrets beyond not having given more to their communities. This is
a very strong and positive affirmation of the learning environment
of the medical school class of ’58 (University of Western Ontario).
acknowledgements
The author thanks Brian Moher for his assistance in preparing
this article.
references
1. Wingard JR, Williamson JW. Grades as predictors of physicians’
career performance: an evaluative literature review. J Med Educ. 1973
Apr;48(4):311-22.
2. Vermeulen L, Schmidt HG. Learning environment, learning process,
academic outcomes and career success of university graduates. Stud
High Educ. 2008 Jul;33(4):431-51.
3. Schneiderman G, Barrera M. Family traditions and generations. Fam
Community Health. 2009 Oct-Dec;32(4):354-7.
4. Schneiderman,G. Doctors Treating Doctors. CPA Bulletin. 2000
Apr;32(2).
5. Lee OE, Ryu S. Effects of pride and regret on geriatric depression: A
cross-cultural study with mixed-methods approaches. Int J Aging
Hum Dev. 2017 Mar;0(0):1-20
6. Schneiderman, G. Coping with Death in the Family, Fourth Edition.
Toronto: Dundurn Press; 1994; page 47.
7. Wu G, Feder A, Cohen H, et al. Understanding resilience. Front Behav
Neurosci. 2013 Feb 15;7:10.
original article
Collaborative care models for integrating
mental health and primary care
A policy overview
Rachelle Maskell, Anna Rudkovska, Marisa Kfrerer, Shannon Sibbald
Faculty Reviewer: Gerald McKinley, PhD (Pathology and Laboratory Medicine)
abstract
Background: Mental health service demands in Ontario of-
ten result in long wait times and a lack of access to specialized
services. As a result, primary care providers are frequently re-
quired to provide mental health care for patients with complex
diagnoses despite a lack of support or sufficient training. To ad-
dress these issues, a shift toward collaborative models of men-
tal health care delivery is occurring. Objective: This paper aims
to assess whether evidence-based policy recommendations to
improve collaborative mental health care are addressed in the
recent Patients First documents. Methods: To achieve this, a
qualitative analysis was conducted using NVivo10©. Results:
While many of the evidence-based policy recommendations
were mirrored in the Patients First documents, very few ad-
dressed collaborative mental health care directly. Implications:
More research is required to fully understand the effects of the
implementation of Patients First on mental health systems and
services.
introduction
In recent years, there has been an increased focus on the need
to reorganize mental health care delivery in Ontario and Canada.
This focus on restructuring arguably comes as a response to an
increase in patient demand coupled with long wait times or in-
ability to access psychiatric services.1 These circumstances place
increased responsibilities on family physicians to treat complex
mental health conditions.2 A lack of support for primary care pro-
viders to adequately and effectively treat mental health disorders
sparked a shift toward collaborative models of care delivery. Such
models of mental health care integrate mental health services and
primary care through the utilization of existing infrastructures and
resources.2 Through these models, different health care providers
are connected in a health service network which allows them to
share resources and expertise. Studies of these models have demon-
strated increased patient and provider satisfaction as well as signifi-
cant reductions in treatment delays and costs.3-5
collaborative care
In 1997, a revolutionary position paper was developed by the
Canadian Psychiatric Association and the College of Physicians of
Canada on the topic of shared mental health care which generat-
ed wide-reaching interest and awareness.6 As a response to this
UWOMJ 86:2 | Fall 2017 Page 13
paper, a working group was created to promote models of shared
care which focused on encouraging coordination between family
physicians and psychiatrists.6 However, in recent years much has
changed including a shift from the focus on the physician/psychia-
trist relationship to a push for collaboration between a wide range
of experts including but not limited to providers of mental health
services and primary care.7
Collaborative mental health care emerged in Canada with the
goal to address the rising needs of Canadians with mental health
concerns as it is now understood that 1 in 5 Canadians experience
mental illness in their lifetime.8,9 The objective was to increase the
capacity of primary care to address issues related to managing men-
tal health and addictions.2 At its core, collaborative mental health
care is a patient-centred approach which relies on different special-
ties, disciplines, or sectors working together to offer services and
support to individuals in need.7 Collaborative mental health care
also leverages personal connections, supporting the unique and
changing needs of individuals, as well as catering care to cultural
and personal preferences. The collaborative mental health model
often draws on local resources, skills, and interests of the partici-
pating partners. While there is no single model, collaborative men-
tal health care is often operationalized through the use of effective
communication, consultation, coordination, co-location and/or in-
tegration of mental health and primary care providers into one care
team.7 Between 2003 and 2007, the Canadian Collaborative Mental
Health Initiative (CCMHI), supported by the Primary Health Care
Transition Fund, embarked on improving and promoting collabo-
rative mental health care across Canada.8 Today, however, the inci-
dences of mental health and addictions are still very high, and the
heavy reliance on primary care providers to support individuals
living with complex mental illness remains despite the lack of re-
sources and inadequate training.
In 2011, Kates et al published a revised position paper to update
collaborative mental health literature on lessons learned through
research, areas and opportunities for improvement, as well as ac-
tion items for change.7 They suggested that there are many chang-
es that can be made at the policy and practice level to encourage
improvement of and access to high-quality collaborative mental
health care. Including patients and their families in care planning
as well as focusing on early detection of mental illness were among
strategies proposed.7 Despite growing evidence showing that col-
laborative mental health care contributes to reduced wait times and
costs and improves overall patient and provider satisfaction, it is
original article
not well-understood how these models have been incorporated into
health policy. This issue, also known as the knowledge-to-practice
gap, is a recognized problem in health research, as federal and pro-
vincial policies are often developed using insufficient evidence.10
This paper aims to provide a brief overview of the recent shift in
Ontario health policy by assessing whether proposed policy chang-
es adequately incorporate the current evidence and recommenda-
tions brought forth in Kates et al’s 2011 position paper.
patients first
The Patients First Act is a policy initiative initiated by the Min-
istry of Health and Long-Term Care (MOHLTC) to improve the
province’s health system.11 Outlined in four public documents, these
proposed policy changes focus on four primary objectives: 12-15
1) Provide faster access to correct care,
2) connect services by providing better coordination and inte - partnership with the individual and based on their
gration closer to home,
3) support families and patients through education and trans-
parency to allow for more informed decision making, and
4) protect the universal health system by focusing on value, collaborative projects. To a large extent, the
quality and sustainability.
The structural changes included in the Patients First Act are an
attempt to develop a more integrated health care system which em-
phasizes quality of care and the patient experience above all other
factors.12-15
methods
The 4 documents outlining these changes were collated and
compared to Kates et al’s ‘Across the System’ and ‘Provincial and
(or) Territorial Governments and Regional Health Authorities’
recommendations.7 NVivo 10, a qualitative analysis software, was
used by the authors to assess whether the noted policy recom-
mendations were addressed in the Patients First documents. The
content of the documents was categorized using the twenty-three
recommendations included by Kates et al7 The qualitative analysis
software provided a visual overview of whether recommendations
were addressed in Patients First and to what degree.
findings
‘Across the System’ Recommendations:
The Patients First documents were coded using the twen-
ty-three Kates et al recommendations and were measured by fre-
quency of occurrence (Table 1 and Table 2). The frequencies at
which the ‘Across the System’ recommendations were mirrored in
the Patients First documents were quite varied with 6 of 10 recom-
mendations appearing in the public documents (Table 1).12-15 The
recommendation most frequently mirrored reflected a focus on
quality improvement, access, and efficiency. To a lesser degree, the
inclusion of individuals, families, and caregivers in project planning
and evaluation was also included. For example, in the Patients First:
211 
Action Plan for Health Care document, families were often dis-
UWOMJ 86:2 | Fall 2017 Page 14
cussed in planning and collaboration.12 Less frequently discussed
recommendations include development of strategies to reduce stig-
ma among providers, promotion of mental health and well-being
as drivers for change, the use of technology for managing informa-
tion and linking providers, and including individuals and families
in their own care. Lastly, of the 10 Kates et al ‘Across the System’
recommendations reflected in the Patients First documents, only 2
directly addressed mental health care while several recommenda-
tions are not discussed at all.
Table 1. Across the system recommendations from Kates et al
Health  Specific to 
Kates et al. Across the System Recommendations  care as  Mental 
a whole    Health 
1. Include individuals and their families and (or) 
caregivers as partners in their own care. Ensure that 
people with mental health problems have clear 
treatment or wellness plans, developed in  X 
 
own goals. A copy of these plans should be provided 
to the individual. 
2. Include individuals and their families and (or) 
caregivers in the planning and evaluation of 
 
development of new projects needs to be based on 
what we can learn from the stories and journeys of  X   
people with lived experience about where our 
systems are failing them and how care could be 
improved. 
3. Develop strategies that will reduce stigma and 
discrimination among all health care providers, 
including those that will lead to a better  X   
understanding of cultural diversity 
4. Promote mental health, wellness, and recovery as 
goals of system changes.  X  X 
5. Focus on quality improvement, access, and efficiency 
as drivers of system change.  X  X 
6. Define competencies for all health professionals 
working in collaborative mental health partnerships. 
   
7. Ensure that respective roles and responsibilities of 
all partners are clearly defined and understood. 
   
8. Strengthen personal contacts by organizing events, 
such as joint clinical rounds, joint educational 
rounds, practice observation, and formal continuing 
professional development events, that bring 
together MH&A and primary care clinicians and staff 
 
9. Use new technologies for managing information, 
including a common electronic medical record and 
evidence‐guided algorithms to enhance 
collaboration and efficient data collection and 
analysis; registries to support proactive, population‐ X 
based care; and telemedicine, which offers new 
ways to link providers, enhance collaboration, and 
provide consultation to underserved communities. 
10. Build networks of providers, information technology 
experts, researchers, and consumers interested in 
collaborative mental health care to enable 
participants to exchange ideas, share experiences, 
and work together to develop new projects. 
original article

‘Provincial and (or) Territorial Governments and Regional ance for mental health care reform, there is a great deal of thematic
Health Authorities’ Recommendations: overlap between Kates et al’s recommendations and the Patients
Frequency of occurrence of provincial/territorial and regional First focus on patient-centredness, quality improvement and inter-
health authorities’ recommendations was greater and less varied disciplinary collaboration. More research is required to see if these
across all documents. Overall, twelve of the thirteen recommenda- policy changes translate into improved collaborative mental health
tions in this category were present in the Patients First documents care.
with 6 directly pertaining to mental health care. There appeared to
be a focus on meeting the needs of marginalized populations, ad- conclusion
dressing health resource shortages, and the development of strat- While the Patients First documents demonstrate substantial
egies to ensure individuals with mental health and addictions re- thematic overlap with Kates et al’s (2011) evidence-based policy
ceive comprehensive primary care. recommendations, gaps remain as few directly address collabora-
tive mental health care. However, it is possible that because there
Table 2. Provincial, territorial governments, and regional health authorities is considerable thematic overlap, these important policy changes
recommendations from Kates et al
Health  Specific to 
will translate into improved mental health care. We support further
Kates et al. Provincial and (or) Territorial Governments and Regional 
Health Authorities Recommendations
care as a  mental  research to understand the full affects of the practical implementa-
whole health
1. Give priority to collaborative projects that offer opportunities for;  
tion of Patients First policies on mental health systems and services.
a. Early detection and intervention, and ongoing monitoring 
of children and youth with mental health problems and  X X
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f. Addressing shortages of health resources, including those 
X Serv Res. Jan 2016:127-139.
created by geographic disparities 
6. Kates N, Craven M, Bishop J, et al. Shared Mental Health Care in Can-
g. Supporting collaborative education projects, especially  ada. Can J Psychiatry. Oct 1997;42(8)
those that take place in the primary care setting  X 7. Kates N, Mazowita G, Lemire F, et al. The Evolution of Collaborative
Mental Health Care in Canada : A Shared Vision for the Future. Can J
h. Mentoring and email or telephone support of family  Psychiatry. May 2011;56(5):1-10.
physicians by psychiatrists, as in the successful Ontario  8. Macfarlane D. Current State of Collaborative Mental Health Care
Collaborative Mental Health Project,65 which is now  X [Internet]. Mississauga (ON): Canadian Collaborative Mental Health
being extended to other specialties  Initiative; 2005 June [cited 2017 Oct 18]. Available from: http://www.
shared-care.ca/files/12_OverviewPaper_EN.pdf.
2. Test demonstration projects that provide data on how 
9. Smetanin P, Stiff D, Adair C, et al. The life and economic impact of
collaborative projects can help address common problems faced by 
major mental illnesses in Canada: 2011 to 2041. RiskAnalytica, behalf
health care systems, including 
Ment Heal Comm Canada 2011. Dec 2011;199.
a. Meeting the needs of underserved populations  10. Curran J, Grinshaw J, Hayden J, et al. Knowledge Translation Re-
X search: The Science of Moving Research Into Policy and Practice. J
b. Serving people in isolated communities  X Contin Educ Health Prof. Sept 2011;31(3):174-180.
11. Bill 210, An Act to Amend Various Acts in the Interests of Patient-Cen-
c. Reducing waiting times and improving access to care  X X tred Care, First Reading, June 2, 2016. Canada; 2016.
d. Improving physical health outcomes for people with 
12. Ontario Ministry of Health and Long-Term Care. Patients First: Action
mental disorders  X X Plan for Health Care. [Internet]; 2015 February. [cited 2017 Oct 18].
Available from: http://www.health.gov.on.ca/en/ms/ecfa/healthy_
3. Develop strategies to ensure that people with mental illnesses and  change/.
addictions have access to appropriate and comprehensive primary  13. Ontario Ministry of Health and Long-Term Care. Patients First: A
health care, 32 including incorporating primary care clinicians  X X
Proposal to Strengthen Patient-Centred Health Care in Ontario.
(nurses, nurse practitioners, physician assistants, and family  [Internet]; 2015 December. [cited 2017 Nov 6] Available from: http://
physicians) into mental health programs  www.health.gov.on.ca/en/news/bulletin/2015/docs/discussion_pa-
per_20151217.pdf.
discussion 14. Ontario Ministry of Health and Long-Term Care. Patients First:
Reporting Back on the Proposal to Strengthen Patient-Centred Health
Of the twenty-three recommendations discussed in Kates et al, Care in Ontario. [Internet]; 2016 June. [cited 2017 Nov 6] Available
from: http://www.health.gov.on.ca/en/news/bulletin/2016/docs/pa-
eighteen (78%) were present in the Patients First documents; how- tients_first_report_back_20160602.pdf.
ever, only 8 of the twenty-three recommendations (34%) addressed 15. Ontario Ministry of Health and Long-Term Care. Patients First: One
Year Results. [Internet]; 2016 March. [cited 2017 Nov 6] Available
mental health care directly. Despite the absence of directed guid- from: http://www.health.gov.on.ca/en/ms/ecfa/healthy_change/docs/
year_one_results_action_plan_en.pdf.

UWOMJ 86:2 | Fall 2017 Page 15

commentary
Racing for accessibility of a life-saving drug
A timeline of naloxone’s changing status in the midst of the opioid crisis
Sandra Botros
Faculty Reviewer: Amardeep Thind MD, PhD (Epidemiology and Biostatistics)
introduction
In recent years, the problem of addiction and misuse of opioid
drugs has been on the rapid rise in Canada. Overdose deaths have
increased dramatically, due partly to increasing availability of pre-
scription opioids on the illicit drug market, and in particular a surge
in the availability of the potent opioid fentanyl. In British Columbia,
the hardest hit province, overdose deaths have doubled since 2012,
and the involvement of fentanyl in these deaths has risen from 5%
to 60%.1,2 Naloxone hydrochloride (sold in the U.S. under the trade
name Narcan®) is an opioid antidote used to reverse the effects of
opioid overdose in emergency situations. In a short time, Canada
has seen rapid changes in regulation and availability of naloxone
in a desperate attempt to reduce overdose deaths in what is being
called a “public health crisis”.1 A key change that has happened re-
cently was the removal of naloxone from the Prescription Drug List
(PDL), making it available over-the-counter in pharmacies. This
article outlines the steps taken to increase availability and remove
prescription status of naloxone in response to Canada’s ongoing
opioid epidemic.
take home programs
While naloxone has been around for many years, its use has
historically been confined to hospitals and emergency rooms. As
overdose rates continued rising, there were increasing efforts to
increase public availability of the life-saving drug. In 2005, the Ed-
monton needle-exchange program Streetworks implemented Can-
ada’s first take-home naloxone program. In 2011, Toronto similarly
launched their POINT program (Preventing Overdose in Toronto),
followed by a province-wide program through the Ontario Harm
Reduction Distribution Program.3 British Columbia began a prov-
ince-wide take-home naloxone program in 2012, operated by the
BC Centre for Disease Control Harm Reduction Program.4 These
programs typically provide opioid users with naloxone prescrip-
tions and kits, overdose prevention education, and training on use
of naloxone kits. Often, training sessions were also provided to fam-
ily and friends of users, who may be present during an overdose.
the road to prescription free status
Prior to the lifting of naloxone’s prescription status, several
provinces took steps to increase accessibility of the drug in over-
dose situations. Since 2015, for example, Manitoba and Nova Scotia
made changes that allowed physicians to prescribe naloxone with-
out having to see the patient; Saskatchewan began allowing physi-
cians to prescribe naloxone directly to family and friends of opioid
users; and BC and Alberta made it possible for registered nurses to
UWOMJ 86:2 | Fall 2017 Page 16
prescribe naloxone.5
Naloxone’s removal from Health Canada’s PDL was achieved
in March 2016. This was the first step to allowing access in phar-
macies without prescription. Health Canada proposed the amend-
ment to the PDL on January 14, 2016 and shortened the normal 75-
day public consultation period to 65 days to expedite the process.
The amendment received overwhelming public support, and it was
approved on March 22. Due to the urgent nature of the situation,
Health Canada opted to bypass the usual six-month delay in imple-
mentation, making the amendment effective immediately.5,6
After a change to the federal PDL, a drug’s status must be
changed on the provincial drug schedules, which describe the legal
conditions for its sale in the respective provinces. When a change
is made in the PDL, The National Association of Pharmacy Regu-
latory Authorities (NAPRA) usually provides a common final rec-
ommendation to all provinces regarding drug scheduling, and the
provinces generally follow NAPRA’s recommendations. Most prov-
inces have a system of “scheduling by reference”, meaning they au-
tomatically implement all NAPRA recommendations, while some
(BC, Alberta, Newfoundland) have additional approval processes in
place, but still generally end up following the same recommenda-
tions. The urgency for naloxone access led to the BC government
and BC College of Pharmacists bypassing this process completely
and classifying naloxone as a Schedule II drug in BC on March 24,
2016.5 NAPRA made their final recommendation on June 24, 2016
to classify naloxone as a Schedule II drug,7 making pharmacies in
most provinces, including Ontario, immediately eligible to dispense
it.
remaining barriers and future directions
Removing naloxone from the PDL has been an important step
in improving its availability. There are still several barriers, howev-
er, in ensuring adequate availability in practice. One concern is the
difficulty of administering an injection drug. Currently, pharma-
cies provide training sessions on use of naloxone kits, but training
isn’t standardized, and the skill can be difficult to master and recall
during high-stress emergency situations.8,9 A nasal spray form of
naloxone exists (Narcan® nasal spray in the U.S.), but until recent-
ly was not approved in Canada. The nasal spray form is far easier
to administer and would likely prevent more overdoses. In an in-
terim order termed “an emergency public health measure”, Health
Canada authorized the nasal spray for import and sale from the U.S.
in July 2016, pending an expedited review for its approval in Can-
ada.8 This allowed it to be sold in Canada before being approved
for manufacture in Canada. Following the review, the nasal spray
commentary

28]. Available from: http://www.cbc.ca/news/canada/british-colum-

was approved for non-prescription use in October 2016, allowing bia/costly-naloxone-nasal-spray-1.3675243.
the manufacturer to begin steps to bring it to the Canadian mar- 10. Health Canada OK’s non-prescription nasal spray overdose antidote
ket.10 In June 2017, Health Canada authorized a Canadian version [Internet]. CBC News; 2016 Oct 3. [cited 2017 Feb 28]. Available from:
http://www.cbc.ca/news/health/naloxone-nasal-spray-1.3789643.
of the nasal spray, to be transitioned into the market when the in-
11. Canadian Pharmacists Association [Internet]. Ottawa (ON); c2017.
terim order expired in July 2017. It is being carried by RCMP, police Environmental Scan: Access to Naloxone across Canada. c2017. [cited
officers, and first responders, but its availability in pharmacies is 2017 Nov 15]. Available from: https://www.pharmacists.ca/cpha-ca/
not well-documented and is likely still in transition.11 Unfortunate- assets/File/cpha-on-the-issues/Environmental%20Scan%20-%20Ac-
ly, a major concern with naloxone nasal spray is the high cost – at cess%20to%20Naloxone%20Across%20Canada_Final.pdf.
approximately $125 for two doses, it is much more costly than the
cheaper injectable kits ($5-$20 per dose), which are free at most
pharmacies.9
Another important consideration is that although naloxone is
an important harm reduction tool, it will not solve the opioid prob-
lem. The Canadian government recognizes that overdose preven-
tion, although important, is just one part of the strategy to combat
opioid abuse. Continuous improvement is also critically needed in
curbing opioid prescription, educating the public, and treating ad-
diction.1
At this point, there has not yet been any formal evaluation of
the effect that removing naloxone from the PDL has made on curb-
ing overdose deaths. Further research is needed moving forward to
determine if this much-publicized public health measure has suc-
ceeded and had its intended effect.

references
1. Parliament of Canada [Internet]. Ottawa (ON): Report and Recom-
mendations on the Opioid Crisis in Canada 2016. [cited 2017 Feb 27].
Available from: http://www.parl.gc.ca/HousePublications/Publication.
aspx?Language=e&Mode=1&Parl=42&Ses=1&DocId=8685723&File=18.
2. White P, Howlett K. Ontario, Ottawa expand free access to antidote for
opioid overdoses [Internet]. The Globe and Mail; 2013 May 18. [cited
2017 Feb 28]. Available from: http://www.theglobeandmail.com/news/
national/ontario-to-make-free-antidote-to-opioid-overdose-available/
article30076911/
3. Eggerston L. Take-home naloxone kits preventing overdose deaths.
CMAJ. 2014 Jan; 186(1): 17.
4. Banjo O, Tzemis D, Al-Qutub D, Amlani A, Kesselring S, Buxton J. A
Quantitative and qualitative evaluation of the British Columbia Take
Home Naloxone program. CMAJ Open. 2014 Jul; 2(3): 153-161.
5. Canadian Centre on Substance Abuse [Internet]. Ottawa (ON); c2017.
CCENDU Bulletin: The Availability of Take Home Naloxone in Can-
ada. c2016. [cited 2017 Feb 28]. Available from http://www.ccsa.ca/
Resource%20Library/CCSA-CCENDU-Take-Home-Naloxone-Cana-
da-2016-en.pdf.
6. Health Canada [Internet]. Ottawa (ON); c2017. Notice: Prescription
Drug List (PDL): Naloxone; c2016 [cited 2017 Feb 27]. Available from:
http://www.hc-sc.gc.ca/dhp-mps/prodpharma/pdl-ord/pdl-ldo-noa-
ad-naloxone-eng.php.
7. National Association of Pharmacy Regulatory Authorities (NAPRA)
[Internet]. Ottawa (ON): NAPRA: c2009. National Drug Schedules:
Final Recommendation on naloxone hydrochloride; c2016. [cited
2017 Feb 28]. Available from: http://napra.ca/pages/home/default.
aspx?id=3758.
8. Health Canada [Internet]. Ottawa (ON); c2017. Notice - Availability of
Naloxone Hydrochloride Nasal Spray (NARCAN®) in Canada; c2016.
[cited 2017 Feb 28]. Available from: http://www.hc-sc.gc.ca/dhp-mps/
prodpharma/activit/announce-annonce/notice-avis-nasal-eng.php.
9. Dimoff A. High price of naloxone nasal spray makes distribution of
vital drug difficult [Internet]. CBC News; 2016 July 12. [cited 2017 Feb

UWOMJ 86:2 | Fall 2017 Page 17

commentary
Doctors without bricks (and mortar)
Akira and the emergence of mobile health services
Alistair D Scott
Faculty Reviewer: Robert John Petrella, MD, PhD, FACSM, FCFP (Department of Family Medicine)
For most of the twentieth century, if you wanted to talk to a
friend who lived across the country, you would call them on a land-
line or you would write them a letter. If you needed a taxi, you could
flag one down on the street or call dispatch and give them your lo-
cation, and have limited options for payment. And if you wanted the
answer to a complex medical question, you would have to search a
library’s catalogue in person and find the relevant book or journal
on the shelf.
Advances in technology and mobile communications in the last
few decades have changed all of that. We now have devices in our
pocket capable of performing all of these tasks with ease. Apps like
Skype, Uber, and Google have each revolutionized our society and
the way we interact with each other, and many are accessible from
a small device we carry in our pocket.
Health is no exception. A large number of mobile apps are avail-
able for patients to manage their health. They can manage their diet
with MyFitnessPal1, log their routes with Map My Run+2, and track
their menstrual health with Flo Period Tracker.3 With the purchase
of a minor accessories, patients can monitor their sugar levels with
MyStar SMS4 or their blood pressure with Qardio.5 Furthermore,
accessories such as Fitbit6 and the Apple Watch have also enabled
patients to manage vast amounts of personal health data.
Despite these changes, much of healthcare that has yet to ful-
ly exploit the new mobile communication technologies available
to patients and healthcare practitioners. Telehealth, the practice
of providing healthcare virtually with the aid of videoconference
or specialized equipment, has been employed in situations such as
providing isolated or remote communities with access to specialty
care7 or managing chronic disease8 but has not become fully main-
stream. However, it is a provocative opportunity to modernize the
way we provide healthcare, and may help address barriers to care
such as appointment wait times. Two very strong predictors of pa-
tient satisfaction are the amount of time spent with the physician as
well as the amount of time patients spent in the wait-room for their
appointments.9
Akira is a smartphone telehealth app that aims to address that
barrier. Based in Toronto, Ontario, and available on both iOS and
Android, Akira provides a platform for patients to access physi-
cians’ opinions and diagnoses for common medical problems, all via
a smartphone. Some of their services include providing prescrip-
tions for simple medical problems such as uncomplicated urinary
tract infections in women, oral contraceptives in otherwise healthy
patients, medication renewals, mental health counselling, referrals
for specialists, and sick notes.10 It is staffed by physicians licenced
in Ontario, as well as registered nurses, nurse practitioners, social
workers, and mental health councillors, who provide care via text
and video chat. Setting up an account takes a matter of moments,
UWOMJ 86:2 | Fall 2017 Page 18
and after a brief conversation with a nurse who establishes your ini-
tial health history, you are connected with the health professionals
to address your issue.
The catch? The service is not covered by the Ontario Health
Insurance Plan. It is available as a subscription for $120/year for in-
dividuals or $240/year for a family of two partners with unlimited
children and covers an unlimited number of consults, though there
is a pay-as-you-go option for $49 per consult.10
Paying for healthcare is legal in Canada. While the Canada
Health Act stipulates that medically necessary healthcare services
must be covered by provincial health plans in order for provinces to
receive federal transfer payments, it leaves most of the determina-
tion of what is medically necessary up to the provinces. Any service
that is not deemed medically necessary may thus be provided for
a fee. The College of Physicians and Surgeons of Ontario (CPSO)
has published guidelines for physicians for how, and how much,
they may charge patients for these services, based on recommen-
dations outlined by the Ontario Medical Association, though these
recommendations do not outline specifically how much should be
charged for telehealth services.11,12 The CPSO also allows for the
provision of telehealth by its members and has published guide-
lines which essentially state that physicians in Ontario are still
governed by the same standards of care that they would were they
seeing their patients in person.13 Furthermore, the Canadian Medi-
cal Protective Association (CMPA) also allows for the provision of
telehealth by its members and will cover a physician practicing tele-
health, provided the patient resides in Canada and any legal action
filed against the physician is initiated in Canada.14 Akira states on its
website that its physicians adhere both the CPSO and CMPA stan-
dards, and that its nurses adhere the College of Nurses of Ontario’s
respective guideline on telehealth.15
Telehealth is not a new concept, and already exists in Ontario
via the Ontario Telemedicine Network. It is however limited to only
managing certain patients with chronic disease (such as heart fail-
ure or emphysema), and allowing certain patients in remote or rural
communities to access specialists with the use of videoconference
and specialized monitoring equipment.7
Systematic and scoping reviews of telehealth have shown
mixed results. Some show modest improvement in the management
of chronic disease,8 doctor-patient communication,16 and encourag-
ing health behaviour change.17 However, limitations in diagnostic
accuracy compared to gold standard remain a challenge,18 and it
does not appear to reduce healthcare spending.19
Telehealth has the potential to vastly change the way that
healthcare is delivered, both in Canada and globally. For Akira, the
fact that the only physicians available currently are Family Physi-
cians and Paediatricians will limit its widespread adoption for the
commentary

docs/prac/41041_telephone.pdf.
time being.10 It is possible that other specialties may become avail- 16. Kashgary A, Alsolaimani R, Mosli M, et al. The role of mobile devices
able in the future, but for the time being it will only be able to ad- in doctor-patient communication: A systematic review and meta-anal-
dress uncomplicated medical concerns in primary care. ysis. Journal of Telemedicine and Telecare. 2016. Epub 2016 Sep 15.
Mobile technology will continue to advance, and until health- 17. Fedele DA, Cushing CC, Fritz A, et al. Mobile Health Interventions for
care delivery catches up, it is my impression that the general public Improving Health Outcomes in Youth: A Meta-analysis. JAMA pediat-
will increasingly view healthcare as an ossified institution, stuck in rics. 2017;171(5):461-9.
the past. 18. Free C, Phillips G, Watson L, et al. The Effectiveness of Mobile-Health
Technologies to Improve Health Care Service Delivery Processes: A
Systematic Review and Meta-Analysis. PLoS Medicine. 2013;10(1).
references 19. Ashwood JS, Mehrotra A, Cowling D, et al. Direct-To-Consumer Tele-
1. MyFitnessPal. Lose Weight with MyFitnessPal [Internet]. Free Calorie
health May Increase Access To Care But Does Not Decrease Spending.
Counter, Diet & Exercise Journal | MyFitnessPal.com; c2017 [cited
Health Affairs. 2017 Jan;36(3):485–91.
2017 May 9]. Available from: https://www.myfitnesspal.com/.
2. MapMyRun. MapMyRun [Internet]. MapMyRun. c2017 [cited 2017
May 9]. Available from: https://www.mapmyrun.com/auth/login/.
3. OWHealth. Flo Period Tracker [Internet]. Flo Period Tracker. c2017
[cited 2017 May 9]. Available from: https://www.owhealth.com/
flo_about.html.
4. Sanofi-Aventis. Star System - Sanofi [Internet]. MyStarSMS. c2016 [cit-
ed 2017 May 9]. Available from: https://starsystem.sanofi.ca/products/
mystar-sms.
5. Qardio Inc. State of the Heart Technology [Internet]. Qardio. c2017
[cited 2017 May 9]. Available from: https://www.getqardio.com/.
6. Fitbit. Fitbit [Internet]. Home. 2017 [cited 2017May9]. Available from:
https://www.fitbit.com/en-ca/home.
7. O’gorman LD, Hogenbirk JC, Warry W. Clinical Telemedicine Utiliza-
tion in Ontario over the Ontario Telemedicine Network. Telemedicine
and e-Health. 2016Jun1;22(6):473–9.
8. Matthew-Maich N, Harris L, Ploeg J, et al. Designing, Implementing,
and Evaluating Mobile Health Technologies for Managing Chronic
Conditions in Older Adults: A Scoping Review. JMIR mHealth and
uHealth. 2016 Sep;4(2):e29.
9. Anderson RT, Camacho FT, Balkrishnan R. Willing to wait? The
influence of patient wait time on satisfaction with primary care. BMC
Health Services Research. 2007;7(1):1–5.
10. Akira.md [Internet]. Toronto (ON): Akira; c2017. Healthcare, right
from your phone, wherever you are; c2017 [cited 2017 March 15].
Available at https://akira.md.
11. The College of Physicians and Surgeons of Ontario [Internet]. Toronto
(ON): The College of Physicians and Surgeons of Ontario; c2010. Block
Fees and Uninsured Services; c2010 [cited 2017 March 15]. Available at
http://www.cpso.on.ca/Policies-Publications/Policy/Block-Fees-and-
Uninsured-Services.
12. Ontario Medical Association. 2017 Schedule of Fees - OMA suggested
fees for uninsured services [Internet]. Ontario Medical Association.
c2017 [cited 2017 May 9]. Available from: https://www.oma.org/
wp-content/uploads/private/schedule-of-fees.pdf.
13. The College of Physicians and Surgeons of Ontario [Internet]. Toronto
(ON): The College of Physicians and Surgeons of Ontario; c2014. Tele-
medicine; c2014 [cited 2017 March 15]. Available at http://www.cpso.
on.ca/Policies-Publications/Policy/Telemedicine.
14. The Canadian Medical Protective Association [Internet]. Ottawa
(ON): The Canadian Medical Protective Association; c2013. Practising
telehealth; c2013 [cited 2017 March 15]. Available at https://www.
cmpa-acpm.ca/web/guest/-/practising-telehealth.
15. College of Nurses of Ontario [Internet]. Toronto (ON): College of
Nurses of Ontario; c2017. Practice Guideline – Telemedicine; c2017
[cited 2017 March 15]. Available at https://www.cno.org/globalassets/

UWOMJ 86:2 | Fall 2017 Page 19

commentary
Availability of novel contraceptive methods in Canada
Polly Tsybina, Kyle Canton
Faculty Reviewer: Shannon Arntfield, MD, MSc, FRCSC (Department of Obstetrics and Gynecology)
Numerous contraceptive options are available in Canada, but
studies show that Canadian women most often use the following
three methods: condoms (54%), oral contraceptives (44%), and
withdrawal (12%).1 Typical failure rates of these methods are 18%,
9%, and 22%, respectively. These statistics may be linked with the
finding that one third of Canadian women have at least one induced
abortion in their lifetime.
Contraceptive failure is lower among long-acting and perma-
nent contraceptive options, primarily because user adherence is
taken out of the equation. However, Canadian women appear reluc-
tant to use long acting options such as intrauterine devices (IUDs),
perhaps because of associated adverse events. For example, some
20% of women discontinue IUDs within the first year of use due to
pelvic pain, irregular bleeding, or spontaneous expulsion.2 DMPA
(Depo-Provera) is often discontinued because of weight gain com-
monly experienced by its users.3 Thus, there remains a need for
novel contraceptive choices for women who are unable to use the
formulations currently available in Canada.
One promising alternative not yet available in Canada is Nex-
planon, an etonogestrel (progestin only) implant inserted into the
inner, upper arm. In adults, its efficacy is higher than that of oral
contraceptives and IUDs, at >99% (efficacy studies in women under
18 years of age are not yet available).4 Effectiveness lasts up to three
years, and the approach for insertion is less invasive than IUDs.
Side effects are similar to other contraceptive methods, with the
most common being breakthrough bleeding, depression, and mood
swings. Abnormal bleeding is the most common reason for discon-
tinuation, but notably, more than three quarters of women retain
their implant for two years or more. Nexplanon is also more cost ef-
fective than both OCP and hormonal or copper IUDs, as seen from
a study in France.5 The combination of superior effectiveness, a
simpler and less invasive insertion, and increased cost effectiveness
makes Nexplanon a preferable alternative to contraceptive options
otherwise available to Canadian women. However, the manufactur-
er of Nexplanon (Merck) recently failed to satisfy Health Canada’s
requirements for new contraceptive devices, and it is uncertain
whether the company will re-apply for approval.6
Another unavailable but promising contraceptive option is
Cerazette, a progestin only pill (POP) that uses desogestrel as its
active ingredient. POPs are important options among women who
prefer or require a non-estrogen containing contraceptive, due to
either medical contraindications to estrogen, patient preference,
side effect profile, or physiologic states such as breastfeeding. Most
POPs function by thickening the uterine mucus lining. However,
Cerazette also prevents ovulation in 97% of cycles.7 What makes
Cerazette truly stand out, however, is its margin for timing variabil-
ities. Most POPs must be taken within a 3 hour window each day to
UWOMJ 86:2 | Fall 2017 Page 20
ensure effectiveness, whereas Cerazette allows a 12 hour window.8
This offers women much greater flexibility without compromising
efficacy.
It is clear that Cerazette and Nexplanon offer advantages over
the contraceptive options currently available on the Canadian mar-
ket. There is a wealth of safety data available for these formulations
as they have been in use for some 20 years. Etonogestrel’s safety
has been demonstrated in clinical trials including over 2,000 wom-
en.9-12 Some 1,000 women have taken part in a clinical trial specif-
ically looking at safety of desogestrel-only contraceptive pill.13 Also,
there have been studies using desogestrel for treatment of other
conditions, such as headaches and endometriosis.14-15 Moreover,
there are numerous studies where desogestrel was combined with
ethinyl estradiol, as it is also a part of several combined OCP for-
mulations.16-17 Finally, many countries have a system for reporting
and surveillance of adverse events (for example, FDA adverse event
reporting system available on www.fda.gov), and neither desoges-
trel nor etonogestrel have raised concerns once approved for use.
With a need for these contraceptive options and the abundance of
research done to date, it seems surprising that these drugs are not
available in Canada.
Health Canada approval process for contraceptives is notori-
ous for delaying or preventing new contraceptives from entering
the market. Troskie and colleagues compared the data for new
hormonal contraception entering the market in Canada, USA, and
UK.18 Canada approved fewer devices than the two other countries
between 2000 and 2015, and it took significantly longer for Health
Canada to approve new drugs: 30% longer than the corresponding
regulatory agency in the US, and 50% longer than the UK. Approv-
al times for contraceptives in Canada likely lag chiefly due to the
stringency of the guidelines required by Health Canada.19 Namely,
the guidelines dictate that clinical trials for new hormonal contra-
ceptives to be introduced in Canada require 800-900 participants,
20,000 cycles of exposure, and multiple endometrial biopsies for
multiparous women enrolled in the trial. Other regulatory agencies
do not require endometrial biopsies, and the FDA, for example, sets
the standard at 10,000 cycles with 200 women enrolled, unless the
hormone is a new molecular entity.20
One could argue that these guidelines are intended to protect
consumers, and, as Health Canada explains, biopsies are important
to distinguish uterine bleeding that is a side effect of the contra-
ceptive from more insidious pathology. However, progesterone an-
alogues are known to decrease risk of endometrial cancer, and are
used to treat endometrial hyperplasia,21-22 so it remains unclear why
endometrial biopsy is a requirement. For etonogestrel implants,
there have been no reports of endometrial atypia or cancer as ad-
verse events.9-12 Additionally, etonogestrel has been used in Canada
commentary
for years as a component of another contraceptive device, NuvaR-
ing, with no adverse effects on endometrial histology.23
It is clear that Canada lags behind in its approval of novel con-
traceptives, arguably due to barriers by Health Canada that appear
unnecessary. This limits the options available to Canadian women,
preventing access to more effective, less invasive, and more flexi-
ble contraceptives such as Nexplanon and Cerazette. In order for
Canadian women to have the best available choices for contracep-
tion, policy should be amended to remove the unnecessary barri-
ers and shorten the approval process. We invite readers to contact
their members of parliament as well as the minister of health with
requests to improve the availability of novel contraceptives to Ca-
nadian women.
references
1. Black A, Guilbert E, Costescu D, et al. Canadian Contraception Con-
sensus (Part 1 of 4). J Obstet Gynaecol Can. 2015. 37(10):S1-S28.
2. Lee G, Ekbladh, L. Short-term IUD discontinuation at an urban center.
Contraception. 2012. 85(3): 324-5.
3. Paul C, Skegg DC, Williams S. Depot medroxyprogesterone acetate:
Patterns of use and reasons for discontinuation. Contraception. 1997.
56(4):209-14.
4. Sanders J, Turok DK, Gawron LM, et al. Two-year continuation of
intrauterine devices and contraceptive implants in a mixed-payer
setting: a retrospective review. Am J Obstet Gynecol. 2017. Accepted
manuscript.
5. Lafuma A, Agostini A, Linet T, et al. Cost-effectiveness of Nexplanon
(Etonogestrel implant) compared to other reimbused contracep-
tive methods in France based on real life data. Value Health. 2015.
Nov;18(7):A735-6.
6. Barton, A. Stringent Health Canada requirements restrict access to
hormonal implants. Globe and Mail. 2015. Acccessed online March
10, 2017: http://www.theglobeandmail.com/life/health-and-fitness/
health/stringent-birth-control-requirements-keep-options-limit-
ed-for-canadians/article23882944/
7. Rice CF, Killick SR, Dieben T, et al. A comparison of the inhibition of
ovulation achieved by desogestrel 75 micrograms and levonorgestrel
30 micrograms daily. Hum Reprod. 1999. Apr;14(4):982-5.
8. Korver T, Klipping C, Heger-Mahn D, et al. Maintenance of ovulation
inhibition with the 75-μg desogestrel-only contraceptive pill (Cera-
zette®) after scheduled 12-h delays in tablet intake. Contraception.
2005. Jan;71(1): 8-13.
9. Meirik O, Brache V, Orawan K, et al. A multicenter randomized clinical
trial of one-rod etonogestrel and two-rod levonorgestrel contraceptive
implants with nonrandomized copper-IUD controls: Methodology and
insertion data. Contraception. 2013. Jan;87(1):113-20.
10. Funk S, Miller MM, Mishell DR Jr, et al. Safety and efficacy of Impla-
non, a single-rod implantable contraceptive containing etonogestrel.
Contraception. 2005. May;71(5):319-26.
11. Croxatto HB, Urbancsek J, Massai R, et al. A multicentre efficacy and
safety study of the single contraceptive implant Implanon. Implanon
Study Group. Hum Reprod. 1999. Apr;14(4):976-81.
12. Mommers E, Blum GF, Gent TG, et al. Nexplanon, a radiopaque etono
Agestrel implant in combination with a next-generation applicator:
3-year results of a noncomparative multicenter trial. Am J Obstet
Gynecol. 2012. Nov;207(5):388.e1–388.e6.
13. Korver T. A double-blind study comparing the contraceptive effica-
UWOMJ 86:2 | Fall 2017 Page 21
cy, acceptability and safety of two progestogen-only pills containing
desogestrel 75 μg/day or levonorgestrel 30 μg/day: Collaborative Study
Group on the Desogestrel-containing Progestogen-only Pill. Eur J
Contracept Reprod Health Care. 1998. Aug;3(4):169-78.
14. Merki-Feld G, Imthurn B, Langner R, et al. Headache frequency and
intensity in female migraineurs using desogestrel-only contraception:
A retrospective pilot diary study. Cephalalgia. 2013. Apr;33(5):340-6.
15. Leone Roberti Maggiore U, Remorgida V, Scala C, et al. Desoges-
trel-only contraceptive pill versus sequential contraceptive vaginal
ring in the treatment of rectovaginal endometriosis infiltrating the rec-
tum: a prospective open-label comparative study. Acta Obstet Gynecol
Scand. 2014. Mar;93(3):239-47.
16. Endrikat J, Dusterberg B, Ruebig A, et al. Comparison of efficacy, cycle
control, and tolerability of two low-dose oral contraceptives in a multi-
center clinical study. Contraception. 1999. 60(5):269-74.
17. Koetsawang S, Charoenvisal C, Banharnsupawat L, et al. Multicenter
trial of two monophasic oral contraceptives containing 30 mcg
ethinylestradiol and either desogestrel or gestodene in Thai women.
Contraception. 1995. Apr;51(4):225-9.
18. Troskie C, Soon JA, Albert AY, et al. Regulatory approval time for
hormonal contraception in Canada, the United States and the United
Kingdom, 2000-2015: a retrospective data analysis. CMAJ Open. 2016.
Nov;4(4):E654-60.
19. Health Canada Guidance Documents. Guidance for Industry: Clinical
Development of Steroidal Contraceptives Used by Women. Published
by authority of the Minister of Health. Accessed on March 11, 2017:
http://www.hc-sc.gc.ca/dhp-mps/prodpharma/applic-demande/
guide-ld/oral/contracep-eng.php.
20. FDA Advisory Committee Briefing Document. Prepared by the Divi-
sion of Reproductive and Urologic Products Office of Drug Evaluation
III. December 21, 2006. General Meeting on Contraceptives. Accessed
on March 8, 2017: https://www.fda.gov/ohrms/dockets/ac/07/brief-
ing/2007-4274b1-01-FDA.pdf.
21. Deligdisch, L. Hormonal Pathology of the Endometrium. Mod Pathol.
2000. Mar;13(3):28-94.
22. Black A, Guilbert E, Costescu D, et al. Canadian Contraception
Consensus (Part 3 of 4): Chapter 8 – Progestin-Only Contraception. J
Obstet Gynaecol Can. 2016. Mar;38(3):279-300.
23. Bulten J, Grefte J, Siebers B, et al. The combined contraceptive vaginal
ring (NuvaRing) and endometrial histology. Contraception. 2005.
Nov;72(5):362-5.
feature article
Applying health promotion theories to improve
depressive symptoms through exercise
Dor David Abelman, Andrew Daniel Hanna
Faculty Reviewer: Jennifer D Irwin, PhD, MA, BA (School of Health Studies)
abstract
Considering both the high monetary and emotional costs
associated with caring for patients afflicted with depression,
it is apparent that health professionals should find effective
treatments to ensure that interventions are both cost effec-
tive and risk-reducing. While exercise is generally known to
be important in maintaining general health and wellbeing, nu-
merous studies have also indicated that it can play a critical
role in moderating symptoms of mild to moderate depression.
Globally, research continues to show a powerful reduction in
depressive symptoms due to the benefits of exercise. This re-
view article will highlight the growing perspective regarding
the influence of exercise as a first-line treatment for depres-
sion over pharmacotherapy for patients with mild to moderate
depression. Health promotion theories including the Theory of
Planned Behaviour, Theory of Reasoned Action, and Motiva-
tional Interviewing will be applied.
background
In 2007, an article in Psychosomatic Medicine highlighted the
impact of physical activity on depressive symptoms, suggesting
that its effects may be comparable to antidepressants in a five-year
prospective cohort study of 200 adults.1 Over the next few years,
both a systematic review and Cochrane review suggested that exer-
cise was as effective as pharmacotherapy, if not more effective, as a
treatment method for mild to moderate depression.2,3 Various addi-
tional studies have found that a correlation exists between physical
inactivity and depressive symptoms.4,5 Worldwide, approximately
340 million people are currently afflicted with depression.2 Given
that depression is projected to be the second leading burden of dis-
ease by 2020, it stands to reason that a variety of approaches are
required to best address this issue for patients and the healthcare
system alike.2
The benefits of exercise are diverse and numerous. The Pub-
lic Health Agency of Canada (PHAC) recommends that Canadian
adults be active for at least 2.5 hours every week, combining both
aerobic and resistance training.6 PHAC also advocates that exer-
cise provides secondary health benefits to patients with depression
such as, but not limited to, substantially reducing the risk of chron-
ic diseases and various cancers – and by extension, mortality.6,7
These findings are reflected in the literature and are applicable at
all ages.8,10
contemporary issues
The Canadian Health Measures Survey suggests that less than
UWOMJ 86:2 | Fall 2017 Page 22
one quarter of Canadians are sufficiently active.11 More troubling is
the finding that only 9% of children and youth get their minimum
physical activity recommendations for optimal growth and well-
being.12 Patients have often reported lack of motivation, commonly
induced by their depressive symptoms, as one of the major barriers
to actually engaging in physical activity.13,14 As such, this lack of pa-
tient motivation actually creates yet another barrier as physicians
become reluctant to prescribe exercise, citing preconceived con-
cerns about patient disinterest in engaging in physical activity on
a regular basis.13
A qualitative study on patient perceptions regarding the poten-
tial reduction of depressive symptoms due to physical activity sug-
gested that patients who perceived exercise to be a positive force
in reducing depressive symptoms actually enjoyed significant ben-
efits.14 Furthermore, the study reported that exercise also helped to
improve patients’ eating habits, social interactions, and sleep pat-
terns – factors which indirectly improved their mood, and ultimate-
ly, reduced their depressive symptoms.14
Taking all these factors into account, it is important to improve
both the public’s perception of exercise and their motivation to en-
gage in physical activity. This shift would theoretically help to re-
lieve the reluctance of physicians in prescribing exercise, thereby
“
allowing them to more successfully encourage patients to exercise
in a way that improves depressive symptoms.
Physicians play an important role
in encouraging exercise behaviour
”
but could be more successful
in this task if health promotion
principles were implemented.
learning from health promotion
The difficulties associated with encouraging the public to ex-
ercise are well-known and well-researched in the field of health
promotion.15,16 This section will discuss and examine several theo-
ries and models that may work to encourage the public to engage
in exercise as a means of reduce and prevent depressive symptoms.
The Theory of Reasoned Action (TRA), developed by Ajzen &
Fishbein, helps one predict how an individual will behave by de-
scribing the components that lead to their behavioural decisions.17
Reasoned action refers to the thought process one goes through to
choose their behaviours.17 The theory’s two main components are
personal beliefs and subjective norms.17 Subjective norms can be
feature article
further broken down to normative expectations (what others ex-
pect of an individual) and motivation to comply (the importance
of doing what others expect).17,18 The theory was innovative for its
emphasis on the importance of subjective norms such as social ac-
ceptance and perceived social support to complete a behaviour.17
When applied to exercise, TRA suggests that peer and com-
munity supports (subjective norms) are essential contributors to
an individual’s desire to exercise.18 This directly relates to the chal-
lenge reported in a review done by Blake et al - that physicians were
reluctant to prescribe exercise because their patients had precon-
ceived notions about the importance of adhering to an exercise rou-
tine.13 In other words, the patients may not have the social support
that the TRA says is essential to motivate them to exercise, as per
physician recommendation.17,18
To address the lack of social support to exercise or abide by
physician requests, health education campaigns that portray exer-
cise or abiding by physician requests in a positive manner should
be implemented. Changing the general public’s perception on this
topic may indirectly promote social support to comply to the be-
haviour.19 These campaigns should focus on the importance of ex-
ercise and trusting physicians. Furthermore, they could be more
effective if they promote healthy subjective norms of normative ex-
pectations and motivation to comply.17 Physicians can consider the
principles of TRA while helping a patient understand that their ac-
tions of exercise are socially acceptable (normative expectations) or
very important (motivation to comply).20 This can be done through
displaying media that promotes physical activity to be more appeal-
ing, or counselling a patient about its significance for health and
wellbeing.20
Another relevant theory for health promotion is the Theory of
Planned Behaviour (TPB), an adapted version of the TRA which
adds an additional component into the process of modifying be-
haviour - a person’s perceived control of the behaviour change.18
Planned behaviour describes the process one uses to plan and fulfill
the actions they take.20 The theory identifies perceived opportu-
nities, skills, and resources as important components of assessing
control.18 The difference between an individual’s perceived oppor-
tunities, skills, and resources and the amount they think is required
to make a behaviour change is important to predict their chance
of complying to a behaviour change request.18 This theory, then,
purports the notion that in commencing an exercise regimen, it is
paramount that patients feel they are able to participate in activi-
ties which would provide them with a sufficient amount of agency
and enjoyment.20 Such a notion could come to fruition through a
physician acknowledging the personal interests and preferences of
patients, and by implementing these into their exercise plan so as to
make it more palatable and enjoyable for patients.20
Lastly, another key approach to health promotion is the Mo-
tivational Interview, which is defined as a “client-centered coun-
seling style that helps people to explore and resolve their ambiv-
alence regarding [behaviour] change.”21 The key components of
motivational interviewing are open-ended questions, affirmation
(sincere acknowledgement of a patient’s concerns to validate their
UWOMJ 86:2 | Fall 2017 Page 23
experiences), reflective listening (demonstrating understanding of
a patient’s communication by restating its meaning), and periodical
summarization (distilling and reiterating select communications
from a patient to acknowledge their ideas and to help guide them to
move on).22 Motivational interviewing is different from traditional
patient interviews because of its focus on a patient’s ability to make
their own choices through self-actualization.22 This is achieved
through helping a patient identify discrepancies between their cur-
rent position and where they hope to be, while promoting their per-
ceived self-efficacy to achieve this goal.22
Those attempting to incite any kind of behavioural change –
namely, patient attitudes towards abiding by a prescribed exercise
regimen – will be privy to individual needs through counselling
sessions, during which counselors should: show empathy, listen
respectfully, avoid conflict, and promote means of resolving a pa-
tient’s ambivalence towards engaging in physical activity.22 A me-
ta-analysis has already demonstrated motivational interviewing to
be successful for inciting behavioural changes in a variety of con-
texts, and it is not so far-fetched to claim that it could also be ef-
fective in this particular context.23 A 2014 randomized control trial
found that primary care physicians trained with principles of mo-
tivational interviewing were better able to encourage their patients
with depression to be interested in treatment options and adhere
to them.24
conclusion
Physicians play an important role in encouraging exercise be-
haviour but could be more successful in this task if health promo-
tion principles were implemented. The Theory of Reasoned Action,
the Theory of Planned Behaviour, and Motivational Interviewing
are evidence-based strategies that have been applied successfully
in a variety of contexts to incite behaviour change. More research
in this area could be applied to find the best way to increase exer-
cise as therapy for depression and reduce what could soon be the
world’s second largest burden of disease.
acknowledgements
We would like to thank Dr Jennifer Irwin and Rebecca Me-
harchand for their support, time, and help in completing this proj-
ect.
references
1. Blumenthal JA, Babyak MA, Doraiswamy PM, et al. Exercise and phar-
macotherapy in the treatment of major depressive disorder. Psycho-
som Med. 2007;69(7):587–96.
2. Josefsson T, Lindwall M, Archer T. Physical exercise intervention in
depressive disorders: Meta-analysis and systematic review. Scand J
Med Sci Sports. 2014 Apr;24(2):259–72.
3. Cooney GM, Dwan K, Greig CA, et al. Exercise for depression (review)
summary of findings for the main comparison. Cochrane Database Syst
Rev. 2013;(9).
4. Galper DI, Trivedi MH, Barlow CE, et al. Inverse association between
physical inactivity and mental health in men and women. Med Sci
Sports Exerc. 2006 Jan;38(1):173–8.
feature article

5. Craft LL, Perna FM. The Benefits of Exercise for the Clinically De- ing: a systematic review and meta-analysis. Br J Gen Pract. 2005
pressed. Prim Care Companion J Clin Psychiatry. 2004;6(3):104–11. Apr;55(513):305–12.
6. Public Health Agency of Canada. Physical Activity Tips for Adults 24. Keeley RD, Burke BL, Brody D, et al. Training to Use Motivational
(18-64 years) - Tips to Get Active - Physical Activity - Public Health Interviewing Techniques for Depression: A Cluster Randomized Trial.
Agency of Canada [Internet]. Physical Activity. 2012 [cited 2017 Mar J Am Board Fam Med. 2014 Sep 1;27(5):621–36.
23]. Available from: http://www.phac-aspc.gc.ca/hp-ps/hl-mvs/pa-
ap/07paap-eng.php.
7. Statistics Canada. The 10 leading causes of death, 2011 [Internet].
Health Fact Sheets. 2015 [cited 2017 Apr 4]. Available from: http://
www.statcan.gc.ca/pub/82-625-x/2014001/article/11896-eng.htm.
8. Gregory MA, Gill DP, Shellington EM, et al. Group-based exercise and
cognitive-physical training in older adults with self-reported cognitive
complaints: The Multiple-Modality, Mind-Motor (M4) study protocol.
BMC Geriatr. 2016 Dec 16;16(1):17.
9. Bauman A, Merom D, Bull FC, et al. Updating the Evidence for Phys-
ical Activity: Summative Reviews of the Epidemiological Evidence,
Prevalence, and Interventions to Promote “active Aging.” Vol. 56,
Gerontologist. 2016. p. S268–80.
10. Anand P, Kunnumakkara AB, Sundaram C, et al. Cancer is a prevent-
able disease that requires major lifestyle changes. Pharm Res. 2008
Sep;25(9):2097–116.
11. Statistics Canada. Directly measured physical activity of adults,
2012 and 2013 [Internet]. Canadian Health Measures Survey. 2015
[cited 2017 Apr 4]. Available from: http://www.statcan.gc.ca/pub/82-
625-x/2015001/article/14135-eng.htm.
12. ParticipACTION. Are Canadian kids too tired to move? The 2016
ParticipACTION Report Card on Physical Activity for Children and
Youth [Internet]. 2016 [cited 2017 Apr 4]. Available from: https://www.
participaction.com/sites/default/files/downloads/2016 ParticipAC-
TION Report Card - Highlight Report.pdf.
13. Blake H. Physical activity and exercise in the treatment of depression.
Front Psychiatry. 2012;3(DEC):106.
14. Searle A, Calnan M, Lewis G, et al. Patients’ views of physical activity
as treatment for depression: a qualitative study. Br J Gen Pract. 2011
Apr;61(585):149–56.
15. Teixeira PJ, Carraça E V, Markland D, et al. Exercise, physical activity,
and self-determination theory: a systematic review. Int J Behav Nutr
Phys Act. 2012 Jun 22;9:78.
16. Khatta M. Models and Interventions to Increase Physical Activity
Among Adults: A Historical Review. Top Adv Pract Nurs . 2008;8(1).
17. Ajzen I, Fishbein M. Understanding attitudes and predicting social
behavior. NJ: Prentice Hall: Englewood Cliffs; 1980. 278 p.
18. US Department of Health and Human Services. Appendix 3: Theories
and Models Used in Physical Activity Promotion. Physical activity
evaluation handbook. Atlanta, GA; 2002.
19. Centers for Disease Control and Prevention. Appendix 2: Guide to
Community Preventive Services Recommendations. Physical activity
evaluation handbook. Atlanta. GA; 2002.
20. Godin G. The theories of reasoned action and planned behavior:
Overview of findings, emerging research problems and usefulness for
exercise promotion. J Appl Sport Psychol. 1993;5(2):141–57.
21. Miller WR, Rollnick S. Motivational Interviewing: preparing people
for change. 2nd ed. New York: The Guilford Press; 2002. 428 p.
22. Center for Substance Abuse Treatment. Enhancing Motivation for
Change in Substance Abuse Treatment. Rockville (MD): Substance
Abuse and Mental Health Services Administration (US); 1999. (Treat-
ment Improvement Protocol (TIP) Series, No. 35.) Chapter 3— Motiva-
tional Interviewing as a Counseling Style.
23. Rubak S, Sandbaek A, Lauritzen T, et al. Motivational interview-

UWOMJ 86:2 | Fall 2017 Page 24

feature article
What does ‘holism’ mean in Indigenous mental health?
A review of the literature and suggestions for healthcare professionals
Ranjana Bhattacharjee, Alana Maltby
Faculty Reviewer: Piotr Wilk (Department of Epidemiology & Biostatistics), Martin Cooke (Department of Sociology & Legal Stud-
ies, University of Waterloo)
abstract
In Canada, suicide and depression rates are much higher
among Indigenous populations compared to the general pop-
ulation. Colonial practices, cultural discontinuity, marginal-
ization, and oppression have led to many of the mental health
issues faced by Indigenous populations today. Recent literature
emphasizes the importance of culture in the treatment and
prevention of mental health problems among Indigenous peo-
ples. Unfortunately, Indigenous perspectives on mental health
or wellness in the peer-reviewed literature are often limited.
This review aims to incorporate the grey literature produced
by Indigenous organizations to better describe what ‘holism’
is as it relates to the wellness of Indigenous peoples, and to
identify some practical implications of this understanding for
healthcare providers addressing the needs of Indigenous pa-
tients and clients.
introduction
Suicide and depression rates in Canada are currently much
higher among Indigenous populations compared to the general
population.1 Mental health inequities have been linked to the many
effects of colonization, including the relocation of communities,
forced sedentarization, residential schools, and the ensuing break-
up of Indigenous family structures, social isolation, and poverty.2-5
Recent literature has highlighted the importance of culture in
the treatment and prevention of mental health problems among In-
digenous peoples.5-7 However, the portrayal of Indigenous perspec-
tives on mental health or healing practices in the peer-reviewed
literature is often limited. Indigenous peoples’ understandings
of health are typically described as ‘holistic’ and often refer to a
Medicine Wheel model, balancing the physical, mental, spiritual,
and emotional aspects of life. However, a deeper understanding of
Indigenous peoples’ conceptualizations of mental health, what ‘ho-
lism’ might mean in the lives of patients, and suggestions for appli-
cation in mental health practice, are needed.
Indigenous perspectives on mental health are more easily
found in the grey literature produced by Indigenous organizations
or research groups, using interviews and focus groups with Indig-
enous peoples, Elders, and service providers. The purpose of this
paper is to incorporate this literature to better describe what is
meant by ‘holism’ and to identify some practical implications of this
understanding for healthcare professionals addressing the needs of
Indigenous patients.
UWOMJ 86:2 | Fall 2017 Page 25
holism as ‘balance’
Notions of well-being are holistic, integrating the spiritual,
emotional, physical, and mental dimensions of health.8-10 Balance
between these four dimensions and within each of these spheres
is necessary to maintain not only the health and wellness of a per-
son, but also their family and community.2, 9, 10 This understanding
of well-being is often placed in opposition to ‘Western’ perspectives
that tend to dichotomize mental and physical health.
Spirituality and spiritual balance were given significance
among the literature. Spiritual wellness among First Nations is
achieved through connectedness to beliefs, values, and identity.2
The First Nations Mental Wellness Continuum (FNMWC) de-
scribes spiritual wellness as having ‘hope for the future’.2 FNMWC
is a Canada-wide framework addressing mental wellness among
First Nations in Canada, built through collaboration of the Assem-
bly of First Nations, Health Canada, and community mental health
leaders. Among Métis women, well-being meant understanding
the spiritual dimension, the importance of prayer, and traditional
spiritual practices to gain inner strength and resilience.8  One study
referred to the Inuit use of spirit possession as explanation for dra-
matic changes in individual behaviours.11  
Emotional balance was found to be important in interviews
with First Nations Elders, healthcare providers, and clients, some
of whom believed that loss of emotional control reflected mental
health problems while others thought that it was important to be
comfortable with emotional outpouring.12  Métis women spoke of
the importance of living daily life while managing emotions, in-
cluding releasing negative emotions quickly, being emotionally self-
aware, and accepting of the need to express emotions.8
In terms of the physical dimension of wellness, the FNMWC
describes how the physical self is affected by a person’s ‘way of be-
ing’, which includes daily activities such as employment and ed-
ucation, nurturing, and caregiving.2  For First Nations, taking care
of one’s physical body as the ‘home of one’s spirit’ is important
for physical wellness.2 Métis women linked physical wellness to
healthy diet, being physically active, and being within a safe, clean
environment.8
Mental wellness is described by the FNMWC as intuitive and
rational thought and the understandings that are derived as a result
of a balance between the two.2 Métis women identified intellectual
and mental well-being as learning new things, being curious, and
keeping an active mind.8 This intellectual and cognitive approach
considered mental wellness to be related to having a sense of mean-
feature article
ing of life and thinking about one’s place in the world, as well as
having intuition or ‘inner knowing’.2  Inuit have various terms for
problems with a person’s state of mind, including isumaaluttuq,
meaning “having heavy thoughts”, “being preoccupied”, or “think-
ing too much”.11
connections to community
Well-being is not only an individual issue, but is typically con-
nected to the community. This included the importance of having
strong social networks within one’s cultural or geographic commu-
nity to maintain mental wellness.13 The feeling of belonging was
identified as important for First Nations, as traditional community
living typically included living with extended families and multi-
ple generations.4,9 The FNMWC relates emotional well-being to the
feeling of belonging and connection to families and communities.2
Mussell refers to the importance of “wholeness, balance, the im-
portance of relationships with family, community, ancestors, and
the natural environment”.10 Thus, well-being is not merely an indi-
vidual concern, but a collective process whereby community mem-
bers share in the responsibility of resolution and continual support
during crisis.10 This is a marked difference to the Western concept
of mental health, which focuses on dysfunction and individual cop-
ing strategies.10
A significant part of this collective process is dependent on
intergenerational learning – having Elders and other adults as
role models and teachers for children and young adults.9 This was
thought to occur naturally from traditional extended family and
clan system ways of living.2,9 Stewart describes the importance of
being able to rely on others, including family, relatives, co-workers
and even other communities for promoting good mental health.13
Likewise, Inuit people mentioned the importance of family and kin-
ship, including sharing time together, carrying out daily activities
together, talking about problems, visiting Elders regularly, hugging,
and ensuring family members were happy.14
land, culture, and wellness
Lack of well-being was seen as a result of disconnection from
culture.15 Remedies for this lack of balance included returning to
the land and taking part in the traditional way of life.16 Inuit El-
ders identified “going on the land, hunting, camping, eating coun-
try food, spending time with elders, making traditional tools, skin
clothing, building an igloo, and Inuit beliefs and cosmology” as con-
tributors to wellness.14
Kant and colleagues identified the importance of land use for
Indigenous well-being, along with traditional diets, community
self-governance, and access to cultural sites.17 The inherent con-
nection of traditional food with community is further highlight-
ed by the FNMWC, which describes the nurturing from Mother
Earth that is gained from consuming and sharing traditional food
in feasts, which reinforces bonds between individuals, families, and
communities.2
UWOMJ 86:2 | Fall 2017 Page 26
wellness and Indigenous identity
Among First Nations, communal and ceremonial events also al-
lowed for the sharing of important values and customs, which were
seen as important aspects of wellness.2  For youth, learning from El-
ders about history, language, culture, and stewardship of the land
was seen as helping youth gain a sense of pride in their identity, and
combating feelings of shame and inferiority resulting from colonial
domination.12,15 Having cultural identity as part of one’s personal
identity was thought to contribute to mental wellness.11 First Na-
tions Elders described the importance of knowledge about culture
and heritage and their use in building positive self-concept.12 Com-
munity self-determination or self-governance were empowering
for individuals to make decisions for their well-being with the help
of their families, communities, Elders, and healers.7, 9
conclusions for practice
This brief review provides some additional understanding of
the meanings of “holistic” as it relates to the wellness of Indigenous
peoples. Many of the sources described the fundamental connec-
tions between aspects of individual wellness and the importance
of community, traditional culture and activities, traditional lands
and waters, and pride in an Aboriginal identity as contributors to
Indigenous conceptions of mental wellbeing. We draw three main
recommendations for physicians working with Indigenous popu-
lations.
On a cautionary note, providers should be aware of the diver-
sity of Indigenous populations, including differences in cultural
approaches to health. There is a great deal of cultural and linguis-
tic diversity among Indigenous populations, as well as variation
in personal and community histories and degrees of cultural con-
nectedness. Although the literature revealed some themes that are
potentially important for healthcare providers, these will not apply
to everyone equally. Given this caution, we suggest that healthcare
providers start by firstly being willing to ask new patients/clients
how they identify themselves. We think that doing so would not
only help guide the healthcare provider, but also acknowledge to
patients that their Indigenous identity is considered an important
aspect of their lives.
Second, where possible, healthcare providers should consider
not only the immediate issues that may be affecting their Indige-
nous patients’ mental health but also the historical, political, and
social factors that can impact health. Recognizing the personal and
intergenerational effects of colonization and the holistic nature of
mental wellness is essential for healthcare providers. Furthermore,
given the importance placed on intergenerational reliance and con-
nectedness, whenever possible, opportunities to include families
and Elders in healthcare discussions and treatment should be of-
fered.
Finally, as outlined in the review, individuals can derive very
real benefits from participating in traditional activities- spiritual
prayer, ceremonies, or connecting with food and land of their an-
cestors. Considering this, we encourage healthcare providers with
Indigenous patients/clients to make connections in their area of
feature article

practice with Aboriginal Health Centres, or local Elders and healers

who can provide culture-based counseling or healing for their pa-
tients. More importantly, we recommend healthcare providers offer
these connections to patients as a component of their overall care.

references
1. Government of Canada. The Mental Health and well-being of Aborig-
inal peoples in Canada. Ottawa, ON: Minister of Public Works and
Government Services Canada, 2006.
2. Assembly of First Nations, Health Canada. First Nations Mental Well-
ness Continuum Framework. Ottawa, ON: Minister of Health; 2015. p.
1-64.
3. Kirmayer LJ, Breass GM, Tait CL. The mental health of Aboriginal
peoples: Transformations of identity and community. Can J Psychiatry.
2000;45(7):607-16. PubMed PMID: 11056823.
4. Mussell B, Cardiff K, White J. The Mental Health and Well-Being of
Aboriginal Children and Youth: Guidance for New Approaches and
Services. BC: Sal’i’shan Institute and The University of British Colum-
bia, 2004.
5. National Aboriginal Health Organization. An Annotated Bibliography:
Cultural Intervention Models in Mental Health. 2006.
6. Kirmayer LJ, Valaskakis GG, editors. Healing traditions: The mental
health of Aboriginal peoples in Canada. Vancouver, B.C.: UBC Press
2009.
7. Mental Health Evaluation and Community Consultation Unit, Aborigi-
nal Mental Health Committee, Adult Mental Health Division, Ministry
of Health Services, Syme V, Mussell B. Aboriginal mental health– what
works best? A discussion paper. B.C.: 200.
8. Bartlett JG. Health and well-being for Métis women in Manitoba. Can
J of Public Health 2005;96 (Supplement 1):S22-S7. PubMed PMID:
15686149.
9. Blackstock C. Rooting Mental Health in an Aboriginal World View:
Inspired by Many Hands One Dream. 2008.
10. Mussell B. Restoration of Well-being for Canada’s First Peoples. n.d.
11. Kirmayer LJ, Fletcher C, Watt R. Locating the ecocentric self: Inuit
concepts of mental health and illness. In: Kirmayer LJ, Valaskakis GG,
editors. Healing traditions: The mental health of Aboriginal peoples in
Canada Vancouver, B.C. : UBC Press 2009. p. 289-314.
12. Nelson SE. Don’t call me crazy: Re-envisioning mental health services
for Aboriginal peoples in Prince George. Library and Archives Canada:
University of Northern British Columbia; 2012.
13. Stewart SL. Promoting Indigenous mental health: Cultural perspec-
tives on healing from Native counsellors in Canada. Int J Health Pro-
mot Educ. 2008;46(2):49-56. doi: 10.1080/14635240.2008.10708129.
14. Kral MJ, Idlout L, Minore JB, et al. Unikkaartuit: Meanings of well-be-
ing, unhappiness, health, and community change among Inuit in Nun-
avut, Canada. American Journal of Community Psychology. 2011;48(3-
4):426–38. doi: 10.1007/s10464-011-9431-4. PubMed PMID: 21387118.
15. Vukic A, Gregory D, Martin-Misener R, et al. Aboriginal and Western
conceptions of mental health and illness. Pimatisiwin: A Journal of
Aboriginal and Indigenous Community Health. 2011;9(1):65-86.
16. Kirmayer L, Simpson C, Cargo M. Healing traditions: Culture, commu-
nity and mental health promotion with Canadian Aboriginal peoples.
Austral Psychiatry. 2003;11:S15-S23.
17. Kant S, Vertinsky I, Zheng B, et al. Social, cultural, and land use deter-
minants of the health and well-being of Aboriginal peoples of Canada:
A path analysis. J Public Health Pol. 2013;34(3):462-76. doi: 10.1057/
jphp.2013.27. PubMed PMID: WOS:000322378100009.

UWOMJ 86:2 | Fall 2017 Page 27

feature article
The detrimental effects of obstetric evacuation
on Aboriginal women’s health
Ann Marie Corrado
Faculty Reviewer: Debbie Laliberte Rudman, PhD, OT Reg. (Ont.) (School of Occupational Therapy)
abstract
In Western society, many colonial practices, such as the
removal of Aboriginal women from their communities prior
to birth, still detrimentally affects Aboriginal peoples’ lives.
Health Canada’s evacuation policy for pregnant Aboriginal
women living in rural and remote areas involves nurses, who
are employed by the federal government, coordinating the
transfer of all pregnant women to urban cities at 36-38 weeks
gestational age to await the birth of their baby.1 The policy
states that it is founded on concerns for the wellbeing of Ab-
original women, in an attempt to “curb First Nations’ child and
maternal mortality rates”.1 However, there is a need to prob-
lematize the practice of obstetric evacuation given its colonial
roots and its impact on Aboriginal women. The objective of
this review paper is to explore and bring awareness to some of
the consequences of Canada’s evacuation policy for pregnant
Aboriginal women who live in rural and remote regions. More
specifically, this paper, drawing on ethnographic research pre-
viously conducted with Canadian Aboriginal women on their
lived experiences of prenatal care and birth, will examine the
lack of social support, loss of control, and lack of cultural-
ly competent care that Aboriginal women face. The findings
demonstrate an urgent need for policy makers to also consider
the lived experience of Aboriginal women when making deci-
sions that impact their health.
introduction
Significant health disparities between Aboriginal peoples and
the general Canadian population are well documented.2,3 Health
disparities, such as lower life expectancy and higher rates of chron-
ic diseases,2 are rooted in colonialism, whereby the oppressive
policies of European settlers led to the forced assimilation of Ab-
original peoples.3 These policies included Aboriginal peoples being
required to admit their children into residential schools and giving
up their land.3 This paper focuses specifically on the obstetric evac-
uation policy as part of these practices.
Prior to colonialism, Aboriginal communities had developed
approaches to supporting women to give birth in their commu-
nities, usually assisted by family members and midwives.4 Health
care delivery to Aboriginal peoples started being formalized in 1867
through the British North America Act which granted the feder-
al government authority over “Indians and lands reserved for In-
dians”.1 Nine years later, the Indian Act gave the colonizing forc-
es control over the location and living conditions for Aboriginal
UWOMJ 86:2 | Fall 2017 Page 28
peoples, and Indian agents were given the job of “ensuring First
Nations people became ‘civilized’ enough to ‘assimilate’ into the
broader Euro-Canadian society”.1 Eventually, the need to protect
Euro-Canadians from the spread of communicable diseases led to
the federal government assuming responsibility for delivering pub-
lic health services to Aboriginals living on reserves.1
The colonizers’ control over health resulted in an impactful
shift in the way Aboriginal peoples received healthcare, whereby
the government’s actions undermined culturally based concepts of
health.5 In the late 19th century, for example, Inuit women began
giving birth in newly established nursing stations, assisted by nurs-
es or midwives employed by the federal government.6 Over time
Aboriginal peoples’ traditional birthing practices and care provid-
ers in their communities were eliminated and “women’s bodies
thus became a site upon which colonial goals of civilization and
assimilation could be realized”.1 Existing research highlights the
imperative need to examine how obstetric evacuation affects Ab-
original women’s health, particularly in relation to social support,
control, and care that respects historical traditions.
social support
The lack of social support that Aboriginal women experience
as a result of obstetric evacuation is related to separation from their
families and communities, as well as a lack of support from medical
professionals during labour and delivery. For example, in a study
of two communities in the central Canadian Arctic, the most fre-
quently identified stressor by women as a result of evacuation, is
“the enforced separation from family…and the community”.7 Un-
fortunately, the lack of social support from partners, family and the
wider community cause many women to experience stress, anx-
iety and fear leading up to birth. One woman from Bella Bella, a
small First Nations community in British Columbia, shared “I really
didn’t want to leave because my whole family is here and I wanted
them to be around”.9
The lack of social support Aboriginal women experience pri-
or to birth is problematic as “neither the public nor care provid-
ers fully understand the long term, highly significant benefits of a
well-supported birth”.10 In addition, researchers have consistently
found that women who do not have social support have less positive
experiences of birth, while those with social support “experience
fewer childbirth complications and less postpartum depression”.11
Unfortunately, Aboriginal women have less social support from
family members because of obstetric evacuation and they also per-
ceive a lack of support from hospital staff.
Many Aboriginal women feel that health professionals are not
feature article
supportive during labour. For example, in the same study done in
the Canadian Arctic, the women expressed getting very little sup-
port from the nursing staff during labour.7 Research examining
continuous support during childbirth by a medical professional or
family member suggest that social support results in more sponta-
neous vaginal births and women who are more satisfied with their
birth experience.2 Therefore, it is critical that the evacuation policy
places greater emphasis on the role urban hospital staff play in pro-
viding support to Aboriginal women as they may be the only ones
present with these women during labour and delivery. Otherwise
the policy must be modified to financially support the presence of
family members during labor and delivery.
loss of control
Research also demonstrates that Aboriginal women from the
North often experience a loss of agency when they are given no
choice in where and how they will deliver. Having agency is im-
portant for all individuals as “lack of control over important dimen-
sions of living, in itself contributes to ill health”.13 Although quan-
titative data have supported the evacuation approach by showing
reduced mortality rates among mothers and babies,1 critics have
asserted that the use of specific statistics that show improvement
is simply an attempt to support assimilation by discouraging Ab-
original birthing practices and emphasizing the superiority of the
biomedical model.1
After the policy was put into place, fewer midwives were hired
in relation to community nurses and the shift in staffing resulted in
nurses no longer feeling prepared to provide care to women during
labour and delivery,7 leaving expectant mothers with almost no
choice but to deliver outside their community. One mother shared
her thoughts about the lack of staffing in the community and its re-
lation to safety when she stated, “when you are pregnant you want
to hear that it’s going to be safe…I wasn’t hearing the things I want-
ed to hear so that’s what made me really scared to have my baby
here”.9 The lack of choices and control women have over birth is
problematic because it increases anxiety during pregnancy, which
is associated with “shorted gestation and has adverse implications
for fetal neurodevelopment and child outcomes”.14 Therefore, the
mother’s mental health as well as the baby’s physical health will
suffer with a lack of agency on where to deliver.
culturally competent care
Another consequence of the evacuation policy is that women
often do not receive culturally competent care that is congruent
with their culture.15 Some researchers found that many women ex-
perience “estrangement from larger cultural norms surrounding
birth”9 such as traditional gatherings to honour the new baby after
birth and elders wrapping a piece of umbilical cord in leather for
the baby.16 It is imperative that urban centres and providers enhance
cultural competence as “care that is congruent with the patient’s
culture promotes not only the patient’s health but also the patient’s
sense of well-being because well-being is a culturally determined
phenomenon”.15 Thus, steps can be taken to respect the culture of
UWOMJ 86:2 | Fall 2017 Page 29
Aboriginal women who do give birth in urban centres away from
their homes through integrating traditions that are meaningful to
women and thereby enhancing sense of well-being as they deliver
their babies in an unfamiliar environment.
conclusion
Canada’s obstetric evacuation policy for Aboriginal women
has detrimental effects on health as mothers must travel alone to
unknown cities, where they are not equal partners in the decision
making regarding the birth of their babies and the care they re-
ceive does not honour their cultural traditions. While quantitative
indicators such as infant mortality rates are important to measure
and address, a more holistic policy approach would also attend to
the lived experiences of women who undergo evacuation and the
negative consequences these events can have on their health. An
improved obstetric evacuation policy should address the need to
enhance resources for local delivery so as to both minimize infant
mortality and promote women’s well-being. Ideally, policy makers
should focus on recruitment and retention of culturally competent
staff in communities serving these women so that all women, re-
gardless of culture, can have a well-supported birth that gives them
the opportunity to meaningfully participate and incorporate their
preferences.
references
1. Lawford K, Giles A. Marginalization and coercion: Canada’s evacu-
ation policy for pregnant First Nations women who live on reserves
in rural and remote regions. J Aborig Indigen Commun Health. 2012;
10(3):327-340.
2. Frohlick KL, Ross N, Richmond C. Health disparities in Canada today:
Some evidence and a theoretical framework. Health Policy. 2006
Dec;79(2-3):132-43.
3. Germov J, Hornosty J. Second Opinion: An Introduction to Health
Sociology. Canada: Oxford University Press; 2012.
4. Couchie C, Sanderson S. A report on best practices for returning birth
to rural and remote Aboriginal communities. J Obstet Gynaecol Can.
2007 Mar;29(3):250-260.
5. Kulig JC, Williams AM. Health in Rural Canada. Toronto: UBC Press;
2012.
6. Douglas, VK. Childbirth among the Canadian Inuit: a review of the
clinical and cultural literature. Int J Circumpolar Health. 2006 Feb
8;4(2):117-32.
7. Chamberlain M, Barclay K. Psychosocial costs of transferring in-
digenous women from their community for birth. Midwifery. 2000
Jun;16(2):116-22.
8. Kornelsen J, Grzybowski S. Safety and community: the materni-
ty care needs of rural parturient women. J Obstet Gynaecol. 2005
Jun;27(6):247-254.
9. Kornelsen J, Kotaska A, Waterfall P, et al. Alienation and resilience:
the dynamics of birth outside their community for rural First Nations
women. J Aborig Health. 2011 Mar 20;7(1):55-64.
10. Humenick SS. The life-changing significance of normal birth. J Perinat
Educ. 2006; 15(4):1-3.
11. Gjerdingen DK, Frogberg DG, Fontaine P. The effects of social support
on women’s health during pregnancy, labor and delivery, and the post-
partum period. Fam Med. 1991 Jul;23(5):370-375.
12. Hodnett ED, Gates S, Hofmeyr G, et al. Continuous support for women
during childbirth. Cochrane Database Syst Rev. 2013 Jul 15;7(2):1-100.
13. Seear M. An introduction to international health. (pp.415-437). Toron-
to: Canadian Scholars’ Press Inc; 2012. 415-437 p.
14. Schetter CD, Tanner L. Anxiety, depression and stress in pregnancy:
implications for mothers, children, research, and practice. Curr Opin
Psychiatry. 2012 Mar;25(2):141-148.
15. Narayan MC. Six steps toward cultural competence: a clinician’s guide.
Home Health Care Manag Pract. 2001 Dec 1;14(1) 40-48.
16. Driscoll T, Kelly L, Payne L, et al. Delivering away from home: the
perinatal experiences of First Nations women in Northwes ern Ontar-
io. Can J Rural Med. 2011; 16(4):126-130.
feature article
The ethical concerns of physician recruitment
from Africa to the global North
Ann Marie Corrado
Faculty Reviewer: Ken Kirkwood, PhD (School of Health Studies)
abstract
For decades, medical recruitment agencies have tried to
deal with physician shortages in rural and remote areas of de-
veloped countries by recruiting physicians from areas of scarce
health human resources in the global South. In South Africa
alone, one-third to one-half of medical school graduates mi-
grate to the global North every year, with the majority settling
down in Canada, the United States, and the United Kingdom.1
This review paper aims to bring attention to the unethical prac-
tice of physician recruitment from Africa to the global North.
In particular, it will explore how physician recruitment nega-
tively impacts the donor countries’ economies, compromises
the quality of care they can give their citizens, and provides
only a short term solution to the recipient country. It is critical
that this practice is prohibited and that countries in the global
North look for sustainable solutions within their own borders
to solve workforce shortages.
introduction
Many foreign medical graduates choose to move to developed
countries due to push factors, such as unsafe living conditions and
famine, which cause people to want to move voluntarily.2 Ethical-
ly, the principle of respect for autonomy supports the idea that
individuals have the right to make choices freely and, therefore,
they should move if they desire.3 The ethical problem arises when
physician-recruiting agencies capitalize on pull factors, which are
circumstances in the destination countries, such as better remu-
neration and career opportunities,2 that are emphasized to entice
physicians and motivate them to migrate.4 From an ethical point of
view, this “selective and targeted ‘raiding’ of developing countries’
medical workforce by wealthier countries is not acceptable”.5
In the 1990s, rural and remote regions in Canada experienced
severe physician shortages6 since Canadian-trained physicians of-
ten avoid locating their practices in these communities. As a result,
Canada began looking abroad for foreign-trained physicians who
would be willing to practice in these areas.6 The recruitment efforts
by Canadian provinces have resulted in 60 South African physicians
migrating each year since the 1990s6 and primarily settling down in
the Canadian prairies.7 These foreign doctors are able to bypass the
normal barriers to accreditation and get their full license as long as
they work in the assigned community for 3-5 years through a Re-
turn of Service agreement.7 In the coming years, it is expected that
physician recruitment from Africa will continue as an aging popula-
tion, coupled with changes in physician demographics (specifically
UWOMJ 86:2 | Fall 2017 Page 30
age and gender) in developed nations, will result in doctors working
fewer hours, and therefore, increasing the need for foreign doctors.6
The World Health Organization (WHO) has recently stated
that, “the world faces a global shortage of over 4.3 million doctors,
nurses, and other healthcare professionals”.2 This lack of health hu-
man resources is one of the most urgent global health issues of our
time, with the greatest burden being in developing countries.2 Al-
though Canada and other developed countries actively recruit more
physicians from India and the Philippines, the proportion of Afri-
can-trained physicians is the highest.8 Moreover, any government
that recognizes that their country has a large number of physicians,
such as the Philippines, encourages those doctors to work in the
global North to gain clinical skills, whereas governments in Africa,
such as Kenya’s, do not encourage migration to the global North as
they have extensive unmet health care needs.9
impact on the donor country’s economy
Countries in Africa with scarce economic resources invest a
significant amount of money into their medical students in order
to provide them with free education.10 The justification for these
states subsidizing the cost of medical education is to ensure that
they are investing enough into the production of human capital,
who will later serve the needs of their populations.7 When physi-
cians are recruited to leave their country of origin, it results in a
substantial economic loss to the country.1 For example, each time
a doctor migrates from Kenya to the global North, it creates a pure
economic loss of $517, 931 to the economy.1 This loss of human cap-
ital is problematic as it violates the principle of distributive justice,
which requires the fair distribution of scares resources among
all persons in society.3 Moreover, the principle of justice also re-
quires that “each and every member of the community should re-
ceive an equal share of the benefits and burdens of the cooperative
venture”.11 Physician recruitment is therefore unjust as it ignores
the rights of patients in Africa, themselves taxpayers, who cannot
benefit from the knowledge and skills that physicians have obtained
with the state’s financial assistance.12
Researchers have stated that the only individuals that benefit
financially from the migration pipeline from Africa to the global
North are the physicians who will earn higher salaries and patients
in the recipient country.11 Currently, is no requirement for countries
in the global North, such as those in Canada and the United States,
to compensate the African countries from which they have recruit-
ed physicians.10 As recipient countries’ economies are stimulated,
they are able to solve their own labour shortages in rural areas, and
they save money by not having to train these health professionals.11
feature article
Critics have challenged the ethical concerns relating to the eco-
nomic losses in African countries by asserting that these physicians
will send money back home to their families.4 However, when con-
sidering the principle of non-maleficence, which supports that a
procedure should not harm a patient or society,3 it is evident that
physician recruitment is not ethical. Available evidence suggests
that the harm done to the system is so significant that, even if doc-
tors earn more in the receiving country and send money home, they
cannot compensate for the damaging effects on the local health care
system.4
compromised quality of care
The quality of care patients receive is also impacted by shortag-
es in staff, which leave existing staff with excessive workloads.13 Al-
though the care patients receive is affected by the number of health
personnel regardless of their country of origin, it is more concern-
ing in Africa as Africans make up 10% of the world’s population but
“bear 25% of the global burden of disease”.2 A lack of physicians
results in patients receiving shorter appointments and doctors feel-
ing stressed when attempting to meet the needs of those patients.12
On average, patients are only given 1-5 minutes for their first clini-
cal encounter with the doctor and even shorter interactions at lat-
er appointments.12 These rushed meetings are problematic as they
have been linked to more errors in diagnosis and treatment12 and as
a result many patients die.3 When physicians are recruited by agen-
cies in the global North, the principle of consequentialism, which is
the view that the morally right action is the one that will have the
best overall consequences, is violated.14 The specific consequence
that results is the widening of health inequities between countries
as citizens in Africa have a harder time accessing high quality, pa-
tient-centered care from physicians.
A counter argument to physician recruitment has been that
doctors will one day return to Africa, with advanced skills and
knowledge11 enhancing the quality of care they provide to patients.
However, the WHO has claimed that the number of physicians who
return is very small and in any year the net emigration of healthcare
professionals, such as doctors, is much higher than the net immi-
gration.11 In addition, when doctors do return, healthcare systems
may not be able to utilize the skills doctors have gained because
the technologies and heath infrastructure in Africa is much less ad-
vanced than those in the global north.4
lack of long-term benefits
The benefits of physician recruitment to developed nations,
such as Canada, have been described as ambiguous because physi-
cian recruitment from the global South provides only a short-term
solution for rural and remote areas.7 After doctors obtain their full
licenses and finish their Return of Service agreements, the majority
move to urban centres in other provinces.7 This movement to larg-
er cities, predominately in British Columbia and Ontario, demon-
strates that recruiting doctors from Africa does not solve the work-
force crisis in the developed world.7 Instead, this practice creates
global disparities in health as it first shifts physician shortages to
UWOMJ 86:2 | Fall 2017 Page 31
African countries that are the least suited to cope with a limited
number of doctors due to the high burden of diseases.2 Moreover,
from a utilitarian point of view, recruitment is not ethical. Utilitar-
ianism is the ethical doctrine that finds the right action to be the
one that promotes “the greatest over-all or average happiness”.15
This ethical framework makes it evident that physician recruitment
should not be practiced as it deprives many people in Africa from
accessing healthcare, in order to help rural areas in the global North
for only a short period of time.
conclusion
Although recruitment from Africa may be practiced with the
intention of helping rural and remote areas of developed countries,
it causes a significant amount of harm to the African economy and
affects the quality of care that African citizens receive. Physician
recruitment is problematic as it detrimentally impacts health sys-
tems as well as patient health, for only a short-term benefit in the
recipient country. It is therefore imperative that this practice is
stopped to ensure more equity in healthcare, so that all individuals
can access good quality care regardless of their location. Countries
in the global North must look within their own borders for sustain-
able solutions and create policies to support the retention of their
own physicians in rural and remote areas.
references
1. Huish R. How Cuba’s Latin American School of medicine challenges
the ethics of physician migration. Soc Sci Med. 2009 Aug;69(3): 301-
304.
2. Aluttis C, Bishaw T, Frank MW. The workforce for health in a glo-
balized context – global shortages and international migration. Glob
Health Act. 2014 Jan;7: 1-10.
3. Gillon R. Medical Ethics: Four principles plus attention to scope. Brit
Med J. 1994 Jul16;309(6948): 184-188.
4. Clarke PF, Stewart JB, Clark DA. The globalization of the labour
market for health-care professionals. Int Labour Rev. 2006 Mar;145(1):
37-64.
5. Dauphinee WD. Physician Migration to and from Canada: the chal-
lenge of finding the ethical and political balance between the individ-
ual’s right to mobility and recruitment to underserved communities. J
Contin Educ Health Prof. 2005 Apr;25: 22-29.
6. Wright D, Flis N, Gupta M. The ‘brain drain’ of physicians: historical
antecedents to an ethical debate. Philos Ethics Humanit Med. 2008
Nov;3(4): 1-8.
7. Grant HM. (2006). From the Transvaal to the Prairies: the migra-
tion of South African physicians to Canada. J Ethn Migr Stud. 2006
Aug;32(4): 681-695.
8. Hagopian A, Ofosu A, Fatusi A, et al. The flight of physicians from
West Africa: views from West African physicians and implications for
policy. Soc Sci Med. 2005 Oct;61(8):1750-60.
9. Kirigia J, Gbary AR, Muthuri LK, Nyoni J, Seddoh A. The cost profes-
sionals’ brain drain Kenya. BMC Health Serv Res, 2006 Jul 17;6(89):
1-10.
10. Astor A, Akhtar T, Matallana A, et al. Physician migration: views from
professionals in Colombia, Nigeria, India, Pakistan, and the Philip-
pines. Soc Sci Med. (2005) Dec;61(12): 2492-500.
11. Hooper CR. Adding insult to injury: the healthcare brain drain. J Med
Ethics. 2008 Oct;24(9): 684-7.
12. Aluwihare, APR. Physician migration: donor country impact. J Contin
Educ Health Prof. 2005 Feb;25(1): 15-21.
13. Chickanda, A. Skilled health professionals’ migration and its impact
on health delivery in Zimbabwe. J Ethn Migr Stud. 2006 Aug;32(4):
667-680.
14. Hurley P. Beyond consequentialism. New York: Oxford University
Press; 2009.
15. Philips DC. Encyclopedia of educational theory and philosophy. Los
Angeles: Sage; 2014.
feature article
Moral distress in health care professionals
Ann Marie Corrado, Monica L Molinaro
Faculty Reviewer: Sandy DeLuca, PhD, RN (Arthur Labatt Family School of Nursing)
abstract
Thousands of health care providers currently live and
practice in Canada,1 and each day these providers are present-
ed with new situations from their patients and clients. Many of
these situations require much contemplation, and often both
personal and professional judgment is used to come to a con-
clusion. In many cases, the decision-making process becomes
difficult due to personal and professional beliefs, as well as in-
stitutional and legal requirements placed upon the health care
provider. This phenomenon, known as moral distress, is “when
one knows the right thing to do, but institutional constraints
make it nearly impossible to pursue the right course of action”.2
This work provides a brief introduction to the topic of moral
distress, the systemic factors that can lead to the development
of moral distress, how it manifests in health care providers, and
coping mechanisms used by health care providers to manage
their moral distress.
introduction
In the year 2001, more than 1.1 million (or one in ten employed)
individuals worked in health care in Canada.1 These health care pro-
viders face a myriad of challenges in their day-to-day work, many
of which require considerate and confident decision-making skills,
as well as the ability to understand the short- and long-term impli-
cations of those decisions. First-line professionals must make im-
portant decisions about priority setting in their day-to-day work.3
The decisions they make are complex, as they must often consider
a variety of factors, such as: the best procedure or treatment for an
individual to undergo, both the present and future needs of the indi-
vidual, and the social determinants of health that may largely affect
this individual, such as their socioeconomic status.3 As a result of
making these decisions, health care providers may experience mor-
al distress, potentially further affecting their decision-making and
causing a multitude of negative physical, emotional, and psycholog-
ical effects.4,5
what is moral distress?
Moral distress has been described as one of the most substantial
problems facing health providers.4 Over the years, a range of defi-
nitions have been used to define moral distress, resulting in a lack
conceptual clarity.6 Jameton presented the first definition of moral
distress in 1984, stating: “Moral distress arises when one knows the
right thing to do, but institutional constraints make it nearly impos-
sible to pursue the right course of action”.2 Raines later modified
the definition by Jameton, and explained that constraints could be
more than institutional in nature.7 From Raines’ definition, multiple
UWOMJ 86:2 | Fall 2017 Page 32
works have outlined additional barriers such as internal barriers,
including a lack of confidence, or external barriers, such as legal
constraints and fear of professional reprimands.8-11
what effects does moral distress have on health
professionals?
Researchers have documented that a significant number of neg-
ative effects stem from moral distress, such as physical, emotional,
and psychological symptoms. Moral distress manifests physically
with symptoms such as headaches and diarrhea, and emotionally
with symptoms such as excessive crying.5 In addition, health care
providers have also experienced psychological symptoms, such as
anxiety and depression, as a result of moral distress.4 As an exam-
ple, in a study of nurses experiencing moral distress, many nurses
reported that moral distress affected their personal relationships
and manifested in ways such as a loss of self-worth, development
of depression, and nightmares.5 These negative symptoms pose an
issue for both health care providers and those that they care for, as
they have the potential to interfere with patient care. This study
also found nurses to be divided in believing that the care they were
giving was better, worse, or the same while experiencing moral
distress.5 However, it was speculated that the patients were more
affected than nurses perceived them to be because (1) nurses per-
ceived themselves as ‘good nurses’ and did not want to consider
themselves as bad care givers, (2) when considering quality of care,
they may have only considered physical aspects, and (3) they may
have believed their quality of care was based on the amount of care
they gave, rather than patient outcomes.5 As well, the participants
in this study admitted that their personal and professional relation-
ships and sense of self had been damaged as a result of experiencing
moral distress.5
Additionally, to further illustrate how moral distress has a neg-
ative effect on health care providers, Lazzarin, Biondi & Di Mauro
found that experiencing moral distress has previously caused indi-
viduals to leave their line of work.4 In their study, 13.7% of partici-
pants said they had changed their unit or hospital due to moral dis-
tress.4 In addition, 15.2% of participants said that they had thought
about changing sectors due to moral distress stemming from insti-
tutional obstacles, such as lack of time, medical power, legal limits,
and institutional policy, all factors that made it difficult for them to
work in a more ethical manner.4 For example, health professionals
encountered distress when they were unable to “act in agreement
with their personal and professional values”.4 It is extremely prob-
lematic when professionals change sectors or move, as it disrupts
continuity of patient care—that is, patients having consistency in
the health care professionals that they see. Researchers have found
that patients that had the most clinical continuity were less likely
feature article
to have future hospitalizations than those with low clinician con-
tinuity.12
Furthermore, while a large concern has been of professionals
leaving their unit or hospital, in many cases, an even more concern-
ing consequence of moral distress in health care is the number of
individuals who leave the profession.13-15 This loss of health care
professionals is problematic as we currently have an insufficient
number of trained professionals practicing in Canada.16 It is there-
fore evident that more needs to be done to mitigate the negative
effects of moral distress so that patients are able to access care from
providers in the future.
how do health care professionals cope with moral
distress?
Health care providers have been shown to cope with moral
distress in a multitude of ways, including: breaking administrative
rules, breaking the law, avoiding particular patients, and purposely
avoiding specific duties.3,5 Wilkinson specifically found that nurses
had 2 dominant ways of coping: deny responsibility for their ac-
tions, or act as if they had some control over the situation causing
them stress.5 In a study conducted by Lievrouw et al., 17 oncologists
and 18 oncology nurses from different departments (internal medi-
cine, gastrointestinal surgery, and day clinic) were interviewed and
discussed how they coped with moral distress.17 While there was no
difference in coping style based on the department they worked in,
it was found that there were coping differences between physicians
and nurses. In particular, it was found that nurses focused on their
feelings and experiences while coping, while physicians used a ra-
tional approach.17
what systemic factors lead to moral distress?
While the type of situation and coping style affects how an in-
dividual experiences moral distress, as previously stated, there are
institutional constraints that, in many cases, lead to the develop-
ment of moral distress in the first place. Although there are a variety
of systemic factors that can contribute to the development of moral
distress, this paper will specifically examine 3 of the most common
factors that were brought forward in the literature: understaffing,
a lack of resources, and providing care for terminal patients.5,13,14
When speaking to staffing and resource management, it was found
that many of the health care settings where participants worked
were understaffed, leading to increased workloads, increased stress,
and the inability to provide quality care to their patients.3,13 Addi-
tionally, workplaces with poorly trained staff also led to difficulty in
ensuring quality patient care from these health care providers.13 In-
stitutional constraints are also significant systemic factors that con-
tribute to moral distress.3,7,18 Examples include budget cuts that lead
to understaffing and longer work hours, and institutional require-
ments, such as administering life-sustaining treatment when it may
not be useful. Also, in having no control over these institutional
constraints, the stress of the staff can be compounded. Lastly, moral
distress also frequently arises in caring for patients who have been
deemed terminal.5,15,19 Wilkinson specifically found that performing
UWOMJ 86:2 | Fall 2017 Page 33
unnecessary procedures, and unnecessarily prolonging a patient’s
life were common causes of moral distress.5 These findings were
also reflected in two other studies that found the greatest cause of
moral distress to be the administering of aggressive treatment to
patients who would not benefit from this care.15,19 Additionally, it
was found that in caring for terminally ill patients, moral distress
emerged when nurses had to manage pain symptoms, as they were
concerned that the treatment they administered could potentially
hasten death.19 Distress also emerged when communicating with
patients about their impending death, as they did not want to deter
their patients’ hope of recovery.19
how can the health care system mediate the effects
of moral distress?
In order to mitigate the negative effects of moral distress, it is
imperative that organizations provide staff with support resources
to help them cope, as well as training in ethics. Researchers have
advocated that health professionals should not try and ignore their
moral distress, but instead they should acknowledge it and be of-
fered support on the job to deal with their feelings in constructive
ways.6 In addition, providing health care professionals with on-the-
job training in ethics is critical. These training sessions will allow
them to discuss the ethics around various patient situations and
teach them about the different ways of reasoning.3 This knowledge
is important as it could aid professionals to “understand better their
own process of ethical decision making and create greater readi-
ness for related situations”.3
conclusion
In sum, moral distress is a phenomenon that affects many
health care providers in their day-to-day work. This paper has only
discussed a small portion of the effects of moral distress and the
factors involved in the development of moral distress, as well as
how it can be mitigated. It is imperative to recognize that addition-
al research is warranted to study this phenomenon, in order to fully
understand the effect that it has on health care providers, how sys-
temic factors contribute to the development of moral distress, and
how health administration can develop and improve on supports
and services available to health care providers.
references
1. Health Care in Canada. Ottawa: Canadian Institute for Health Infor-
mation (CIHI) and Statistics Canada; 2005. 117 p.
2. Jameton A. Nursing practice: the ethical issues. Prentice-Hall, Engle-
wood Cliffs, New Jersey; 1984.
3. Kälvemark S, Höglund AT, Hansson MG, et al. (2004). Living with
conflicts – ethical dilemmas and moral distress in the health care
system. Soc Sci Med. 2004 Mar;58(6):1075-1084.
4. Lazzarin M, Biondi A, Di Mauro S. Moral distress in nurses in oncolo-
gy and haematology units. Nurs Ethics. 2012 Mar;19(2): 183-195.
5. Wilkinson JM. Moral distress in nursing practice: experience and
effect. Nurs Forum 1988 Apr;23(1): 16–29
6. McCarthy J, Deady R. Moral distress reconsidered. Nurs Ethics. 2008
Mar;15(2): 254–262.
feature article

7. Raines ML. Ethical decision making in nurses: relationships among

moral reasoning, coping style and ethics stress. JONAS Healthc Law
Ethics Regul. 2000 Mar;2(1):29-41.
8. Burston AS, Tuckett AG. Moral distress in nursing: contributing fac-
tors, outcomes and interventions. Nurs Ethics. 2013 May;20(3):312-24.
9. Epstein, EG. Moral distress, moral residue, and the crescendo effect. J
Clin Ethics. 2009;20(4)330-342.
10. Hamric AB, Davis WS, Childress, MD. Moral distress in health
care professionals. Pharos Alpha Omega Alpha Honor Med Soc.
2006;69(1):16-23.
11. Meltzer LS, Huckabay LM. Critical care nurses’ perceptions of futile
care and its effect on burnout. Am J Crit Care. 2004 May;13(3):202-
208.
12. Mainous AG 3rd, Gill, JM. The importance of continuity of care in
the likelihood of future hospitalization: is site of care equivalent to a
primary clinician? Am J Public Health. 1988 Oct;88(10); 1539-1541.
13. Corley MC. Nurse moral distress: a proposed theory and research
agenda. Nurs Ethics 2002 Nov;9(6): 636–50
14. Corley MC, Elswick RK, Gorman M, et al. Development and evaluation
of a moral distress scale. J Adv Nurs. 2001 Jan;33(2): 250–6.
15. Elpern EH, Covert B, Kleinpell R. Moral distress of staff nurses in a
medical intensive care unit. Am J Crit Care 2005 Nov;14(6): 523–30.
16. Sinha SK, Griffin B, Ringer T, et al. An Evidence-Informed National
Seniors Strategy for Canada – 2nd edition. Toronto (Canada): Alliance
for a National Senior Strategy; 2016.
17. Lievrouw A, Vanheule S, Deveugele M, et al. Coping with moral dis-
tress in oncology practice: nurse and physician strategies. Oncol Nurs
Forum. 2016 Jul;43(4): 505-12.
18. Corley MC, Minick P, Elswick RK, et al. Nurse moral distress and ethi-
cal work environment. Nurs Ethics. 2005 Jul;12(4):381-90.
19. Georges JJ, Grypdonck M. Moral problems experienced by nurses
when caring for terminally ill people: a literature review. Nurs Ethics.
2002 Mar;9(2): 156–78.

UWOMJ 86:2 | Fall 2017 Page 34

feature article
Healthcare systems within the Middle East
Elizabeth Dent, Damilola Toki, Natalie Dupuis, Josiah Marquis, Tharmitha Suyeshkumar, Meriem Benlamri
Faculty Reviewer: Lloy Wylie, PhD, MA (Department of Psychiatry)
abstract
Diverse health systems within the Middle East continue to
experience a high degree of variability with regards to accessi-
bility, capacity, and the quality of care provided within each in-
dividual country. This paper summarizes the unique challenges
and achievements within the healthcare systems of six coun-
tries in the Middle East region. Additionally, the review aims
to provide evidence for how healthcare systems in the Middle
East are managed and sustained despite differences in wealth
and infrastructure, as well as the presence of conflict in certain
areas. Canada can play an important role in supporting these
countries with unique healthcare needs, and in supporting
populations arriving to Canada from these countries.
introduction
Healthcare systems around the world are constantly evolv-
ing in order to adapt to new challenges presented by changes in
the environment, disease patterns, demographics, and a myriad of
other factors that may affect the delivery of healthcare services.1
Many factors have a direct impact on local health systems, includ-
ing a country’s wealth, population size, human resource capacity,
and exposure to conflict.2 This paper will illustrate the heteroge-
neity of healthcare systems across the Middle East by profiling six
countries. The countries included are Oman, United Arab Emirates
(UAE), Egypt, Lebanon, Palestine, and Yemen.
These countries share a similar two-tiered healthcare system
structure, with both public and private streams of financing and ser-
vice delivery. However, there is a great deal of variability of public
and private insurance coverage within a given population, as well as
the amount of cost-sharing that may be required for public health
services. There is a significant range in amount of government
funds allocated towards healthcare across the region. For example,
Oman is considered to be at the higher end of the range, where the
healthcare system is 82% government funded. Meanwhile, Yemen’s
healthcare system is only 28% government funded.1,3 In terms of
infrastructure and organization, health service delivery across the
region varies greatly. Oman has a centralized system, whereas the
remaining five countries are considered to have a decentralized ser-
vice delivery organization.
As the world becomes more globalized and conflicts around
the world cause vast migrations of people from one continent to the
next, Canada can learn from international health systems such as
those in the Middle East in order to prepare for the challenges that
may arise abroad and at home. An awareness of the various vulner-
abilities that can affect a citizen’s health is the first step towards
building a resilient health system, and by observing others this
awareness can occur much faster.
UWOMJ 86:2 | Fall 2017 Page 35
oil wealth
The Persian Gulf states of the Middle East, including the rela-
tively small populations of Oman and the UAE, acquire significant
wealth from the oil industry.2 The wealth attained by these oil-pro-
ducing countries allows them to allocate significant amounts of
resources towards their healthcare systems, providing a means to
further develop their physical infrastructure, healthcare training
programs, and healthcare administration capabilities.2 Addition-
ally, this wealth provides opportunities of forming partnerships at
an international level. These conditions have allowed the UAE to
strive to become a global leader in healthcare, whereby efforts to
advance the current health system include improvements to infor-
mation technology infrastructure and enhancing integration of ser-
vices throughout the Emirates.4 These attributes are driving forces
behind the creation of effective health systems within the Persian
Gulf region, which will continue to play a role in improving the
health of citizens living within this region.4
adequate infrastructure and social determinants of
health
Countries with minimal financial resources and larger pop-
ulations, such as Egypt and Lebanon, often have sufficient infra-
structure, healthcare professionals, and other resources required
to adequately support the delivery of health services in the pop-
ulation.2 Unfortunately, these healthcare systems often result in
health service inequities due to the significant effects of the social
determinants of health, including family income, insurance cover-
age, education, gender, and geographical location, which result in a
wide array of negative long-term health outcomes.5 In Egypt, an in-
dividuals ability to access health insurance and high-quality health
services is heavily influenced by their financial status and income.5
Therefore, an individual who lacks financial resources will ulti-
mately find themselves with a reduced quality of healthcare. This
is the case for 55% of the population, whereby uninsured citizens
must exclusively pay out-of-pocket when accessing healthcare ser-
vices.1
Many of these countries continue to face additional burdens
on their healthcare system from the high influx of refugees fleeing
from nearby conflict zones, as seen in Lebanon. An approximate 4.6
million residents live in Lebanon, including over one million Pales-
tinian and Syrian refugees who have sought refuge from conflicts.6
This has led to significant instability within Lebanon, both struc-
turally and socially, which has negatively influenced access to high
quality healthcare services.1 With an already overstretched health-
care system, utilization of primary healthcare centers for maternal
and child health-related services has increased by approximately
50% since the Syrian refugee crisis in recent years.6 Although there
are ongoing international efforts in supporting the Syrian and Pal-
feature article
estinian refugees currently residing with Lebanon, contributions
are far from being sufficient enough to provide coverage of health-
care services for all individuals residing within the country in an
equitable manner.6
war and conflict
Countries that are currently involved in war or conflict expe-
rience unique and severe complications within their health system.
Examples include Palestine and Yemen, although other Middle
Eastern countries have also experienced similar effects since the
Second World War.2 Conflicts in these countries have placed a great
deal of stress on healthcare systems, affecting infrastructure, orga-
nization, financing, and human resources. For example, the civil
war that has resulted in Yemen over the years has led to only 45%
of the 3507 healthcare facilities within the country to be fully func-
tional.7 Additionally, since only 28% of healthcare financing comes
from government, Yemen cannot provide full health coverage to its
citizens, resulting in cost-sharing and community health insurance
initiatives.1 Within this region, hospitals and healthcare professions
have often been the targets of conflict, thus resulting in a high de-
gree of uncertainty regarding the safety of seeking healthcare ser-
vices and their availability to citizens.8
The geopolitical context in Palestine results in limited freedom
of movement and economic stability due to Israeli occupation. Such
factors introduce major challenges for the maintenance of health
for the Palestinian population.9 Additionally, a lack of political unity
in Palestine leads to the exacerbation of inaccessibly to high-quality
health care services, which already exist due to imposed territorial
segregation.10 Due to years of political instability and conflict, large
waves of Palestinian refugees have escaped to nearby countries. For
the population that remains in Palestine, the UN Relief and Works
Agency, the Ministry of Health, Hamas, NGOs, and private sector
players have been responsible for administering healthcare services
to Palestinians within Gaza and the West Bank regions.11
conclusion
There are many important factors to consider when creating
and maintaining a robust healthcare system within a country. The
highest quality of care appears to be a direct result of sufficient fi-
nances, adequate infrastructure, exceptional governance, and social
stability within the country. There will continue to be significant
challenges to accessing quality care for populations throughout the
Middle East as a result of politics, past and current conflicts, lack
of financial resources, physical and social environments, and the
negative outcomes that are derived from inaccessible medical treat-
ments and healthcare services. These intersectional factors create
unique and complex challenges to ensuring a high quality of life for
residents. By addressing current issues at national and internation-
al levels, with particular focus on the governance, organization, and
financing of health services, opportunities for successful interven-
tions can be created and implemented.
In a similar manner to the Canadian context, anticipating
evolving healthcare needs and appropriately planning and investing
UWOMJ 86:2 | Fall 2017 Page 36
in the future of the system is vital. As stakeholders of the Canadian
healthcare system, we must remain aware of the vulnerabilities that
exist for incoming refugees that result due to previous exposures to
war, conflict, social instability, and consequent unmet health needs.
By adopting a health equity lens and working with the populations
we serve, we must move towards reducing health disparities and
improving overall quality of life for vulnerable individuals who ar-
rive in Canada.
references
1. WHO. Health System Profile: Yemen. EMRO [Internet]. 2006 [Cited
14 Jan 2017]. Available from: http://apps.who.int/medicinedocs/docu-
ments/s17314e/s17314e.pdf.
2. Parkash J, Younis MZ, Ward W. Healthcare for the Ageing Populations
of Countries of Middle East and North Africa. Ageing International.
2015; 40(1).
3. Alshishtawy MM. Four Decades of Progress, Evolution of the Health
System in Oman. Sultan Qaboos University Medical Journal. 2010;
10(1).
4. US-U.A.E. Business Council. The U.A.E Healthcare Sector Report. [In-
ternet]. 2010 [14 Jan 2017]. Available from: http://usuaebusiness.org/
wp-content/uploads/2014/06/HealthcareReport_Update_June2014.
pdf.
5. WHO. Health System Profile: Egypt. EMRO [Internet]. 2006 [Cited 14
Jan 2017]. Available from: http://apps.who.int/medicinedocs/docu-
ments/s17293e/s17293e.pdf.
6. WHO. Lebanon. Country Cooperation Strategy at a Glance [Internet].
2014 [Cited 25 Jan 2017]. Available from: http://apps.who.int/iris/bit-
stream/10665/136909/1/ccsbrief_lbn_en.pdf.
7. WHO. Health system in Yemen Infographic [Internet]. 2016 [Cited 14
Jan 2017]. Available from: http://reliefweb.int/sites/reliefweb.int/files/
resources/yemen-herams-infographic-november2016.pdf.
8. Moszynski P. Attacks on Doctors in the Middle East Need to be Inves-
tigated. BMJ. 2011; 342(7799).
9. Vitullo A, Soboh A, Oskarsson J et al. Barriers to the Access to Health
Services in the Occupied Palestinian Territory: A Cohort Study.The
Lancet. 2012; 380.
10. Bhaiwala Z. Health Under Occupation: Constraints on Access to
Healthcare in the Palestinian Territories [Internet]. 2015 [Cited 14
Jan 2017]. Available from: http://mondoweiss.net/2015/08/con-
straints-palestinian-territories/.
11. Schoenbaum M, Afifi AK, Deckelbaum RJ. Strengthening the Palestin-
ian Health System (Rep.). Santa Monica, CA: RAND Corporation. 2005
[Cited 14 Jan 2017].
feature article
The application of quality improvement
methodologies in surgery
Stephanie Fong
Faculty Reviewer: Sayra Cristancho, PhD (Centre for Education Research & Innovation)
abstract
Quality improvement (QI) practices were originally de-
veloped in the manufacturing industry to reduce unnecessary
steps in a process, minimize error, and provide maximum ben-
efit to the consumer. QI is defined as a formal approach to the
analysis of performance and systemic efforts to improve it. QI
methodologies have been adopted by industries outside man-
ufacturing, including healthcare. In the healthcare environ-
ment, performance consists of many factors including patient
safety, clinical results, and system efficiency. Given the publicly
funded, limited resource environment in which the Canadian
healthcare system operates, the practice of delivering safe,
quality healthcare in an efficient and cost-effective manner is
an important factor in promoting the economic viability and
sustainability of the system. Surgical practice has been iden-
tified as an area in which QI methodologies can be applied,
given its resource intensive nature and highly regulated envi-
ronment. Current research supports the use of QI in surgery,
with interventions showing improvements in non-operative
time, on-time starts, and operating room patient volume. Lim-
itations to the application of QI include the heterogeneity of in-
terventions and variability in terms of procedures and patient
factors. Further high-quality studies are required to support
evidence-based applications of QI in the surgical setting as well
as the greater healthcare environment.
introduction
In Canada’s publicly funded single-payer healthcare system,
the challenge of allocating limited healthcare dollars across a
growing population with increasingly complex medical needs has
healthcare leaders working to identify ways to improve system effi-
ciency without compromising care. Increasing healthcare demands
along with rising treatment and technology costs have led to grow-
ing funding concerns.1 The Canadian Institute for Health Infor-
mation (CIHI) estimates health expenditures to reach $228 billion
or $6,299 per person, representing 11% of Canada’s gross domestic
product (GDP) in 2016. Hospitals make up the largest proportion of
health care spending in Canada at 29.5%.2
Funding challenges in combination with the need to provide
high quality patient care in a fixed resource environment has led
to the increasing application of quality improvement (QI) method-
ologies from industry.3 In the healthcare setting, surgical practice
is an area that presents opportunities for improved efficiency as it
requires a regimented environment and is inherently resource in-
UWOMJ 86:2 | Fall 2017 Page 37
tensive. Small, medium, and large-scale QI initiatives have been
introduced in the surgical setting with the goals of reducing wait
times, improving operating room (OR) efficiency, decreasing op-
erative complications, limiting unnecessary costs, and minimizing
hospitalization duration. The largest portion of surgical dollars is
allocated to the OR4, making it a high priority for QI initiatives. The
purpose of this article is to provide a succinct review of QI method-
ologies and their application in surgery.
quality improvement methodologies
There are several QI methodologies adopted by healthcare
from the manufacturing industry, with select examples listed be-
low:
Continuous quality improvement (CQI) developed from sta-
tistical process control, a method of quality control using statistical
methods. This management philosophy incorporates quality into
processes at the outset, rather than addressing issues as they arise.
CQI is used to reduce waste, increase efficiency, and boost inter-
nal and external satisfaction. Quality improvement is derived from
continuously evaluating performance.1
Total quality management (TQM) is a management approach
to achieve consumer expectations though continuous improve-
ment in the quality of products and processes. In TQM, everyone
involved in the production or use of a product or service is respon-
sible for quality and participates in improving processes, products
and services, and workplace culture. TQM practices include con-
sumer feedback, committed leadership, employee involvement,
process management, and strategic planning.1
Plan-Do-Check-Act (PDCA) or Plan-Do-Study-Act (PDSA)
is an iterative process involving a four-step system to monitor the
effect of a change over time. The initial “planning” step includes
establishing the objectives and processes to deliver results aligned
with the desired output. The second step, “do”, involves small-
scale implementation of the new process. The third step, “check”
or “study”, requires observing differences between the desired and
observed outcome. The final step, “act”, involves analyzing the dif-
ference between expected and observed results and determining
the cause of the disconnect. The process is then repeated.1
Lean methods (“lean”) originated in the Japanese automotive
manufacturing sector in 1990 with the Toyota production system.4
Lean aims to eliminate waste in a system by removing unnecessary
steps in a process pathway while preserving steps that maximize
value to the consumer.3,5,6 Other lean principles include reducing
the time and resources required to generate results for the consum-
er and improving the system’s ability to respond to the changing
feature article
needs of the consumer.7 Value stream mapping in lean management
methods analyze the flow of information and materials required to
produce a product or service.7
Six sigma was developed in 1986 by the Motorola Corporation
and aims to eliminate defects in a system by reducing process vari-
ation through identifying and correcting the causes of errors. The
methodology requires constant data collection and statistical anal-
ysis. The ultimate goal is to operate at a six sigma level, 3.4 defects
per million opportunities (DPMO).1,3,8
Lean six sigma was created in the early 2000s and combines
the waste elimination principle of lean management methods with
the defect reduction focus of six sigma. The two methodologies are
combined in the DMAIC (Define, Measure, Analyse, Improve, Con-
trol) toolkit.1,3
quality improvement in surgery
There are a variety of QI interventions that have been applied
to the surgical setting. Depending on the scale of the initiative, the
degree of human capital and hospital resource requirements vary.
Small-scale interventions can be employed relatively quickly and
require limited human capital.9 An example of a small-scale proj-
ect is standardization of operating instruments, which has been
shown to reduce set up time, counting time, turnover time, and
operative costs. Medium-scale interventions require buy-in from
a larger group of people, one example being an entire OR floor or
group of practitioners. The concept of teaming, where surgeons
work with fixed teams on similar procedures, can reduce OR time.
Cases run more efficiently as teams have an increased familiarity
with instruments and surgeon preferences, as well as an increased
ability to anticipate needs. An example of a large-scale intervention
was studied at Massachusetts General hospital where an “OR of the
Future (ORF)” was created to investigate physical space redesign
on efficiency. In this study, induction and recovery rooms were ad-
joined to improve patient flow and patient beds doubled as gurneys,
reducing patient transfers and improving throughput. The ultimate
result of the ORF was increased capacity to perform two additional
procedures daily.9 Lean processes and six sigma strategies, which
aim to reduce waste and eliminate defects in a system, respectively,
are two of the most recognized QI methodologies in the manufac-
turing industry and have been applied to large healthcare initiatives
with positive results.
In 2013, the Veteran’s Health Administration (VHA) designed
several pilot projects in collaboration with lean experts with the
goal of decreasing wait times, improving access to care, and in-
creasing scheduling efficiency though the implementation of lean
processes.7 The Richard L. Roudebush Veterans Affairs Medical
Center is a tertiary centre in Indianapolis that focused specifical-
ly on reducing surgical wait times within the general surgery ser-
vice. Initial steps involved the meeting of a multidisciplinary group
including surgeons, nurses, OR staff, administrators, and lean ex-
perts to identify and map out a value stream that included current
inefficiencies, delays, and communication breakdowns. The team
then created an idealized value stream and developed strategies
UWOMJ 86:2 | Fall 2017 Page 38
to achieve this future state with the goal of improving access and
reducing wait times. Specific areas targeted included standardiz-
ing work across surgical subspecialties, restructuring consultation
methods, and improving interdepartmental communications. Re-
sults of the study demonstrated increases in patient volume both in
general surgery clinic and in the OR.
Lean and six sigma strategies were also used during a 2008 ini-
tiative undertaken at the Mayo Clinic to enhance operating room
efficiency.8 A global assessment of patient flow from the initial sur-
gical consult to post-operative recovery was conducted. The initial
step in this process was to create a value stream map of patient flow
that detailed location, personnel involved, information technolo-
gy requirements, and bottlenecks. Objectives were then identified
by a multidisciplinary team and included reducing non-operative
OR time, decreasing over and underuse of OR resources, reduc-
ing the redundant collection of patient information, and enhanc-
ing employee engagement. Strategies such as parallel processing
to decrease non-operative OR time and working with information
technology programmers to develop standardized data collection
and terminology across electronic applications were employed.
One of the largest barriers to the success of QI initiatives was em-
ployee engagement. This barrier was addressed by the creation of
a multidisciplinary communication council that acted to resolve
differences between various stakeholder groups and establish clear
expectations for specific roles. Results from this project included
improvements in non-operative time, improvements in on-time
starts, and reductions in the number of cases past scheduled OR
time.8
limitations
There are several challenges in applying QI methodologies
in surgery. The range of patient problems, procedures, and unex-
pected events make it difficult to apply QI initiatives that rely on
minimizing variability. There can also be difficulty in conducting
research into QI. The Hawthorne effect is a process where indi-
viduals modify their behavior due to their awareness of being ob-
served. As applied to QI initiatives, the Hawthorne effect can result
in increased productivity during the observation period that dissi-
pates after the observation period is over, making it difficult to dis-
cern the true effects of the proposed intervention.3,5
Given the research conducted in the field thus far, there ap-
pears to be a role for QI in surgery. Although there are examples in
the literature of successful QI initiatives in surgical practice, high
quality studies are required to support evidence-based manage-
ment for specific indications as current studies and interventions
are heterogeneous and difficult to apply broadly.
conclusion
Reducing system inefficiencies in the surgical setting is neces-
sary in a publicly funded healthcare system with limited resources.
Hospitals comprise the largest proportion of health care expendi-
tures in Canada2 and OR activities tend to be the most resource in-
tensive, thereby making it an attractive target for QI applications.
feature article

Given the economic climate both nationally and internationally,

QI methodologies in surgery constitute an emerging practice that
should be considered at all levels of healthcare organizations, as
they contribute to the financial viability and sustainability of the
Canadian healthcare system for future generations.

references
1. Nicolay CR, Purkayastha S, Greenhalgh A, et al. Systematic review
of the application of quality improvement methodologies from
the manufacturing industry to surgical healthcare. Br J Surg. 2012
Mar;99(3):324-35.
2. Canadian Institute for Health Information. National Health Expendi-
ture Trends, 1975 to 2016. Ottawa, ON: CIHI; 2016.
3. Mason SE, Nicolay CR, Darzi A. The use of Lean and Six Sigma meth-
odologies in surgery: a systematic review. Surgeon. 2015 Apr;13(2):91-
100.
4. Barbagallo S, Corradi L, Goyet JV, et al. Optimization and planning
of operating room theatre activities: an original definition of path-
ways and process modeling. BMC Med Inform Decis Mak. 2015
May;15(38):1-16.
5. Collar RM, Shuman AG, Feiner S, et al. Lean management in academic
surgery. J Am Coll Surg. 2012 Jun;214(6):928-36.
6. Stoutzenberger TL, Kitner SA, Ulrich BL, et al. Using Lean strategies
to improve operating room efficiency. OR Manager. 2014 Jan;30(1):18-
20.
7. Valsangkar NP, Eppstein AC, Lawson RA, et al. Effect of Lean Process-
es on Surgical Wait Times and Efficiency in a Tertiary Care Veterans
Affairs Medical Center. JAMA Surg. 2016 Sep 7. [Epub ahead of print]
8. Cima RR, Brown MJ, Hebl JR, et al. Use of lean and six sigma meth-
odology to improve operating room efficiency in a high-volume tertia-
ry-care academic medical center. J Am Coll Surg. 2011 Jul;213(1):83-92.
9. Fong AJ, Smith M, Langerman A. Efficiency improvement in the oper-
ating room. J Surg Res. 2016 Aug;204(2):371-83.

UWOMJ 86:2 | Fall 2017 Page 39

feature article
Why can’t patients last the wait?
Decreasing substance abuse treatment waiting list attrition
Nicole A Guitar
Faculty Reviewer: John Campbell, PhD (Department of Psychology)
abstract
One million people in North America are currently waiting
for publicly funded substance use treatment. Unfortunately,
long waiting times have been listed as the number one reason
for not seeking treatment for substance use problems. While it
is possible that successful abstinence during the waiting period
convinces patients that they do not need treatment at all, more
emphasis must be placed on interventions that can bridge the
gap between initial contact by patients for substance use treat-
ment and treatment intake. Recommendations in this review
include: (1) decreasing the length of time between a patient’s
initial contact for treatment and the pre-intake interview, (2)
initiating regular phone contact with patients, and (3) decreas-
ing resentful demoralization in patients who are ready for
change but who are forced to wait for treatment.
introduction
Treatment for substance use problems is critical for reducing
and preventing drug-related harms. However, in North America
waiting lists for substance use treatment experience a 50% attrition
rate.1-5 Kaplan and Johri (2000) found that the average tolerance for
waiting for treatment is one month, and that 40% of substance us-
ers will drop from a waiting list within the first two weeks of being
on one.6 According to the Center for Substance Abuse Treatment
approximately one million people are waiting for publicly funded
treatment. Longer waiting times are consistently associated with a
lower likelihood of treatment entry and are indicated as the num-
ber one deterrent from seeking treatment.7-11 In a 2009 study with
120 heroin users seeking methadone treatment, only 20.8% of those
placed on a waiting list entered treatment four months later.7 The
patients indicated that the idea: “I will have to be on a waiting list
for treatment” was their greatest barrier to treatment entry.8 Sim-
ilarly, the most frequently stated reason for not seeking help is the
expectation of a long waiting time.10 Patients seeking substance use
treatment also experience high psychosocial distress while on wait-
ing lists.11
Whether attrition occurs because of demographic, socio-eco-
nomic, social support, substance related or mental health predic-
tors, discovering how to prevent waiting list attrition could aid
treatment facilities to designate treatment sooner and more effi-
ciently. Some researchers argue that demographic factors can pre-
dict waiting list attrition.12-15 Socio-economic and social environ-
ment factors have also been considered as predictors for waiting
list attrition.12,16,17 Substance related predictors such as: abstinence,
UWOMJ 86:2 | Fall 2017 Page 40
harm reduction, past treatment, history of overdose, readiness for
change and drug of choice have also been examined alongside men-
tal health status, the number of suicide attempts, mental health
diagnoses and past treatments attempts.12,16-19 Unfortunately, there
remains no conclusive answers regarding who is the most at risk
for substance use waiting list attrition and much of the current data
conflicts. Therefore, current approaches should emphasize meth-
ods that can be used to decrease substance abuse treatment waiting
list attrition in general, as opposed to identifying those most at risk.
why patience is not enough
Various theories have been proposed to explain why patients
disappear from waiting lists at such high rates. Redko, Rapp and
Carlson (2006) hypothesize that the request for abstinence during
the waiting period convinces patients that their successful absti-
nence is a sign that they do not require treatment at all. The re-
searchers also suggest that the longer a waiting time becomes, the
more opportunities patients have for other life events to arise that
interfere with treatment entry.16 These authors further argue that if
self-help groups are implemented during the waiting period, then
patients show a decreased rate of attrition. Housing assistance, case
management, regular phone contact, motivational interviewing and
parental involvement for youth cases all decrease waiting list attri-
tion.2,20,21 In contrast, research also suggests that too many demands
or requirements of patients during the waiting period is a deterrent
for waiting.8 In a pre-treatment survey, 16% of patients indicated
that “I will have to go through too many steps to get into treatment”
was a large barrier to entering treatment, along with the fact that
they would have to be on a waiting list in the first place (34.3%).8 An
inability to access substance use treatment is commonly associated
with increased substance use.22
recommendations for bridging the gap
Schedule Pre-Intake Interviews Immediately
Scheduling pre-intake appointment interviews immediate-
ly when new patients request them could have a profound influ-
ence on patient success. Patients are 33% less likely to arrive for
intake appointments scheduled only 24 hours after an initial phone
call requesting one.23 Therefore, these appointments must happen
immediately to ensure patients make it into treatment. Albrecht,
Lindsay and Treplan (2011) suggest that the length of time between
placing a call to a treatment facility and the scheduled pre-intake
interview is a significant predictor of pre-intake dropout.23 Initial
appointments must be made as soon as patients seek them. When
feature article
patients are ready for change they need to be validated and assist-
ed immediately. Research shows that if a patient indicates they are
ready for change and are told they will be on a waiting list, the effect
is detrimental.
Initiate Weekly Phone Contact
Patients on a waiting list must receive weekly phone calls from
the treatment facility and must not be responsible for maintaining
contact. When patients are called by the facility every week, they
are 30-40% more likely to enter treatment when compared to situ-
ations where the patient is responsible for maintaining contact.21 In
a study of 654 patients waiting for publicly funded drug treatment
in Washington, D.C., 70% of patients successfully entered treat-
ment when they were regularly contacted by telephone.2 Donohue21
suggests that reminder phone calls 2-3 days prior to patient’s first
appointment also produce 30-40% higher attendance rates when
compared with patients who did not receive reminder phone calls.
Prevent Resentful Demoralization
Patients must be treated as though their treatment has started
even when they are on a waiting list. Evidence shows that patients
who are ready for treatment and are placed on a waiting list use an
average of 6 more drinks per week.24 Participants in a Check Your
Drinking online intervention were asked to monitor and record
their alcohol consumption habits. Two groups of alcoholics partic-
ipated in this study, and for one group the mere act of being told
they were on a waiting list while completing the online intervention
caused them to drink an average of 6 more drinks per week, despite
both groups being provided identical online interventions. The re-
searchers termed this phenomenon “Resentful Demoralization”. It
cautions against putting motivated patients on waiting lists and has
profound implications for their treatment success.24 It also has im-
plications for the language health care providers use with patients
who are on waiting lists for treatment.
conclusion
Preventing waiting list attrition is an important step in reduc-
ing and preventing substance-related harms. Recent research from
Israel shows that there is significant threat to patients’ lives while
they are on waiting lists.9 Of 608 patients seeking opiate treatment,
only 60.2% were admitted to treatment. Of the 242 individuals re-
maining on a waiting list after two years, 24 died. The mortality rate
was 10 times higher for non-treated addicts compared to those who
were admitted to methadone maintenance treatment.9 For those
patients who were not admitted to treatment, 47.9% were unable
to be contacted, 18.2% reported newfound abstinence, 0.04% were
rejected for violent behaviour and 5.4% of the patients on the wait-
ing list died. This highlights the need for easily accessible, publicly
funded substance use treatment. Therefore, a goal must be deter-
mining how to decrease substance use waiting list attrition. Sched-
uling pre-intake interviews immediately, initiating weekly phone
contact and preventing resentful demoralization are excellent steps
forward in the prevention of waiting list attrition.
UWOMJ 86:2 | Fall 2017 Page 41
references
1. Stark MM, Campbell BB, Brinkerhoff CC. “Hello, may we help you?” A
study of attrition prevention at the time of the first phone contact with
substance-abusing clients. Am J Drug Alcohol Abuse, 1990; 16:67-76.
2. Donovan DM, Rosengren DB, Downey L, et al. Attrition prevention
with individuals awaiting publicly funded drug treatment. Addiction,
2001; 96:1149-1160.
3. Festinger DS, Lamb RJ, Kountz MR, et al. Pretreatment dropout as a
function of treatment delay and client variables. Addict Behav. 1995;
20:111-115.
4. Hser Y, Maglione M, Polinsky ML, et al. Predicting drug treatment
entry among treatment-seeking individuals. J Subst Abuse Treat, 1998;
15(3):213-220.
5. Kaplan EH, Johri M. Treatment on demand: An operational model.
Health Care Manage Sci, 2000; 3:171-183.
6. Chun J, Guydish JR., Silber E, et al. Drug treatment outcomes for per-
sons on waiting lists. Am J Drug Alcohol Abuse. 2008; 34:526-533.
7. Gryczynski J, Schwartz R, O’Grady K, et al. Treatment entry among
individuals on a waiting list for methadone maintenance. Am J Drug
Alcohol Abuse. 2009; 35:290-294.
8. Rapp RC, Xu J, Carr CA, et al. Treatment barriers identified by sub-
stance abusers assessed at a centralized intake unit. J Subst Abuse
Treat, 2006; 30:227-235.
9. Peles E, Schreiber S, Adelson M. Opiate-dependent patients on a
waiting list for methadone maintenance treatment are at high risk for
mortality until treatment entry. J Addict Med, 2013; 7:177-182.
10. Notley C, Maskrey V, Holland R. The needs of problematic drugs
misusers not in structured treatment–a qualitative study of perceived
treatment barriers and recommendations for services. Drug Ed Prev
Pol, 2012; 19:40-48.
11. Nordfjaern T. Prevalence of substance use and mental distress among
patients on waiting lists for substance use disorder treatment. J Psy-
choactive Drugs, 2013; 45(3):233-240.
12. Mueser KT, Yarnold PR, Rosenberg SD, et al. Substance use disorder
in hospitalized severely mentally ill psychiatric patients: Prevalence,
correlates, and subgroups. Schizophr Bull, 2000; 26:179-189.
13. Lister ES, Scott J. Did not attend: Characteristics of patients who fail
to attend their first appointment at a psychiatric out-patient’s clinic.
Health Trends, 1988; 20:65-66.
14. Farid B, & Alapont E. Patients who fail to attend their first psychiatric
out-patient appointment: Non-attendance or inappropriate referral? J
Mental Health, 1993; 2:81-83.
15. Love J, & Gossop M. The processes of referral and disposal within a
London Drug Dependence Clinic. Brit J of Addict, 1985 ;80:435-440.
16. Redko C, Rapp RC, & Carlson RG. Waiting time as a barrier to treat-
ment entry: Perceptions of substance users. J Drug Issues, 2006;
36(4):831-852.
17. James I, & Milne J. Opting into treatment: Increasing the rate of first
appointment attendance with a community addiction team. J Mental
Health, 1997; 6(3):281-288.
18. Miller BA, Pokorny AD, & Hanson PG. A study of dropouts in an in-pa-
tient alcoholism treatment program. Diseases Nervous System, 1968;
29(2), 91-99.
19. Caplehorn JRM, Dalton MSYN, Cluff MC, et al. Retention in metha-
done maintenance and heroin addicts risk of death. Addiction. 1994;
89:203-207.
20. Winn JL, Shealy SE, Kropp GJ, et al. Housing assistance and case
management: Improving access to substance use disorder treatment
for homeless veterans. Psychol Services, 2013; 10:233-240.
21. Donohue B, Azrin NH, Lawson H, et al. Improving initial session
attendance of substance abusing and conduct disordered adolescents:
A controlled study. Child Adolesc Subst Abuse, 1998; 8:1-13.
22. DeBeck K, Kerr T, Nolan S, et al. Inability to access addiction treat-
ment predicts injection initiation among-street involved youth in a Ca-
nadian setting. Subst Abuse Treatment Prevention Policy. 2016; 11:1-5.
23. Albrecht J, Lindsay B, & Terplan M. Effect of waiting time on sub-
stance abuse treatment completion in pregnant women. J Subst Abuse
Treatment. 2011; 41:71-77.
24. Cunningham JA, Kypri K, McCambridge J. Exploratory randomized
controlled trial evaluating the impact of a waiting list control design
Med Resea Method. 2013; 13:150-156.
feature article
Vicarious trauma and secondary traumatic
stress in health care professionals
Nicole A Guitar, Monica L Molinaro
Faculty Reviewer: Paul Frewen, PhD (Department of Psychology)
abstract
Three-quarters of Canadians are exposed to a traumatic
event sufficient to cause psychological trauma in their lifetime.
In fact, post-traumatic stress disorder is a global health issue
with a prevalence as high as 37%. Health care professionals
trained to provide mental health treatment for these individ-
uals are at risk of developing vicarious trauma and secondary
traumatic stress, both of which result in adverse symptoms
for the health care provider that often mimic post-traumatic
stress disorder (PTSD). Vicarious trauma develops over time
as the clinician is continually exposed to their clients’ traumat-
ic experiences, while clinicians experiencing secondary trau-
matic stress begin to experience the symptoms of PTSD due
to secondary exposure of the traumatic event. Both vicarious
trauma and secondary traumatic stress cause mental, physical,
and emotional issues for health care professionals that include
burnout and decreased self-worth. Health care systems and ad-
ministration should aim to develop training and professional
education for health care providers. This review will empha-
size what factors lead to the development of vicarious trauma
and secondary traumatic stress, and what aids or supports can
be implemented to treat the symptoms. The implications for
policy development and training will be discussed.
Based on current statistics, 1 in 5 Canadians will experience a
mental health or addiction problem in their lifetime, and 50% of in-
dividuals over 40 years of age will experience some form of mental
illness.1 Mental illness is one of the leading causes of disability in
Canada.2-4 There are a variety of health care professionals trained to
provide mental health treatment to patients who seek it; however,
these health care professionals may be vicariously affected by their
clients while providing care. This paper will discuss the concepts
of vicarious trauma (VT) and secondary traumatic stress (STS) in
health care providers, what factors lead to the development of VT
and STS, and what aids or supports can be implemented to assist
individuals affected by VT and STS.
Vicarious trauma refers to negative changes that can occur in
a health care provider that specifically alter their beliefs regarding
themselves, others, and their worldview.5,6 VT results from expo-
sure to individuals who have undergone traumatic experiences.5,6
The concept of VT was developed using constructivist theories
which posit that learning is a constructive process where people
actively construct their own subjective representations of subjec-
tive reality.7 Clinicians can experience VT when exposed to their
UWOMJ 86:2 | Fall 2017 Page 42
patients’ traumatic experiences which triggers negative beliefs
about safety, power, independence, esteem, and intimacy.6 VT can
also lead to “decreased motivation, efficacy and empathy”.7 Typical-
ly, VT develops over time as an individual is continually exposed to
their clients’ experiences, and often manifests mentally while pre-
senting as symptoms that align with post-traumatic stress disorder
(PTSD).6
Secondary traumatic stress, often referred to incorrectly as
“compassion fatigue”,8 describes a set of symptoms similar to those
of PTSD,5,8,9 such as “exhaustion, hypervigilance, avoidance, and
numbering”.8 STS can occur in health care professionals, family
members, friends, and caregivers of individuals who have experi-
enced traumatic events, and who often have post-traumatic stress
themselves.5,8-10 Individuals experiencing STS do not experience
the traumatic events first-hand; instead, due to secondary exposure
of the traumatic event, they begin to experience the symptoms of
PTSD.5,8-10
Vicarious trauma and secondary traumatic stress have many
similarities and while the two terms are meant to describe different
experiences, they are often used interchangeably to represent the
same phenomenon.5 However, VT and STS represent two distinct
experiences and they apply to different populations.10 STS can be
experienced by multiple sets of individuals, while vicarious trau-
ma applies only to those individuals in direct care positions, such
as first responders, health care providers, and social workers.10 STS
and VT can be clearly differentiated by examining the length of
manifestation of these two disorders. STS typically manifests for a
shorter period of time compared to VT.5 For example, STS can oc-
cur in an emergency response worker or response team, who has a
limited exposure time to the individual experiencing trauma, which
differs from the development of VT and “the experience of a psy-
chotherapist bearing witness to years of sexual abuse”.5
Individuals who provide care or treatment for trauma-related
incidents are at a significantly higher risk for the development of
STS and VT, since the symptoms of these disorders present them-
selves after “exposure to traumatic experiences described by their
clients”.10 There are risk factors specific to the development of VT
and STS. Previous studies have reported that an individual’s person-
al history of trauma is directly linked to the development of VT.5,11-14
Additionally, the amount of time spent with patients or clients who
have experienced trauma, and the proportion of trauma cases that
a health care provider treats, are predictors for the development
of VT.15 Personal trauma history and the quantity of exposures to
different patients and their traumatic experiences are significantly
linked to the development of STS.5,11-15 Health care providers treat-
feature article
ing PTSD with cognitive therapies are at greater risk for VT and
STS because many psychological treatment methods require pa-
tients to provide a detailed account of their traumatic experience.8
By providing therapy for individuals that can manage symptoms of
their PTSD, the health care provider is at a greater risk of develop-
ing STS themselves.8
Both secondary traumatic stress and vicarious trauma manifest
in particular ways. In a study conducted by Baird & Kracen (2006),
it was found that VT “is associated with disruptions to schemas”
in five areas: (1) safety, (2) trust, (3) esteem, (4) intimacy, and (5)
control, each of which represent a crucial “psychological need”.5
Schemas represent patterns of thought that organize categories of
information.5 VT negatively affects these five important schemas,
and can create a health care provider’s perception that there is a
lack of safety in their own world.5,7 In contrast, STS often manifests
physically as “exhaustion, hypervigilance, avoidance, and numb-
ing”5 and is specifically associated with PTSD.
VT and STS can be mediated or prevented in multiple ways.
Health care systems and administration can aim to develop training
and professional education for VT and STS in health care provid-
ers, and seek to evaluate existing programs for efficacy and areas
of improvement.5 Specifically, health care professionals need re-
sources and improved clinical training, with additional resources
and treatment availability for individuals who have been affected by
VT or STS.10 Health administrators should take actions to decrease
health care provider’s caseloads, increase leave time for health care
professionals, increase supervision and staff support, and increase
the development and provision of additional mental health resourc-
es.10,16 Health care providers should ensure that they are cognizant
of the symptoms of VT and STS and that they are participating in
their own self-care, maintaining their personal and professional ob-
ligations and activities, and reflecting on any cognitive or physical
changes they may experience.10
VT and STS pose many mental, physical, and emotional prob-
lems for health care professionals, including burnout, decreased
self-worth and low morale.17,18 This can lead to higher staff turnover,
as well as decreased productivity amongst health care profession-
als.17 Nevertheless, recent research suggests that in a small number
of cases, health care providers affected by VT and STS may develop
vicarious resilience in the form of strength, growth, and empower-
ment arising from an optimism for hope and change.16 This idea has
implications for policy development and health care practices that
encourage health care providers to share both positive and negative
work experiences as part of the prevention and treatment of VT and
STS.
references
1. Smetanin P, Stiff D, Briante C, et al. The life and economic impact of
major mental illnesses in Canada: 2011-2041. Prepared for the Mental
Health Commission of Canada. 2011. Toronto: RiskAnalytica.
2. Lim K, Jacobs P, Ohinmaa A, et al. A new population-based measure
of the burden of mental illness in Canada. Chronic Disease Can, 2008;
28: 92-8.
3. Mental Health Commission of Canada [Internet]. Ottawa (ON): Mental
UWOMJ 86:2 | Fall 2017 Page 43
Health Commission of Canada; c2014. Why investing in mental health
will contribute to Canada’s economic prosperity and to the sustainabil-
ity of our health care system; c2014 [cited 2017 March 20]. Available
from: http://www.mentalhealthcommission.ca/English/media/3104
4. Institute for Health Metrics and Evaluation [Internet] Seattle (WA):
Institute for Health Metrics and Evaluation; c2015. Global Burden
of Diseases, Injuries, and Risk Factors Study, 2013; c2015.[cited 2017
March 20]. Available from: http://www.healthdata.org/data-visualiza-
tion/gbd-compare
5. Baird K, Kracen AC. Vicarious traumatization and secondary traumat-
ic stress: A research synthesis. Counsl Psych Quart 2006; 19(2):181-188.
6. Pearlman LA, Saakvitne KW. Trauma and the therapist: Counter-
transferance and vicarious traumatization in psychology with incest
survivors. New York: W. W. Norton; 1995.. 451 p.
7. McCann IL, Pearlman MM. Vicarious traumatization: A framework
for understanding the psychological effects of working with victims. J
Traumatic Stress 1990; 3:131-149.
8. Figley C. Compassion Fatigue. New York: Bruner/Mazel; 1995. 292 p.
9. Stamm B (Eds). Secondary traumatic stress: Self-care issues for clini-
cians, researchers, and educators. Lutherville MD: Sidran Press; 1999.
332 p.
10. Elwood LS, Mott J, Lohr JM, et al. Secondary trauma symptoms in cli-
nicians: A critical review of the construct, specificity, and implications
for trauma-focused treatment. Clinical Psych Rev. 2011; 31:25-36.
11. Camerlengo H. The role of coping style, job-related stress, and person-
al victimization history in vicarious traumation of professionals who
work with abused youth. Doctoral dissertation, Rutgers University,
New Jersey.
12. Dickes SJ. Treating sexually abused children versus adults: An ex-
ploration of secondary traumatic stress and vicarious traumatization
among therapists. Doctoral dissertation, California School of Profes-
sional Psychology, Fresno.
13. Pearlman LA, MacIan PS. Vicarious traumatization: An empirical
study of the effects of trauma work on trauma therapists. Prof Psych
Resea Pract 1995; 26:558-565.
14. Trippany RL. Predictors of vicarious traumatization: Female therapists
for adult survivors versus female therapists for child survivors of sexu-
al victimization. 2000. Doctoral dissertation: University of Alabama.
15. Brady, JL, Guy JD, Poelstra PL, et al. Vicarious traumatization, spiri-
tuality, and the treatment of sexual abuse survivors: A national survey
of women psychotherapists. Professional Psychology, Research and
Practice. 1999; 30(4):386-393.
16. Puvimanasinghe T, Denson LA, Augoustinos M, et al. Vicarious
resilience and vicarious traumatization: Experiences of working with
refugees and asylum seekers in South Austrailia. Transcultu Psych.
2015; 52(6):743-765.
17. Showalter SE. Compassion fatigue: What is it? Why does it matter?
Recognizing the symptoms, acknowledging the impact, developing the
tools to prevent compassion fatigue and strengthen the professional
already suffering from the effects. Am J Hospice Palla Med. 2011;
27(4):239-242.
18. Simon CE, Pryce JG, Roff LL, et al. Secondary traumatic stress and
oncology social work: Protecting compassion from fatigue and com-
prising the worker’s worldview. J of Psychosocial Oncology. 2005;
23(4):1-15.
feature article
Parsing Anhedonia: A reverse-translational strategy
for treatment of anhedonia in clinical populations and
potential implications of conditioned motivators
Roger Hudson
Faculty Reviewer: Steven Laviolette, PhD (Department of Anatomy and Cell Biology)
abstract
Anhedonia is defined as reduced interest or pleasure in
activities previously considered enjoyable and is a cardinal
symptom of many neuropsychiatric disorders including ma-
jor depression, schizophrenia and substance dependence.
Pleasurable experiences involve a variety of psychobiological
components including learning, memory and motivation that
influence engagement with rewarding events and can there-
fore impact affective responding. Despite the capacity to dis-
sociate these processes in humans and nonhuman animals,
contemporary preclinical animal models of anhedonia empha-
size responses to immediately pleasurable stimuli including
palatable food and drugs of abuse. This limits translatability
to the clinic as human patients exhibiting anhedonia largely
display normalized responsivity to pleasurable stimuli and in-
stead show deficits in responding for associative cues. Condi-
tioned motivators can serve to bridge the gap between clinical
and preclinical knowledge, as they can be dissociated into each
independent component process associated with anhedonia.
Following several distinct temporally-contingent associations
with reward, neutral stimuli acquire meaning and become con-
ditioned motivators, which can be uniquely manipulated to
parse several component processes within a variety of tasks.
Thus, the properties of conditioned motivators in anhedonia
and the neural substrates underlying them will be critical in
translating knowledge about these independent neuropsychi-
atric processes to the clinic. This review emphasizes the utili-
zation of ‘reverse-translation’, integrating patient-based find-
ings with preclinical animal models to experimentally parse
component processes of anhedonia and develop holistic exper-
imental models to measure it. Dissociating the independent,
measurable component processes of anhedonia is critical for
accurate representation in preclinical animal models and for
acceleration of treatment strategies to the clinic.
introduction
Healthcare systems have naturally relied on preclinical animal
models to reveal potential indications of etiology and diagnosis, fos-
ter drug discovery, and guide treatment regimens in clinical popula-
tions. The term ‘translational research’ has been devised to describe
this approach of exporting basic research findings into clinical
practice.1,2 Although experimental animal models are indispensable
UWOMJ 86:2 | Fall 2017 Page 44
in terms of informing future medical practice, clinical discoveries
are evidently shaping the aims and directions of preclinical neuro-
psychiatric research.2,3 Indeed, evolving diagnostic criteria and in-
sights into the nature of clinical phenomena continue to refine our
understanding of psychiatric illness.4 This method of drawing on
patient-based findings to develop assays that measure the funda-
mental characteristics of clinically relevant symptoms in preclinical
animal models is known as ‘reverse-translational research’.5,6
Anhedonia presents as a fundamental symptom in many psy-
chiatric disorders including major depression, substance depen-
dence and schizophrenia, among others which affect significant
portions of the population worldwide.7-9 Despite its prevalence,
there has been limited success in developing novel treatments for
anhedonia.10 One major reason for this dearth may be the lack of
precision in preclinical animal models of anhedonia, the majority
of which emphasize hedonic responses to primary reinforcers (re-
wards) such as palatable food, drugs of abuse, sex, and sociabili-
ty.11,12 However, evidence suggests that human patients exhibiting
anhedonia frequently display normal subjective reports of ‘liking’
for primary rewards.13-15 Rather, deficits in hedonic responding can
be better characterized by responses to conditioned stimuli which
have become associated with primary reinforcers through numer-
ous contingent pairings, such as contextual or associative cues that
signal reward.16-18 An example of a response engendered by a condi-
tioned motivator would be that of an alcohol addict to the sight or
presence of a beer bottle.
The following review emphasizes ‘reverse-translational’ strat-
egies, integrating patient-based findings with preclinical models
to experimentally parse component processes of anhedonia (see
Figure 1) and develop holistic experimental models to measure it.
Shortfalls from insufficient models are addressed and some exist-
ing examples of this strategy are highlighted including models that
have provided insight into neurobiological mechanisms underlying
anhedonia. Parsing anhedonia into its independent, measurable
component processes is critical for accurate representation in pre-
clinical animal models and for accelerating treatment strategies to
clinical populations.
dissociating component processes of anhedonia
Exposure to rewarding stimuli stimulates memory consolida-
tion and increases the prospect that behaviours that lead to reward
will be performed in the future.19 Rewarding stimuli can be catego-
rized as 1) primary rewards that are instinctively and consciously
feature article
pleasurable, including sexual intercourse, food, and drugs of abuse;
and 2) secondary rewards—neutral stimuli that gain emotional val-
ue as they become reliable predictors or ‘cues’ of primary rewards
through multiple contingent pairings.20,21 Despite pervasive assess-
ment of primary rewards in preclinical animal models of anhedo-
nia, responses to associative secondary rewards that require cogni-
tive appraisal and specific learned behavioural responses may more
accurately reflect the complexity of the human condition in ways
that primary reward assays are not capable of capturing due to the
nature of component processes underlying anhedonia.14,16,22
Despite more than a century since anhedonia was originally
defined as an “inability to feel pleasure”23 and the proposal of co-
pious preclinical animal models to characterize it,11,12 therapeutic
interventions remain only partially effective.10 This may be due to
discrepancies between clinical anhedonia and representations of
anhedonic-like phenotypes in preclinical animal models.12,14,24 In-
deed, anhedonic patients often display normal affective facial reac-
tions and subjective pleasure ratings relative to healthy controls.13,14
However, rodent models that induce anhedonic-like effects reliably
observe deficits in sucrose consumption and drug intake suggest-
ing that primary reward measures are not ideal for research into
translational anhedonia. Furthermore, these deficits are consistent-
ly reversible by administration of common antidepressant medica-
tions,11,12 which is paradoxical because as few as 30% of depressed
patients with anhedonic features respond successfully to antide-
pressant drug regimens and treatment rates for substance abuse
and schizophrenia are much lower.10,25
Alternatively, blunted behavioural and neural responsivity are
consistently observed in anhedonic individuals when assessed in
tasks measuring anticipation and attentional capacity for cues that
predict reward.16-18,26,27 Preclinical models measuring behavioural
and neurophysiological responses to associative cues have demon-
strated similar distinctions between primary and secondary re-
wards and further identified brain areas regulating behavioural
abnormalities characteristic of anhedonia such as the basal gan-
glia and various mesolimbic structures.28,29 Interestingly, anhedo-
nia often presents comorbidly with substance abuse, obesity and
obsessive-compulsive disorders which share the common feature
of increased incentive salience towards cues associated with re-
ward.22,30,31 Thus, it is evident that widely used contemporary pre-
clinical animal models do not accurately portray the intricacies as-
sociated with anhedonia in clinical populations.
Indeed, recent clinical evidence implicates multiple features of
reward processing in anhedonia.16-18 These features can be parsed
into multiple distinct component processes including affect,7,32
learning and memory,22,23 motivation18,22,34 and psychomotor fac-
tors35,36 that are each characterized by diverse neuropsychological
mechanisms (Figure 1). Thus, deficits in responding for primary
rewards may be attributed to dysfunction in any of these compo-
nents and not necessarily affect. Although these processes can be
experimentally dissociated in humans and nonhuman animals,22,37,38
preclinical models of anhedonia routinely only measure affective
responses to primary rewards such as consumption of palatable
UWOMJ 86:2 | Fall 2017 Page 45
food or self-administration of drugs of abuse.11,12,14 Nevertheless,
complex associative-learning and approach-based (psychomotor
activating, motivational) criteria are often implicit in tasks measur-
ing affective ‘liking’ as subjects must learn correct behaviours that
lead to reward. Similarly, behaviours may be misinterpreted due to
ubiquitous, but often overlooked facets of reward anticipation and
expectancy.11,39 These factors can be accounted for by implementing
conditioned motivators in preclinical models. Conditioned motiva-
tors are the product of emotionally relevant learned associations
that evoke approach-based and anticipatory behaviours and are
importantly involved in each component process of anhedonia.40-42
Thus, they represent a possible mediator for these theoretically in-
dependent mechanisms and an avenue for preclinical exploration.
Figure 1. Distinct component processes of anhedonia, their associated
discrete neuropsychological mechanisms and possible behavioural measures
for each.
role of conditioned motivators in component pro-
cesses of anhedonia
Conditioned motivators are emotionally relevant associative
stimuli that acquire meaningfulness from a previously neutral state
because over multiple contingent pairings they come to reliably
predict the presence or onset of pleasurable events.40,43 This tran-
sition involves affect, learned associations, as well as psychomotor
and motivational components.40-42 In this way, conditioned motiva-
tors are inherently pleasurable, enhance memory consolidation and
induce approach responses just as primary rewards do through in-
creases in corticolimbic dopamine release.20,28,40,44-46 Consequently,
conditioned motivators encompass the full spectrum of component
processes pertinent to anhedonia, can be utilized in many available
measures of reward processing and thus possess great translational
potential.
Preclinical models of anhedonia demonstrate remarkable
translatability when they use conditioned motivators in tasks that
model symptomatology of human patients. For example, temporal
and probabilistic reward tasks including fixed ratio or variable in-
terval schedules of self-administration allocate ambiguity to asso-
ciative cues by only occasionally reinforcing correct behavioural
feature article
responses and can thus more appropriately distinguish changes in
component processes as multiple domains of cognition and affect
are involved.44,47 Additionally, responses for conditioned motivators
in these tasks may more accurately reveal behavioural abnormali-
ties of anhedonia due to the complex nature of learned associations
between stimuli.14,16,22
Tests of conditioned approach including conditioned place
preference and self-administration can similarly dissect many of
the component processes underlying anhedonia using models of
Pavlovian or instrumental conditioning.41,48 Using alcohol self-ad-
ministration as a model, the drug can be deposited into a dish fol-
lowing successful responding and require additional approach re-
sponses to obtain the primary reward.49 Alternatively, alcohol can
be directly infused intra-orally to dissociate flexible approach from
uncompromising consummatory responses,49,50 or intracranially to
reveal underlying neural circuitry or genetic changes associated
with these responses. Moreover, cues such as a light or tone that
predict reward availability can be integrated to further dissociate
complex actions of conditioned motivators in anhedonia.45 As tasks
assessing the multifaceted nature of anhedonia are more likely to
translate findings to successful clinical treatments,14,22 and because
conditioned motivators effectively comprise each component pro-
cess of anhedonia, they represent primary importance in future
preclinical and clinical research into the mechanisms underlying
rewarded behaviour.
These similarities between conditioned motivators and prima-
ry rewards may underlie contradictory findings between preclinical
animal models of anhedonia.51 For decades, the neurotransmitter
dopamine was speculated to be involved in anhedonia exclusive-
ly through the processing of primary rewards.35,36,52 However, the
function of dopamine has since been clarified to more accurately
characterize its involvement in motivational, anticipatory and psy-
chomotor aspects of reward processing.35,36,38,40,41,53,54 This has led to
changes in the measurement of reward-related events, altered the
scope of research into component processes of anhedonia and may
help to more clearly interpret results across various preclinical lab-
oratories.14,51,52
Accordingly, assessment of the properties of conditioned mo-
tivators in existing preclinical animal models of anhedonia will en-
hance the likelihood that convergent evidence proceeds efficient-
ly to clinical treatment applications. Neuropsychological facets of
learning and motivation must be integrated with affective measures
to develop a more holistic view of anhedonia.
conclusion
Translational strategies utilizing preclinical animal models are
indispensable in realizing fundamental knowledge relative to neu-
ropsychiatric care. Nevertheless, reverse-translational approaches
are providing useful guidance to preclinical models, informing an
increasingly comprehensive understanding of anhedonia and its
dissociable component processes. Anhedonia can be parsed into
multiple categories that conditioned motivators may fully encom-
pass, and experiments exploiting subtle differences in responding
UWOMJ 86:2 | Fall 2017 Page 46
for primary rewards vs. conditioned motivators may engender re-
sults directly relevant to complexities associated with the human
condition. These conditioned motivators can be uniquely manipu-
lated to parse several component processes within a variety of pre-
clinical assays and thus will be crucial in effectively relaying knowl-
edge between preclinical and clinical researchers in the future.
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UWOMJ 86:2 | Fall 2017 Page 47

feature article
Wait times for psychiatric care in Ontario
Rachel Loebach, Sasha Ayoubzadeh
Faculty Reviewer: Javeed Sukhera, MD, FRCPC (Department of Psychiatry)
abstract
Mental illness is a prevalent and costly health care issue.
Lengthy wait times for psychiatric services in Ontario are a
barrier to adequate mental health care for adults, children and
youth. The objective of this paper is to highlight the current
state of psychiatric wait times in Ontario by looking at provin-
cial policies and comparing data to physical health services, as
well as between provinces and other developed nations. The
Ontario government has successfully implemented mandato-
ry reporting of wait-time data for many medical and surgical
services. However, such policies have yet to be implemented
for psychiatric services. As a result, availability of current data
for comparison is limited. Nova Scotia is currently the only
province to government mandate reporting of wait times for
mental health. Furthermore, The Organisation for Economic
Co-operation and Development ranks Canada below average
on measures related to accessibility of psychiatric inpatient
services compared to other developed nations. While Ontario
has implemented new initiatives to address the issue of timely
mental health care, there is still insufficient evidence to deter-
mine if they are effective. Continued advocacy for mandatory
wait-time reporting at the provincial level and further analysis
of current initiatives worldwide are essential steps toward re-
ducing wait times.
background
The impact of mental illness in Canada is staggering. While
mood disorders, such as depression, and anxiety are the most prev-
alent psychiatric illnesses, other disorders such as bipolar disorder,
psychotic disorders and substance abuse are some of the many con-
ditions that lead to personal distress and functional impairment.
One in five people in Canada will experience a mental health is-
sue in their lifetime. Mental illness cost the Canadian health care
system a conservatively estimated $48.6 billion in 2011. Based on
the current trajectory, a cumulative cost exceeding $2.3 trillion is
projected over the next 30 years.1 A significant portion of this cost
includes productivity and work loss due to mental illness. Timely
access to psychiatric services can therefore contribute to better
economic and patient-related outcomes.2
Wait-time monitoring is the responsibility of provincial gov-
ernments. The province of Ontario has been successful in reducing
wait times for many priority medical services, in part by implement-
ing mandatory wait-time reporting standards.3 This paper aims to
outline the current state of wait-time reporting in Ontario and high-
light disparities between physical and psychiatric conditions. The
literature suggests early mental illness intervention is an important
UWOMJ 86:2 | Fall 2017 Page 48
factor associated with improved outcomes. Such outcomes can vary
from increasing the number of opportunities for effective treatment
in people experiencing mental illness to reducing the number of re-
lapses and rehospitalizations for patients receiving first-time treat-
ment for psychosis.4,5
current policy
Government mandated legislation for the creation of bench-
mark targets, mandatory tracking, and reporting of wait times in
psychiatry do not currently exist in Ontario.6 Meanwhile, wait-time
targets have been in place for key health services including cardiac
procedures, joint replacements, and numerous surgeries since 2005
when Ontario launched a wait-time strategy. The strategy called for
mandatory tracking, reporting and publishing of wait-time data in a
publicly accessible domain. Evidence-based benchmarks were cre-
ated for target wait times in each of these areas.7,8 Shortly thereafter,
similar strategies were employed by other provinces and data trans-
parency allowed provincial providers and policy makers to compare
and learn from one another.9 This has led to significant alterations
in federal funding and consequently, the 2017 Ontario budget esti-
mates that since 2005, approximately 322 million days of waiting
have been saved for patients.10
The only widely accepted benchmark data available for psychi-
atry wait times in Canada dates back to 2006 when the Canadian
Psychiatric Association (CPA) and Wait Time Alliance developed
target timelines based on analysis of clinical evidence (Table 1).11
Table 1. Wait time benchmarks for psychiatric illness
CLASS TIME TARGETS
Emergenta within 24 hours for first episode psychosis, mania,
major depression, and postpartum mood disorders
Urgentb within 1 week for first episode psychosis, mania and
postpartum mood disorders and 2 weeks for major
depression
Scheduledc within 2 weeks for first episode psychosis and 4
weeks for postpartum mood disorders and major
depression
a
immediate danger to life
b
unstable situation with potential for deterioration
c
situation involving minimal pain11
feature article
Some data regarding psychiatric wait times in Canada is avail-
able from the Fraser Institute, an independent research foundation.
Waiting Your Turn is an annual report summarizing medical wait
times for the fiscal year obtained by surveying physicians across
specialties. In 2016, the overall response rate to the psychiatric sur-
vey was only 7.2% (compared to 21% for medical and surgical spe-
cialties).12 While this information may be useful for drawing rough
comparisons; results must be interpreted with caution. Above all,
the low response rate emphasizes the need for mandatory wait-
time reporting.
physical and psychiatric conditions
During the five years following the launch of Ontario’s wait-
time strategy, healthcare saw major improvements for cataract sur-
gery (61% reduction), hip replacements (53% reduction), coronary
angiography (51% reduction) and cancer surgery (22% reduction).13
As of September 2016, Ontario scored above average on reaching
wait-time targets compared to countrywide averages for many of
these procedures. For example, 85% of hip replacements and 81%
of knee replacements occurred within their respective timeframes
in Ontario compared to national averages of 79% and 73%, respec-
tively.14
The best available estimates currently suggest wait-time av-
erages for various psychiatric services generally fall outside of the
recommended CPA timeframes. For example, the average wait for
adult mental health counselling and treatment services is 45 days.
For adult mood disorders, the average wait for outpatient services
is 57 days and inpatient services is 47 days, well beyond the sug-
gested 28 day standard.15 Children and youth populations wait even
longer. A recent survey conducted by Children’s Mental Health On-
tario looked at wait times for patients age 6-18 in need of long-term
counselling and intensive therapy. Across the province, wait times
vary from 3 months up to 1.5 years.16
Furthermore, a recent study in Ontario reported only 63% of
people who had been hospitalized for depression received a fol-
low-up visit with a physician within 30 days after discharge, com-
pared to 99% of people with heart failure. In those same 30 days,
25% of depressed patients either revisited the emergency depart-
ment or were rehospitalized.17
Moreover, wait-time data for specific mental illnesses, such as
eating disorder services, are of limited use without predetermined
benchmarks. For example, there is currently an estimated 71 day
wait for adult inpatient treatment and 34 day wait for outpatient
counselling and treatment for eating disorders in Ontario.18 It is
difficult to determine the consequences of such values and provide
recommendations for improvement without adequate targets.
comparing provinces
The only province in Canada that government mandates wait-
time reporting in any capacity for mental health services is Nova
Scotia. Beginning in 2014, wait times are measured as the time be-
tween receipt of an elective patient referral to a community-based
mental health service and the date of the first appointment. Bear-
UWOMJ 86:2 | Fall 2017 Page 49
ing in mind the 28-day CPA standard, data from 2016 demonstrated
that 50% of adults were seen within 33-42 days and 90% were seen
within 97-106 days. Again, young people waited longer than adults
as 50% of children were seen within 36-61 days and 90% within
109-127 days.19
Open Minds, Healthy Minds: Ontario’s Comprehensive Men-
tal Health and Addictions Strategy is a multidisciplinary strategy
that was launched in 2011 to improve mental health services for
Ontarians. The plan specifies an approach for improving care by
expanding mental health facilities, training healthcare workers,
and targeting efforts in specific demographics, including children
and Indigenous communities. Similar initiatives also exist in oth-
er provinces. However, until updated target wait times are estab-
lished, data will continue to be insufficient to properly evaluate the
success of such programs.20
comparing countries
According to data from the Organisation for Economic Co-op-
eration and Development (OECD), Canada falls below average
among developed countries with respect to access to inpatient psy-
chiatric services. A 2011 report on number of psychiatric beds per
1000 population ranks Canada 27 out of 34 among OECD countries.
Several European countries including the Netherlands, Germany,
and the Czech Republic rank near the top. Australia and England
also rank higher than Canada, although they too fall below the av-
erage.21
Unfortunately, information regarding wait times for psychiatric
care among OECD countries is not available. A 2014 report, Measur-
ing and Comparing Health Care Waiting Times in OECD Countries,
details numerous wait-time trends including joint replacements,
cataract surgeries and multiple modes of medical imaging. Howev-
er, there is no mention of psychiatric services in the report.22
Like Ontario and other Canadian provinces, many nations are
implementing unique strategies to improve timely access to mental
health care. One example is England. The National Health Society
and Department of Health put forth “Improving access to mental
health services by 2020”, a publication aiming to ensure mental and
physical health services are given equal priority in terms of timely
access to care. The strategy provides guidance as to how new stan-
dards for mental health wait-time reporting can be implemented
and is well underway.23 Currently, wait-time information for treat-
ment of first episode psychosis and eating disorders is already avail-
able to the public.24,25 England’s approach uses clear goal setting
and effectiveness tracking to achieve measurable improvements in
quality and access to psychiatric care.23 Information regarding out-
comes of this strategy as it becomes available may be beneficial for
use by other countries, including Canada.
summary
Poor outcomes are associated with delayed treatment for psy-
chiatric illnesses. The importance of addressing the issue of long
wait times for mental health care in Canada is becoming increas-
ingly apparent. The Ontario government has yet to mandate provi-
feature article
sional reporting of wait-time data despite significant success in this
area for numerous medical and surgical services. Improving access
to mental health care is a challenge for all Canadians; the impor-
tance of collaboration at all levels cannot be overstated.
references
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7. Ministry of Health and Long Term Care. First ever common bench-
marks will allow Canadians to measure progress in reducing wait
times. [Internet]. Toronto, ON; 2005 Dec 12 [cited 2017 May 30];
Available from:
8. https://news.ontario.ca/archive/en/2005/12/12/First-ever-common-
benchmarks-will-allow-Canadians-to-measure-progress-in-reducin.
html.
9. Canadian Intergovernmental Conference Secretariat. A 10-Year Plan to
Strengthen Health Care. [Internet]. Ottawa, ON. 2004 Sept [cited 2017
May 30]. Available from: http://www.scics.gc.ca/CMFiles/800042005_
e1JXB-342011-6611.pdf.
10. Wait Time Alliance. Time to Close the Gap: Report Card on Wait
Times in Canada. [Internet] Ottawa, ON: Wait Time Alliance; 2014
June [cited 2017 Feb 27]. Available from: http://www.waittimealliance.
ca/wp-content/uploads/2014/06/FINAL-EN-WTA-Report-Card.pdf.
11. Government of Ontario. [Internet]. 2017 Ontario Budget: A Stronger,
Healthier Ontario, Chapter IV: Reducing Wait Times. Ottawa, ON. 2017
[cited 2017 May 30]. Available from: http://www.fin.gov.on.ca/en/bud-
get/ontariobudgets/2017/ch4a.html#a4.
12. Canadian Psychiatric Association. Wait Time Benchmarks for Patients
With Serious Psychiatric Illnesses, A series of recommendations made
by Canada’s psychiatrists. [Internet]. Ottawa, ON: Canadian Psychiat-
ric Association; 2006 [cited 2017 Feb 27]. Available from http://www.
cpa-apc.org/wp-content/uploads/Wait_times-CPA_policy_paper_1-
web-EN.pdf.
13. Fraser Institute. Waiting your turn: Wait times for health care in
Canada, 2016 report. [Internet]. Vancouver, BC: Fraser Institute; 2016
Nov 23 [cited 2017 Mar 7]. Available from: https://www.fraserinstitute.
org/sites/default/files/waiting-your-turn-wait-times-for-health-care-
in-canada-2016.pdf.
14. Ministry of Health and Long-Term Care. [Internet] Ontario Wait Time
Strategy. Toronto, ON: Ministry of Health and Long-Term Care; 2010
UWOMJ 86:2 | Fall 2017 Page 50
July 17 [cited 2017 Feb 25]. Available from: https://news.ontario.ca/
mohltc/en/2010/06/ontarios-wait-time-strategy.html.
15. Wait Times for Priority Procedures in Canada, 2017. [Internet]. Otta-
wa, ON: Canadian Institute for Health Information; 2017 Mar 23 [cited
2017 May 4]. Available from: https://www.cihi.ca/sites/default/files/
document/wait-times-report-2017_en.pdf.
16. ConnexOntario Health Services Information. Average Wait in Days for
Mental Health Services in Ontario by Service Category, Average Wait
in Days for Services that are Restricted to or Specialized for Mood
Disorders. [Data extracted from the ConnexOntario Database on 2017
Mar 8].
17. Children’s Mental Health Ontario via Ministry of Children and Youth
Services. Child and Youth Mental Health. [Internet]. Toronto, ON:
Children’s Mental Health Ontario, 2016 Nov 26 [cited 2017 Mar 30].
Available from: http://www.auditor.on.ca/en/content/annualreports/
arreports/en16/v1_301en16.pdf.
18. Lin E, Diaz-Granados N, Stewart DE, et al.. Postdischarge care for
depression in Ontario. Can J Psychiatry. 2011 Aug;56(8):481-9.
19. ConnexOntario Health Services Information. Average Wait in Days for
Mental Health Services in Ontario by Service Category, Average Wait
in Days for Services that are Restricted to or Specialized for Eating
Disorders. [Data extracted from the ConnexOntario Database on 2017
Mar 8].
20. Nova Scotia Wait Times. [Internet]. Government of Nova Scotia, 2017
[cited 2017 May 14]. Available from: https://waittimes.novascotia.ca/
procedure/mental-health-adult-community-based-services#trends.
21. Ministry of Health and Long Term Care. [Internet]. Open Minds,
Healthy Minds; Ontario’s Comprehensive Health and Addictions
Strategy. Toronto, ON; 2011 June [cited 2017 Mar 20]; Available from:
http://www.health.gov.on.ca/en/common/ministry/publications/re-
ports/mental_health2011/mentalhealth_rep2011.pdf.
22. 21 Hewlett E and Horner K. Mental Health Analysis Profiles (MhAPs):
England, UK. [Internet]. Paris, FR: OECD Health Working Papers.
2015 July [cited 2017 Mar 30]. Available from: http://www.oecd.org/
officialdocuments/publicdisplaydocumentpdf/?cote=DELSA/HEA/
WD/HWP(2015)4&docLanguage=En.Siciliani L, Borowitz M, Moran
V. Measuring and comparing health care waiting times in OECD coun-
tries. Health Policy. 2014 Dec;118(3):292–303.
23. National Health Service England, Medical Doctorate and Mental
Health Team. [Internet]. Guidance to support the introduction of ac-
cess and waiting time standards for mental health services in 2015/16.
London, UK. 2015 Feb 12 [cited 2017 May 14]. Available from: https://
www.england.nhs.uk/wp-content/uploads/2015/02/mh-access-wait-
time-guid.pdf.
24. National Health Service England. Statistical work areas, Early Inter-
vention in Psychosis Waiting Times. [Internet]. NHS England Data-
base [cited 2017 May 14]. Available from: https://www.england.nhs.uk/
statistics/statistical-work-areas/eip-waiting-times/.
25. National Health Service England. Statistical work areas, Children and
Young People with an Eating Disorder Waiting Times. [Internet]. NHS
England Database [cited 2017 May 14]. Available from: https://www.
england.nhs.uk/statistics/statistical-work-areas/cyped-waiting-times/.
feature article
Medical smartphone applications
A new and innovative way to manage health conditions from the palm of your hand
Marcello G Masciantonio, Aneta A Surmanski
Faculty Reviewer: Christopher J Licskai, BSc, MD, FRCPC (Department of Medicine, Division of Respirology)
abstract
Smartphones have a variety of unique features including
text-message communication, camera, sensors, and health ap-
plications (apps), which can be used to assist in monitoring an
individual’s health, diet, and exercise, as well as support goal-fo-
cused strategies personalized to user needs. Mental health and
diabetes management apps are two prominent examples that
have been shown to be effective in improving specific health
outcomes. Mental health apps provide day-to-day patient care
by teaching users how to reduce stress, focusing on strategies
to enhance mental well-being. Apps such as Kokoro, Headspace,
and PRISM have been demonstrated to reduce symptoms of
depression and anxiety, and psycho-education apps have been
demonstrated to reduce symptoms and to enhance concentra-
tion during specific tasks. Many diabetes apps are accessible
by patients and physicians, and include tracking features for
nutrition, fitness, and hemoglobin A1c levels. Specialized apps
with text-messaging services and personalized support have
been associated with improvements in blood pressure and
blood glucose control. Social forums also provide patients pri-
vacy and the freedom to discuss their conditions with comfort.
Health apps are easily accessible and available at low or no cost,
and can be an effective tool for educating patients with chronic
disease, supporting collaborative self-management, extending
the impact of healthcare providers, and include response ano-
nymity. There remain significant challenges including the pro-
tection of private health information and the development of
regulatory frameworks to evaluate app quality, effectiveness,
and absence of harm. Overall, the implementation of smart-
phone apps in healthcare systems may decrease demand in
clinics, reduce healthcare costs, and lead to an improvement in
patient health.
introduction
Over one billion smartphones have been shipped worldwide to
date and are expected to continuously increase in number.1 Since
the introduction of smartphones, there has been continuous inno-
vation allowing users to access a variety of functions, such as mobile
health (mHealth) applications (apps) that provide consumers with
disease information and monitor an individual’s health, diet, and
exercise. Smartphones have many features (camera, CPU, sensors,
etc.) that work concordantly with various apps to attain goal-fo-
cused strategies that are personalized to a user’s needs (weight loss,
ways to decrease stress, etc.). The functional complexity and ubiq-
UWOMJ 86:2 | Fall 2017 Page 51
uitous nature of smartphones combine to create the potential for
the integration of mHealth apps into our health system.
Changes in population demographics, including the rise in se-
nior populations, will result in an increased burden of chronic dis-
eases and disorders, such as mental health, COPD, congestive heart
failure, diabetes, hypertension, and HIV/AIDS. Health budgets can-
not double to meet the anticipated increase in demand, so trans-
formative health system innovation is required. In addition, acces-
sibility to healthcare can be limited by geography and economics,
which may cause individuals to avoid seeking medical attention
when needed. As the world continues to be connected via increased
access to the Internet, apps become extremely accessible to any-
one. Many health apps are currently available at a low or no cost,
enabling users to track progress of health plans, manage symptoms,
seek support among other users, and bridge the communication gap
between patients and healthcare providers.
Although there are thousands of health-related apps available
for download, there is very little evidence available that demon-
strates their efficacy. To date, the best evidence exists for mental
health and diabetes management apps due to their high user rate
and demonstrated effectiveness.
mental health management
It is estimated that one in five adults will experience issues as-
sociated with mental health in any given year,2 yet only 41% of those
individuals seek medical treatment.3 Mental disorders, such as de-
pression, anxiety, and bipolar disorder, are an increasing challenge
felt worldwide and their prevalence has been rising at an alarming-
ly fast rate.4 Their presence poses significant economic, personal,
and societal costs and are often more difficult to treat than physical
illnesses.5 Given the broad spectrum of mental illness and the lim-
ited number of available psychiatrists accepting new patients, it is
often a challenge for psychiatrists to diagnose accurately, schedule
regular meetings with all patients, and to frequently access patient
progress in order to tailor treatment options. Traditional psycho-
therapy and pharmacological interventions have been the standard
care of practice for many years. However, certain therapies and
their durations may not be readily accessible or affordable to cer-
tain patients needing routine clinical care.6
One affordable and convenient adjunct to present day treatment
options are free, novel smartphone apps. Mental health apps pro-
vide day-to-day patient care by teaching users how to reduce stress
and manage symptoms, focusing on strategies to enhance mental
well-being. These mental health services support various elements
of mental healthcare, such as rapid/open access, personalized treat-
ment, convenience, establishing feelings of personal safety, preven-
feature article
tion options, and behavioural supports for those who would like to
refrain from taking pharmaceuticals.7 Apps like Kokoro, Headspace,
and PRISM (Personalized Intervention for Stabilizing Mood), have
been demonstrated to reduce symptoms of depression and anxi-
ety in a variety of clinical trials.8-10 Psycho-education apps, which
provide patients and their families the education, information, and
skills to co-manage their mental illnesses, have been demonstrat-
ed to reduce depressive symptoms over a six-week period and have
also enhanced concentration during specific tasks.11 In addition,
they can serve as an adjunct to psychotherapy and pharmacother-
apy in individuals classified as “treatment-resistant”, patients that
do not experience changes with their regular treatment.12
To protect private patient health information, most apps have
the option for patients to remain anonymous. The current stigma
associated with mental health may result in many individuals that
are hesitant to seek medical attention. The ability to remain anony-
mous enables patients to freely seek help at their own convenience
as well as maintains patient anonymity for privacy purposes. With
this in mind, patients are more likely to disclose symptoms related
to mental well being as it may be stressful to talk to healthcare pro-
fessionals with the fear of being judged.
diabetes management
Diabetes is estimated to affect 9.3% of Canadians, and for many
people the responsibility, dedication, and attention required to live
with this disease can be overwhelming.13 Diabetes applications with
a focus on lifestyle, access to personal health records, text messag-
ing, and wound care have improved diabetes management.
Diabetes is heavily influenced by lifestyle choices and manage-
ment of these, including nutrition and exercise, can be supported
by medical apps.14 A recent study compiled the top nutrition and
fitness tracking apps available for smartphone users and assessed
them by their food databases, logging options, and interoperabil-
ity with other devices and apps.15 Some apps included additional
features such as daily reminders and online communities to engage
patients socially.
Personal Health Record (PHR) services are available on se-
lect apps, giving patients the option to manage and maintain their
health records by themselves.16 These apps are synchronized with
the hospital Electronic Medical Record (EMR) system and allow
patients to monitor Hemoglobin A1c (HbA1c: glycosylated hemo-
globin level), Low-Density Lipoprotein (LDL) and Blood Urea Ni-
trogen (BUN) levels. PHR services provide patients with a sense
of responsibility and a substantial body of data for physicians and
clinical researchers to integrate and analyze.17
Text-messaging services have also been studied as a way to
provide important psychological and motivational support. Partic-
ipants in txt4health, a large-scale, public health-focused text mes-
sage program targeting type 2 diabetes, reported that 67.1% of users
gave the app a satisfaction rating 8 on a 10-point scale. In addition,
88.8% of users found the app made them knowledgeable about their
risk for type 2 diabetes and made them conscious of their diet and
physical activity.18 In an alternate study, a nurse-facilitated, mobile
UWOMJ 86:2 | Fall 2017 Page 52
phone-based clinical decision support system-enabled intervention
in primary care was associated with improvements in blood pres-
sure and blood glucose control.19 In a comparable study, patients
in the TEXT ME intervention for smoking program received four
messages per week for six months that provided advice, motivation
and support, resulting in investigators reporting significantly lower
LDL-cholesterol, systolic blood pressure, and body mass index in
patients.20 These findings suggest that a similar program for diabet-
ics could lead to improvements in health.
Diabetic wound care is a common problem that requires fre-
quent hospital visits for inspection and cleaning. Researchers at
Worcester Polytechnic Institute created Sugar, an app to assess
chronic diabetic foot ulcers.21 The patient takes a picture of the
wound, which is analyzed by a series of image processing steps.
Image and colour segmentation are performed to measure wound
area boundaries and healing progress, respectively. Sugar tracks
the progress of the wound, reducing the number of hospital visits
previously required. This unique feature gives patients a sense of
responsibility and an active role in their wound care.
challenges and barriers influencing app integration
into the health system
Smartphone affordability, operation and security, and app per-
formance and effectiveness are challenges influencing app inte-
gration into the health system. Lower socioeconomic groups may
struggle to afford smartphones, while senior populations may have
difficulties operating app features. Online security and protection
of private health information remains a concern.22 Mobile malware
capable of accessing user information or making remote transac-
tions (i.e. financial transactions) and on-line attacks are becoming
more frequent.1 Medical apps must be required to ensure that trans-
mitted data is strongly encrypted and anonymous, and regulatory
frameworks are needed to certify app performance and security .23
Another challenge is whether the advice provided by apps is
grounded in legitimate medical knowledge and demonstrates ef-
fectiveness and absence of harm. Websites such as PsychologyTo-
day.com and PsychiatryAdvisor.com, have provided a short list of
quality assured apps that have been developed by board-certified
clinicians.24 As previously stated, early-adopted apps focused on
tracking information.25 Initiatives such as the Mobile Applications
Rating Scale (MARS) assess the quality of health apps and prom-
ise to provide patients and healthcare providers with the highest
quality tools.26 Services like txt4health and apps like Sugar will con-
tinue to be developed and adopted by healthcare systems going for-
ward.18,21 In addition, governments and healthcare systems need to
develop a system to regulate and establish a set of standards against
which an app can be measured voluntarily.
conclusion
The impact of the changing demographics in our society de-
mand more than incremental changes in our health system; trans-
formative innovations are required. Failure to act may lead to
increased demand for doctors, increased wait times, delayed diag-
feature article
nosis, and a health system with unsustainable costs. Smartphone
apps provide patients and healthcare providers with an efficient
and effective tool to communicate and manage symptoms and
treatments. In addition, patients may feel more comfortable track-
ing progress and receiving support from the comfort of their homes
as opposed to coming into a hectic and stressful clinic environ-
ment. All of these benefits may potentially lead towards decreased
demand in clinics, a reduction in healthcare costs, and improved
health. Research needs to continue to assess innovative opportuni-
ties that fully leverage the strength of this unique platform to deliv-
er effective patient care in our health system.
references
1. Agu E, Pedersen P, Strong D, et al. The smartphone as a medical
device: assessing enablers, benefits and challenges. In Proc. 2013 IEEE
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2. NIMH: Any Mental Illness AMI Among US Adults [Internet]. 2017
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statistics/prevalence/any-mental-illness-ami-among-us-adults.shtml.
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United States: results from the 2014 national survey on drug use and
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NSDUH-FRR1-2014.pdf.
4. Kessler RC, Aguilar-Gaxiola S, Alonso J, et al. The global burden of
mental disorders: an update from the WHO world mental health
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5. Ratnasingham S, Cairney J, Manson H, et al. The burden of mental
illness and addiction in Ontario. Can J Psychiatry. 2013;58(9):529-37.
6. McInnis-Perry G, Greene A, Mina ES, et al. Canadian standards for
psychiatric-mental health nursing [Internet]. Fourth Edition. Toronto
(ON): Canadian Federation of Mental Health Nurses; 2014 [cited
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8. Kauer SD, Reid SC, Crooke AHD, et al. Self-monitoring using mobile
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sus counselling supplemented with guided use of a well-being app for
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11. Kinderman P, Hagan P, King S, et al. The feasibility and effectiveness of
Catch It, an innovative CBT smartphone app. 2016 May;2(3):204-9.
12. Morganstein J. Mobile applications for mental health providers. Psy-
chiatry. 2016;79(4):358–63.
13. Diabetes Statistics in Canada [Internet]. The Canadian Diabetes Asso-
ciation. 2017 [cited 2017 Mar. 8]. Available from: http://www.diabetes.
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ca/how-you-can-help/advocate/why-federal-leadership-is-essential/
diabetes-statistics-in-canada.
14. Hale K, Capra S, Bauer J. A framework to assist health professionals
in recommending high-quality apps for supporting chronic disease
self-management: illustrative assessment of type 2 diabetes apps.
JMIR mHealth uHealth. 2015;3(3):e87.
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mobile applications for diabetes patient use. Diabetes Technol Ther.
2016;18(3):200–12.
16. Jung EY, Kim J, Chung KY, et al. Mobile healthcare application
with EMR interoperability for diabetes patients. Cluster Comput.
2014;17(3):871–80.
17. Kumar RB, Goren ND, Stark DE, et al. Automated integration of
continuous glucose monitor data in the electronic health record using
consumer technology. J Am Med Informatics Assoc. 2016;23(3):532–7.
18. Buis LR, Hirzel L, Turske SA, et al. Use of a text message program
to raise type 2 diabetes risk awareness and promote health behavior
change (Part II): assessment of participants’ perceptions on efficacy. J
Med Internet Res. 2013;15(12):1–9.
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hypertension and diabetes mellitus management package to facilitate
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the mPower heart project. J Am Heart Assoc. 2016;5(12):e004343.
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diease: a randomized heart disease. JAMA. 2015;314(12):1255-1263.
21. “Sugar”, a WPI-Built Diabetes App, Enters Clinical Testing [Internet].
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feature article
The current state of Health Links
Rachelle Maskell, Connor Cleary, Keri Selkirk, Shannon Sibbald
Faculty Reviewer: Amanda Terry, PhD (Department of Family Medicine)
abstract
Health Links is a model of care focused on integrating ef-
forts across the spectrum of health and social service providers
in the province of Ontario. Health Links is driven by govern-
ment policy and has been implemented by leveraging a local,
flexible approach. As a recent initiative, existing documenta-
tion on Health Links is comprised largely of fragmented or-
ganizational and procedural documents (often called grey
literature). This paper aims to fill crucial knowledge gaps by
introducing the Health Links approach to care, providing a
high-level overview of key processes and stakeholders, and dis-
cussing the evolution of the Health Links approach.
introduction
Health Links is an approach that aims to integrate the health
and social requirements of patients with complex needs under one
umbrella, in an effort to improve care and reduce costs.1 The Health
Links approach is intended to embed tools and processes that allow
for a deeper level of coordination within the existing health system
infrastructure. Health Links is designed to bring together multiple
clinical and social service providers to leverage a team-based ap-
proach, extend beyond organizational boundaries, and create care
plans for individuals with multiple comorbidities and complex care
needs. To decrease health care utilization, Health Links aligns pa-
tients with primary care providers and increases communication
across sectors by facilitating relationships and providing informa-
tion sharing tools.2 This approach is positioned at the forefront of
Ontario’s commitment to transform patient care through a Patients
First approach.3,4 The Health Links approach was first launched
in December 2012 and has expanded to include 82 Health Links
across Ontario.5 Early adopters have provided tangible knowledge
and best practices that are being used to inform the evolution of
this model.5
target population
Integrated care and coordinated care planning is most bene-
ficial to individuals with complex care needs, who utilize an array
of services from multiple providers.6 The Ministry of Health and
Long-Term Care (MOHLTC) defined the Health Links target popu-
lation as individuals with four or more comorbidities and/or those
who are negatively impacted by the social determinants of health.4
This population accounts for 5% of Ontario’s populace and use 66%
of all health care resources. Targeting individuals with four or more
comorbidities strikes a balance between capturing current high-
cost users and those who are at risk of becoming high-cost users of
the health care system.4
UWOMJ 86:2 | Fall 2017 Page 54
coordinated care planning
The Health Links approach uses Coordinated Care Planning
as the process to bring patients and their care providers together
to articulate goals and develop a plan to achieve positive patient
outcomes.7 Health Quality Ontario (HQO) described five steps of
Health Links as: patient identification, patient invitation, initial pa-
tient interview, care conference, maintenance and transitions.8-11
Patient Identification: Multiple avenues of identifying the tar-
get population are utilized with an aim to ensure equitable access
to coordinated care. Currently emergency department and hospital
admission data, Community Care Access Centres (CCACs) and pri-
mary care providers are common methods of identification.
Patient Invitation: Once an individual is identified, their con-
sent is sought. It is most effective when a care provider who has
an existing relationship with the individual introduces the concept
and obtains consent.
Initial Patient Interview: After consent is acquired, an initial
patient interview is held. The interview is led by a Lead Care Coor-
dinator. The purpose is to understand the patient’s perspective. The
goal is to have patients articulate their goals, and together with the
Lead Care Coordinator, identify a Care Team.
Care Conference: The Care Conference provides an opportu-
nity for the entire identified Care Team to come together and for-
mulate a care plan that will enable the patient to meet their elicited
goals.
Maintenance and Transitions: During this phase, the patient
interacts with providers more efficiently. Established best practic-
es in this phase of Coordinated Care Planning include; medication
reconciliation, assessment of health literacy and patient learning
initiatives. The Care Team remains connected through the Coordi-
nated Care Plan, which is updated as necessary.
The main tangible output of the Health Links approach is the
Coordinated Care Plan (CCP), which is a standardized tool that
places the patient at the center of the approach. The tool has been
adopted by 79% of Health Links across the province.12 As Health
Links focuses on providing integrated, holistic care, the CCP is de-
signed to address both health and social needs. It aims to identify a
range of patient goals, coordination requirements and identifies the
responsibilities of individual providers in the care team.12 Between
patient identification and the care conference, a lead care coordi-
nator is identified. The role of the lead care coordinator often falls
to the health professional that is either responsible for the greatest
amount of that patient’s care or is expected to be involved with that
patient for the longest period of time.13 Ideally, Coordinated Care
 feature article
Planning enhances collaborative relationships between providers
and across sectors with the intent of transcending the individual-
ized CCP, and leads to systemic transformation and a more integrat-
ed health system.14
Table 1. Organizational involvement in Health Links
Organization Roles
MOHLTC •Devised the philosophy of
care and launched the initia-
tive in early 2012
•Outline the provincial direc-
breadth of knowledge
tion for Health Links including
the dissemination of best
practices
Provincial
involvement •Establish evolution frame-
work in response to experien-
tial learning
•Provincial oversight of the
initiative through reporting
and third party evaluation
Health Quality •Responsible for the evalua-
Ontario tion and quality improvement
initiatives surrounding Health
Links across the province
LHINs •Responsible for facilitating
and overseeing the develop-
ment of Health Links across
Regional corresponding jurisdictions
involvement
•Report on performance indi-
cators to the MOHLTC
Lead organization •Responsible for the gov-
ernance, establishment,
operations and performance
of their individual Health Link
•This includes engagement
of local partners to support
Local to implementation and
spread and coordinated care
involvement planning.
depth of knowledge
•Attend provincial and re-
gional Health Links meetings
•Voluntary involvement
Local partners
•Once involved, partners are
required to declare their com-
mitment and act as change
agents across their organiza-
tional/sectoral representation
UWOMJ 86:2 | Fall 2017 Page 55
structure and collaborating organizations
The Health Links approach is supported by a cascading set of
roles and structures that vary in level of breadth and engagement.
Table 1 has been provided below to outline the roles of various
collaborating organizations, as well as to provide a visual repre-
sentation of how the Health Links approach has been embedded
into provincial, regional and local structures. The scope of this inte-
grated initiative requires numerous stakeholders with varying lev-
els of involvement. For example, Health Quality Ontario acts as an
evaluating body by providing feedback to the MOHLTC regarding
Health Links development. This feedback provides the MOHLTC
with a high-level understanding of how Health Links is evolving
across the province.4 However, Health Links knowledge is experi-
enced differently at the local level as local actors maintain a more
intimate understanding of the application of Health Links process-
es. Thus, provincially, the MOHLTC and Health Quality Ontario
(HQO) maintain a high-level or macro understanding of Health
Links progress whereas lead organizations and partners maintain
an intimate depth of knowledge at the local level.
evolution
The Health Links approach was introduced by the MOHLTC
in 2012 as an innovative approach to Coordinated Care Planning
for individuals with complex health and social needs.1 Initially a
‘low rules’ approach was taken by the MOHLTC to enable Health
Links to align with local needs and contextual environments.1 This
‘low rules’ setting gave early adopters the flexibility to implement
the approach based on their unique structures and contexts. By
allowing for a locally-driven approach, early adopters identified
and outlined best practices through experiential learning.4 While
this latitude for flexibility and creativity encouraged innovation in
early phases, it also led to wide variability in terms of governance
and patient identification.4 In recognition of these limitations, and
to minimize the resulting variability in processes between Health
Links, the Ministry developed the Advanced Health Links Model in
2015.4 The Advanced Health Links Model aims to standardize and
systematically embed the emerging best practices that are designed
to support large-scale spread and sustainability.12 As the Health
Links approach continues to spread throughout Ontario, the Ad-
vanced Model will act as a guide in translating the small-scale suc-
cess experienced by early adopters into large scale sustainability
province-wide.4
conclusion
Coordinated Care Planning is the central element of the Health
Links approach to care. An increased understanding of this process
enhances clarity of its use and deployment and increases awareness
of the breadth of the Health Links initiative. Through Coordinated
Care Planning, Health Links aims to initiate system transformation
leading to a more efficient, effective and sustainable health system
by targeting the 5% of the population who use the health system
most frequently. A more integrated health system will enable pro-
viders to better support individuals with complex care needs. How-
feature article

ever, there remains a lack of rigorous empirical review, this coupled

with the fragmented nature of available literature on the Health
Links approach, produces large gaps in knowledge and understand-
ing. Further evaluation is required at local, regional and provincial
levels to better understand the impact of the Health Links approach
to care.

references
1. Evans JM, Grudniewicz A, Wodchis WP, et al. Leading the implementation of
Health Links in Ontario. Healthcare Papers. 2015 Apr; 14(2), 21–25.
2. Lundsky Y, de Oliveira C, Wilton D, et al. High cost users of health care among
adults with developmental disabilities: Summary report [Internet]. Applied
Health Research Question Series; 2017 Jan [cited 2017 May 3]. Available from:
http://hsprn.ca/uploads/files/HSPRN_AHRQ_High_Cost_Users_Summary_2017.
pdf
3. Ministry of Health and Long-Term Care. Patients First: Ontario’s Action Plan
for Health Care [Internet]. Ministry of Health and Long-Term Care; 2012 [cited
2017 May 3]. Available from: http://www.health.gov.on.ca/en/ms/ecfa/healthy_
change/docs/rep_healthychange.pdf
4. Ministry of Health and Long-Term Care. Guide to the Advanced Health Links
Model [Internet]. Ministry of Health and Long-Term Care; 2015 [cited 2017 May
3]. Available from: http://www.health.gov.on.ca/en/pro/programs/transforma-
tion/docs/Guide-to-the Advanced-ealth-Links-Model.pdf
5. Ministry of Health and Long-Term Care. Transforming Ontario’s health care
system [Internet]. Ministry of Health and Long-Term Care; 2016 Mar 22 [cited
2017 May 3]. Available from: http://www.health.gov.on.ca/en/pro/programs/
transformation/community.aspx
6. Wodchis W, Williams A, Mery G. Integrating care for persons with chronic
health and social needs [Internet]. Institute for Health Policy Management and
Evaluation. 2015 [cited 2017 May 3]. Available from: http://www.queenshealth-
policychange.ca/resources/2014-WhitePaper-Wodchis.pdf
7. South West Local Health Integration Network. Coordinated Care Planning
- Information for clients and caregivers [Internet]. South West Local Health
Integration Network; 2016 [cited 2017 May 3]. Available from http://www.
southwesthealthline.ca/healthlibrary_docs/WhatIsCoordinatedCarePlanning-
ClientCaregivers.pdf
8. Health Quality Ontario. Community of practice: Coordinated care planning
series, engaging the patient in care coordination and obtaining consent to share
information with the Health Links care team [Internet]. Health Quality Ontario;
2015 [cited 2017 May 3]. Available from:http://www.hqontario.ca/portals/0/doc-
uments/qi/health-links/ccp-webinar-step-2-en.pdf
9. Health Quality Ontario. Community of practice: Coordinated care planning
series, ‘identifying patients’ for care coordination [Internet]. Health Quality
Ontario; 2015 [cited 2017 May 3]. Available from: http://www.hqontario.ca/
portals/0/documents/qi/health-links/ccp-webinar-step-1-en.pdf
10. Health Quality Ontario. Community of practice: Coordinated care planning
series, interviewing the patient [Internet]. Health Quality Ontario; 2015 [cited
2017 May 3]. Available from: http://www.hqontario.ca/portals/0/documents/qi/
health-links/ccp-webinar-step-3-en.pdf
11. Health Quality Ontario. Community of practice: Coordinated care planning se-
ries, maintenance and transitions [Internet]. Health Quality Ontario; 2015 [cited
2017 May 3]. Available from: http://www.hqontario.ca/portals/0/documents/qi/
health-links/ccp-webinar-step-5-en.pdf
12. Health Quality Ontario. Coordinated Care Management: Document the Coor-
dinated Care Plan [Internet]. 2016 [cited 2017 May 3]. Available from: http://
www.hqontario.ca/Portals/0/documents/qi/health-links/ccm-care-coordina-
tion-tool-en.pdf
13. 13. Health Quality Ontario. Central East Health Links Toolkit: Coordinated
Care Planning [Internet]. 2016 Jan [cited 2017 May 3]. Available from:http://
healthcareathome.ca/centraleast/en/who/Documents/Health_Links/toolkit/
CEHealthLinks-Toolkit-V2.pdf
14. Keresteci M. Health Links: turning the concept into reality. Ontario Medical
Review. 2014 Jan; 4, 10-22.

UWOMJ 86:2 | Fall 2017 Page 56

feature article
Approaches to incorporating indigenous health
into the Canadian medical school curriculum
Danielle Robinson, Chowdhury Anika Saiva, Purathani Shanmuganathan
Faculty Reviewer: Lloy Wylie PhD, MA (Department of Psychiatry)
abstract
In Canada, there are significant health status disparities
that exist between Indigenous and non-Indigenous popula-
tions. Cultural competency among physicians is a probable
way to address this large gap. The purpose of this article is to
discuss the current challenges that exist in designing and deliv-
ering an Indigenous health curriculum in Canadian undergrad-
uate medical school programs. This article will highlight the
importance of cultural competency for improving the health
outcomes of Indigenous populations. Additionally, it will ex-
plore potential approaches for better integration of Indige-
nous health into medical curricula.
introduction
The Indigenous peoples of Canada represent a subset of the
population with worse health outcomes than their non-Indigenous
counterpart,1,2 demonstrating the prevalence of health disparities
that exist among them.3 In response to the growing awareness of
the differences in health status between Indigenous and non-In-
digenous people, more undergraduate medical school programs are
incorporating curricula surrounding Indigenous health and history.
We present current challenges that exist in developing and deliver-
ing Indigenous health curricula in Canadian medical schools. Ad-
ditionally, we will explore potential approaches to better train un-
dergraduate medical students in Indigenous cultural competency.
First, we discuss the current mandates in place that emphasize
the importance of cultural competency in Canadian medical school
curricula.
undergraduate medical schools
In 2000, the Liaison Committee on Medical Education (LCME)
set standards to ensure that all accredited Canadian medical schools
would include mandatory cultural diversity education in the under-
graduate curriculum.4,5 These standards aim to enhance the under-
standing of how health and illness are perceived across diverse cul-
tural and belief systems.4,5 These standards also emphasize the need
for medical students to be aware of their own biases, as well as the
importance of providing culturally competent care.4,5
canadian family medicine residency programs
Under the Canadian Family Medicine guidelines (College of
Family Physician of Canada [CFPC]), Family Medicine residents
and physicians are required to address the health needs of Indige-
nous populations.6 In 2012, the CFPC released new guidelines, the
UWOMJ 86:2 | Fall 2017 Page 57
Triple C Competency-based Curriculum, which makes it mandato-
ry for Family Medicine residents to incorporate Indigenous health
issues in the curricula.6 The Triple C curriculum encourages the
implementation of a curriculum that incorporates comprehensive
care and education, ensures continuity of education and patient
care, and emphasizes family medicine centered care. This curricu-
lum encourages social accountability of medical schools to address
“priority health concerns” among Indigenous populations through
approaches like cultural competency education.6
current challenges
Despite the guidelines that are currently in place, only 67% of
Canadian medical schools provide some education on multicultural
issues.5 Therefore, the incorporation of cultural diversity education
and training in undergraduate medical curriculum remains insuf-
ficient.5 Additionally, there is lack of uniformity with regard to the
concepts, structure, and formats taught in cultural diversity edu-
cation, indicating an inadequate and standardized approach.5 Fur-
thermore, cultural diversity education is more commonly provided
as an elective during pre-clinical years, and rarely in clinical cours-
es.5 Lastly, there are huge variations on the length of time allocated
to cultural diversity education and training across different medi-
cal schools.5 While some medical schools provide comprehensive
learning opportunities through field placements, community visits,
and clinical rotations, others dedicate only few hours to teaching
culturally competent care.5
Overall, there is lack of clarity and consensus on the definition
of cultural diversity and what it encompasses, in terms of the peda-
gogical methods, content, format and structure needed for medical
school curriculum.5 This lack of clarity, even among the licensing
and governing bodies, creates confusion on what should be taught
in medical schools.5 Additionally, there are challenges among stu-
dents themselves, whose perception of the importance of cultural
competence education is low.5 Lastly, the lack of evaluation strat-
egies to assess medical students’ cultural competence, or more
broadly, to assess the effectiveness of existing cultural competence
educational models, is highly problematic.5
potential approaches for better integration of
indigenous health in medical curricula
Due to the existence of governing policies that continue to dis-
empower Indigenous people, colonization is a critical determinant
of health for Indigenous populations.7 As the mounting health con-
cerns of Indigenous communities are largely perpetuated by his-
torical attitude and structures that are ever-present today, chang-
feature article
es need to be made to address the ways that these inequities are
continually recreated within the healthcare system. Ensuring that
this knowledge is instilled among undergraduate medical students
is one approach to foster the growth in numbers of doctors with
Indigenous cultural competency.
In response to the inadequate coverage of Indigenous health
in the medical school curriculum, advocates for Indigenous com-
munities have advised medical schools on how to expand teaching
time and resources dedicated to Indigenous health. To ensure that
students acquire Indigenous cultural competency, medical school
curricula need to allocate adequate teaching resources and time to
Indigenous health. An understanding and acknowledgement of the
residual effects of colonialism can help ensure that medical profes-
sionals can more effectively address the health inequities that dis-
proportionately affect Indigenous communities.8 Medical students
need to recognize the historical structures rooted in colonialism
that continue to produce health disparities for Indigenous peoples,
such as the Indian Act, the reservation system, and discriminato-
ry practices in employment, education, and housing. In addition,
medical students need to understand how their personal privileges
can affect clinical practice, and how ignorance to the social contexts
of Indigenous patients and families can lead to inappropriate rec-
ommendations for care.8 There are three key questions that need
to be taken into consideration when incorporating post-colonial
perspectives into Canadian healthcare training programs: (i) what
content relating to post-colonialism and health should be taught;
(ii) how this content should be taught, including teaching strate-
gies and who should teach the content, and; (iii) why this content
is being taught.8 Collaboration with Indigenous partners to answer
these three questions is key in developing teaching strategies and
training programs.8
Various medical schools have taken novel approaches to en-
hance the knowledge, cultural competency, and commitment of
medical students to Indigenous health. In particular, the incorpora-
tion of experiential learning has been shown to be effective for the
Indigenous health curriculum.9 During years 1 and 2, the Northern
Ontario School of Medicine (NOSM) incorporates clinical learning
experiences with case-based modules that focus on Indigenous
health topics.10 Additionally, medical students at NOSM engage in
an Indigenous cultural immersion experience, where they continue
their medical education through sessions in Indigenous communi-
ties, while also focusing on cultural activities and community learn-
ing.10 Currently, the success of this program can only be gauged in
relation to the thoroughness of Indigenous health topics discussed
in the curriculum and through the sustained commitment of Indig-
enous community partners.10 Similar cultural immersion programs
implemented in New Zealand demonstrate significant shifts in stu-
dents’ self-perceptions of their commitment and preparedness to
improve Indigenous health.9
Additionally, arts-based teaching programs are often incor-
porated into medical school curricula through various mediums,
such as literature, drama, visual arts, and music.11 In one arts-based
teaching program, medical students who attended workshops that
UWOMJ 86:2 | Fall 2017 Page 58
explored healthcare issues worked to develop their professional
skills in communication, self-presentation, and observation.11 Over-
all, students found that this arts-based teaching program was a
valuable contribution to their education, with group work facilitat-
ing opportunities to learn new skills and engage with people of dif-
ferent backgrounds.11 When incorporating Indigenous health into
the medical curriculum, arts-based teaching programs may be po-
tential avenues to explore in order to increase student engagement.
However, it is also important to acknowledge the challenges
with developing and delivering an Indigenous health curriculum in
medical schools. Traditionally, medical schools are constrained by
discipline and lecture-based courses and it can be challenging to
find the appropriate space in the curriculum to accommodate these
changes.10 Another significant challenge is being aware of the ste-
reotypes and misconceptions that are associated with Indigenous
people, and ensuring that these views are not reinforced by the
curriculum.10 Lastly, there are challenges in evaluating the impact
of such programs and ongoing efforts to track specific educational
outcomes need to be further pursued.10
conclusion
The divide in health status between Indigenous and non-Indig-
enous populations is well-documented in the current literature.1,2
Cultural competency is frequently suggested as a probable way to
address this large gap.6 Experiential learning allows students to be
fully immersed in Indigenous health care. This immersion allows
them to better understand and witness first-hand the hardships and
barriers that are currently present within the healthcare system.10
Supplementary to this, arts-based learning is very engaging and
creates a safe space for the students to learn and examine multiple
perspectives on the problems that Indigenous populations encoun-
ter in healthcare.11
Despite how promising these teaching strategies may be, there
are challenges to curriculum implementation, including reinforce-
ment of stereotypes and incorporation into predominantly didactic
curriculum structures.10 In spite of these challenges, it is important
to improve the Indigenous health curriculum in medical schools to
foster the growth of doctors who advocate for Indigenous popula-
tions. Most importantly, educational content relating to post-colo-
nial health should be better integrated into the medical school cur-
riculum to ensure the provision of equitable healthcare services by
culturally competent care providers.
references
1. Ball J. Early Childhood Development Intercultural Partnerships
[Internet]. Cultural Safety in Practice with Children, Families and
Communities. University of Victoria; 2017.
2. Waldram JB, Herring A, Young TK. Aboriginal health in Canada:
Historical, cultural, and epidemiological perspectives. University of
Toronto Press; 2006.
3. Elliott CT, de Leeuw SN. Our aboriginal relations When family
doctors and aboriginal patients meet. Can Fam Physician. 2009 Apr
1;55(4):443-4.
4. Dogra N, Reitmanova S, Carter-Pokras O. Teaching Cultural Diversity:
Current Status in U.K., U.S., and Canadian Medical Schools. J Gen
Intern Med. 2010; 25:164–8.
5. Gustafson DL, Reitmanova S. How are we ‘doing’ cultural diversity? A
feature article

look across English Canadian undergraduate medical school pro-

grammes. Med Teach. 2010; 32:816–23.
6. Baker AC, Giles AR. Cultural safety: A framework for interactions be-
tween Aboriginal patients and Canadian family medicine practitioners.
Int J Indig Health. 2012 Nov 1;9(1):15.
7. Kirmayer L, Simpson C, Cargo M. Healing traditions: Culture, commu-
nity and mental health promotion with Canadian Aboriginal peoples.
Australas Psychiatry. 2003 Oct 1;11(s1):S15-23.
8. Beavis AS, Hojjati A, Kassam A, et al. What all students in healthcare
training programs should learn to increase health equity: perspectives
on postcolonialism and the health of Aboriginal Peoples in Canada.
BMC Med Educ. 2015 Sep 23;15(1):155.
9. Paul D, Carr S, Milroy H. Making a difference: the early impact of an
Aboriginal health undergraduate medical curriculum. Med J Aust.
2006 May 15;184(10):522.
10. Jacklin K, Strasser R, Peltier I. From the community to the classroom:
the Aboriginal health curriculum at the Northern Ontario School of
Medicine. Can J Rural Med. 2014 Oct 1;19(4):143.
11. De la Croix A, Rose C, Wildig E, et al. Arts based learning in med-
ical education: the students’ perspective. Medical Educ. 2011 Nov
1;45(11):1090-100.

UWOMJ 86:2 | Fall 2017 Page 59

feature article
Conservative management strategies
to mitigate the increasing burden of
osteoarthritis on the healthcare system
James J Young
Faculty Reviewer: Bert M Chesworth, BA, BScPT, MClScPT, PhD (School of Physiotherapy)
abstract
In Canada, the incidence is expected to increase in the up-
coming years due to changing population demographics. As
such, researchers have recently started to focus on conserva-
tive management strategies. This article will review the cur-
rent evidence available for the effectiveness of self-manage-
ment and therapeutic exercise programs in individuals with
hip and knee OA, as well as discuss the potential for mitigating
rising healthcare costs in this population.
introduction
Osteoarthritis (OA) is the most common form of arthritis, in-
volving structural changes in the joint as well as inflammation.1
There are currently over 4 million Canadians living with OA, repre-
senting 13% of the population.2 In the coming years, the proportion
of affected individuals is expected to increase due to an aging pop-
ulation, which will result in more people developing OA.2,3 More-
over, it has been predicted that 25% of the Canadian population will
be diagnosed with OA by the year 2040.2 This increase will place a
large financial burden on the Canadian healthcare system as these
individuals seek continual care. A recent cohort study in the United
States found that individuals with arthritis or joint pain accounted
for higher total healthcare expenditures than those who are not af-
fected.4
A recent scoping review found that the key factor in deter-
mining an OA patient’s self-perceived need for healthcare services
was their symptom control.5 This finding is further supported in
the Arthritis Alliance of Canada 2011 report, which predicted that
the development of adequate pain management strategies for OA
would result in a cumulative savings of $488 billion over the next
30 years.2 Self-management patient education and therapeutic ex-
ercise interventions may offer clinically significant pain and symp-
tomatic relief for the patient while allowing providers to decrease
costs of care delivery, resulting in a more efficient healthcare sys-
tem.
guidelines
Many organizations from around the world have published
guidelines for the management of hip and knee OA, most of which
recommend that patients participate in self-management educa-
tional programs, including weight loss if overweight, and engage
in regular aerobic, resistance, and flexibility exercises.6-10 One such
UWOMJ 86:2 | Fall 2017 Page 60
guideline, published by the European League Against Rheumatism
(EULAR), recommends that every patient with hip or knee OA
should receive a core non-pharmacological intervention consist-
ing of education, self-management, weight loss if overweight, and
regular exercise.8 These interventions represent a patient-centred
and multidisciplinary approach, utilizing the main principles of
non-pharmacological management.8 The reduced need for clinical
interaction with individuals who implement these patient-centric
interventions may provide a cost-effective alternative for OA pain
and disability management, with the potential to reduce the eco-
nomic burden on the healthcare system. However, little is known
about how these treatment guidelines influence patient outcomes
and healthcare expenditures.
review of evidence
While little is known regarding the effectiveness of compre-
hensive management programs like that recommended by EULAR,
key elements of these guidelines have been tested experimentally.
Self-management strategies and therapeutic exercise have been
proposed as conservative interventions for the treatment of OA-re-
lated pain and disability, and have been studied extensively.11-17
Self-management programs for OA comprise a package of inter-
ventions specifically targeted at patient education and behaviour
modification, which encourage people with chronic disease to take
an active role in the management of their own condition.14 Weight
loss is often considered its own form of OA intervention, but for
the purposes of this review, will be considered as part of a broader
self-management category.
In 2014, the Cochrane Library published a review of random-
ized controlled trials assessing the effectiveness of self-manage-
ment education programs.14 Twenty-nine studies were included
in the review, which found low to moderate quality evidence for
self-management programs.14 However, when compared to usu-
al care for individuals with OA, these interventions may improve
self-management skills, pain, function, and symptoms. It was con-
cluded interventions of this nature are unlikely to cause harm to
patients, and that more research is needed on other models of
self-management education programs.14
Weight loss is also recommended as a basic self-management
tenet for individuals with osteoarthritis.8 A systematic review of
454 patients with diagnosed knee OA in four randomized con-
trol trials found that disability can be significantly improved with
weight loss of greater than 5% of total body weight over a 20-week
feature article
period.13 However, only a small pooled effect size for improvement
in pain was found with a reduction in weight.13 A particular strength
of this review was the inclusion of both dietary and exercise inter-
ventions to reduce weight, highlighting the potential to incorporate
patient preference into the shared decision making process.
Therapeutic exercise has also been the focus of much clinical
research and is defined as a range of targeted physical activities that
directly aim to improve muscle strength, joint range of motion, and
aerobic fitness.15,16 The Cochrane Library published a review of fif-
ty-four randomized controlled trials examining the effectiveness
of land-based therapeutic exercise in individuals with knee OA.15
Moderate to high quality evidence suggests that land-based exer-
cise provides sustained benefit in pain and physical function for
up to 6 months following cessation of treatment.15 These findings
are comparable to reported improvements in the same outcomes
following the use of non-steroidal anti-inflammatory drugs.15 Fur-
thermore, a similar review for individuals with hip OA found that
land-based therapeutic exercise improved pain and physical func-
tion levels immediately after treatment, and improvements were
sustained for three to six months.16 It is important to note that ther-
apeutic exercise for individuals with hip or knee OA was unlikely
to cause any adverse events, and that further research is needed to
determine optimal dosage parameters for exercise.15,16
In addition to land-based exercise, aquatic exercise interven-
tions may provide symptomatic relief of OA. A review of aquatic
exercise interventions for people with OA of the hip or knee was
recently published by the Cochrane Library.12 This review included
13 trials (1190 participants) and found moderate quality evidence
that aquatic exercise provides small, but clinically relevant effects
on pain, disability, and quality of life, with minimal risk of any ad-
verse events.12 With both land-based and aquatic exercise shown
to produce clinically significant outcomes for individuals with OA,
patients may select a more preferable program to manage their OA.
There is little consensus on the optimal frequency and dura-
tion of self-management education and exercise programs, as more
research examining these interventions is needed. Moreover, this
article limited its focus to a discussion of self-management and
therapeutic exercise effectiveness individually but there is growing
evidence examining these treatments in combination or as part of a
larger multimodal intervention.18,19 There is potential for multimod-
al conservative and pharmacological interventions, tailored to the
individual patient, to provide effective symptomatic and functional
improvement.
conclusion
Due to the increasing number of Canadians with OA and
subsequent burden on the healthcare system, it is important for
practitioners to be aware of interventions that have the potential
to reduce costs while simultaneously improving patient health.
The purpose of this review was to highlight the latest evidence on
self-management and therapeutic exercise strategies for patients
with OA. These interventions were found to provide small to mod-
erate improvements in pain levels and physical functioning and
UWOMJ 86:2 | Fall 2017 Page 61
were unlikely to cause harm in these individuals.
After review of the available high-quality evidence, it is recom-
mended that clinicians consider referral of patients to self-manage-
ment and exercise programs to manage the symptoms of OA in ad-
dition to standard care. Treatment approaches such as this require
collaboration from a multidisciplinary team and highlight the need
for effective communication within the patient’s entire healthcare
team. These interventions can provide meaningful results to pa-
tients with OA and may help reduce the costly burden of OA on the
healthcare system. It is hoped that this article provides clinicians
with a review of the most up-to-date evidence on approaches to the
management of OA, while aiming to stimulate thought and further
research in the development of efficacious and cost-effective OA
management strategies.
references
1. Cross M, Smith E, Hoy D, et al. The global burden of hip and knee osteoarthritis:
estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis. 2014
Jan24;73:1323–1330.
2. Bombardier C, Hawker G, Mosher D. The Impact of Arthritis in Canada: Today
and Over the Next 30 Years. Toronto: Arthritis Alliance of Canada; 2011.
3. Busija L, Bridgett L, Williams SR, et al. Osteoarthritis. Best Pract Res Clin Rheu-
matol. 2010 Dec;24(6):757–68.
4. Williams EM, Walker RJ, Faith T, et al. The impact of arthritis and joint pain
on individual healthcare expenditures: findings from the Medical Expenditure
Panel Survey (MEPS), 2011. Arthritis Res & Ther. 2017 Feb28;19(1):38.
5. Papandony MC, Chou L, Seneviwickrama M, et al. Patients’ perceived health
service needs for osteoarthritis (OA) care: a scoping review. Osteoarthritis
Cartilage. 2017 Feb;17.
6. Richmond J, Hunter D, Irrgang J, et al. American Academy of Orthopaedic Sur-
geons clinical practice guideline on the treatment of osteoarthritis of the knee. J
Bone Joint Surg Am. 2010 Apr;92(4):990-3.
7. Hochberg MC, Altman RD, April KD, et al. American college of rheumatology
2012 Recommendations for the use of nonpharmacological and pharmacologic
therapies in osteoarthritis of the hand, hip and knee. Arthritis Care & Research.
2012 Apr;64(4):465-74.
8. Fernandes L, Hagen KB, Bijlsma JW, et al. EULAR recommendations for the
non-pharmacological core management of hip and knee osteoarthritis. Ann
Rheum Dis. 2013 Jul;72(7):1125-35.
9. Nelson AE, Allen KD, Golightly YM, et al. A systematic review of recommenda-
tions and guidelines for the management of osteoarthritis: The chronic osteo-
arthritis management initiative of the U.S. bone and joint initiative. Seminars in
Arthritis and Rheumatism. 2014 Jun;43(6):701-12.
10. McAlindon TE, Bannuru RR, Sullivan MC, et al. OARSI guidelines for the
non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014
Mar;22(3):363-88.
11. Ashworth NL, Chad KE, Harrison EL, et al. Physical activity programs for older
adults. Cochrane Database Syst Rev. 2005 Jan;1.
12. Bartels EM, Juhl CB, Christensen R, et al. Aquatic exercise for people with osteo-
arthritis in the knee or hip. Cochrane Database Syst Rev. 2016 Mar;3.
13. Christensen R, Bartels EM, Astrup A, et al. Effect of weight reduction in obese
patients diagnosed with knee osteoarthritis: a systematic review and meta-analy-
sis. Ann Rheum Dis. 2007;66:433-39.
14. Kroon FBP, van der Burg LRA, Buchbinder R, et al. Self-management education
programmes for osteoarthritis (Review). Cochrane Database Syst Rev. 2014
Jan;1:1-3.
15. Fransen M, McConnell S, Harmer AR, et al. Exercise for osteoarthritis of the
knee. Cochrane Database Syst Rev. 2015 Jan;1:1-3.
16. Fransen M, McConnell S, Hernandez-Molina G, et al. Exercise for osteoarthritis
of the hip. Cochrane Database Syst Rev. 2014 Apr;4:1-3.
17. Regnaux J, Lefevre-Colau M, Trinquart L, et al. Benefits and harms of high-
versus low-intensity exercise programs for hip or knee osteoarthritis. Cochrane
Database Syst Rev. 2015 Oct;10.
18. French, HP, Galvin R, Abbot J, et al. Adjunctive therapies in addition to land-
based exercise therapy for osteoarthritis of the hip or knee. Cochrane Database
Syst Rev. 2015 Oct;10:1-12.
19. Devos-Comby, L, Cronan T, Roesch SC. Do exercise and self-management inter-
ventions benefit patients with osteoarthritis of the knee: A metaanalytic review.
J Rheumatol. 2006 Apr;33(4): 744-56.
clinical procedures
Poverty: A clinical instrument for family physicians
Gayathri Sivakumar, Brandon Chau
Faculty Reviewer: Thomas Freeman, MD, MClSc, CCFP, FCFP (Department of Family Medicine)
abstract
The primary driver of health outcomes is not medical pro-
fessionals and the treatment they provide, but rather the so-
cioeconomic environments enveloping individuals from the
time they are born until their last breath. Social determinants
of health (SDOH), which are factors such as income, education,
ethnicity, disability, and access to healthcare, create disparities
in morbidities and mortalities across a social gradient. Pover-
ty constitutes one of the most well-studied and well-acknowl-
edged SDOH, with a wide-ranging and treacherous impact on
one’s health and well-being. A new poverty tool, created by
the College of Family Physicians of Canada and the Centre for
Effective Practice, enables front-line clinicians to tackle the
social challenges associated with a low socioeconomic status.
Consideration of socioeconomic conditions in a clinical prac-
tice setting can improve health outcomes by optimizing clinical
management decisions and reduce the burden on our health-
care system.
introduction
Case study: Amanda is a 38-year old single mother of three kids.
She has a history of smoking 10-pack-years. In addition to being on
income support, Amanda works as a maid and laundry worker at a
motel for minimum wage and works extremely long hours. She has
a Grade 7 education. Amanda lacks family and community support.
She has a history of abuse by alcoholic parents. Amanda rarely visits
a family doctor because of her childcare duties and inability to take
time off from work. She presented to the emergency room suddenly
and was diagnosed with Stage IVB metastatic cervical cancer. Sadly,
she passed away within two months of her diagnosis.
While the official cause of Amanda’s death was her cancer,
could the real culprit of her demise be related to her status of
poverty?
The evidence supporting the link between health status and
disease burden to a social gradient can be traced back to the early
1800s and continues to become more powerful.1,2 Inequalities in the
distribution of income, power, and resources patently contribute
to the growing disparities in health outcomes amongst Canadians.
SDOH contribute to one’s socioeconomic status (SES) and are liv-
ing conditions that shape the health and well-being of individuals
and communities. The SDOH include, but are not limited to ear-
ly-childhood development, income, education, ethnicity, gender,
sexuality, Indigenous status, immigration status, and access to the
healthcare system.3,4
UWOMJ 86:2 | Fall 2017 Page 62
poverty as a clinical tool to identify risk factors in
primary care
Poverty has been demonstrated to be a health risk compara-
ble to smoking, hypertension, and high cholesterol levels.5 Living in
poverty has been inextricably tethered to a higher risk for chronic
diseases including diabetes, cardiovascular disease, stroke, respira-
tory illnesses, nervous system disorders, alcoholic cirrhosis, mental
illnesses, accidents, and trauma.5-9 A study assessing trends in mor-
tality demonstrated that income accounts for 24% of potential years
of life lost in Canada.7 In Hamilton, ON, there is a gap of 21 years in
the average age at death between the residents of highest- and low-
est-income neighborhoods.10 Moreover, those who are chronically
homeless are at 8-10× greater risk for premature death in compari-
son to the general population.3-5
For those with a lower SES, barriers to housing, food security,
education, employment, and physical and mental well-being be-
come more significant.3 For instance, in contrast to the richest of
Ontarians, the poorest report higher rates of smoking and physical
inactivity, reduced fruit and vegetable intake, and increased inci-
dences of multiple chronic disorders.5 Lower SES is also associated
with reduced access to quality healthcare services.5 Inequitable ac-
cess to healthcare diminish the opportunity for routine checkups
including recommended screenings such as pap smears, hinder
health education, early diagnosis, and clinical management of an
illness, and ultimately contribute to the perpetuation of poor health
outcomes. Reduced accessibility to healthcare further prompts a
higher proportion of emergency room visits and hospitalizations
for conditions that could be well-managed in a community clinic,
contributing to a greater economic burden.5
addressing poverty in a clinical encounter
Family physicians, being providers of comprehensive and lon-
gitudinal care, are in an unparalleled position to address poverty in
their practices.11 However, according to a qualitative study, family
physicians feel ill-prepared in confronting poverty needs in clinical
encounters.12 Just as one would screen for diabetes, hypertension,
and cardiovascular disease, there is a need for a systematic way to
screen for poverty that would help health care providers recognize
socioeconomic inequities within their practice populations, enable
better patient-centered care for the disadvantaged, and reduce
their health risks and related unfavourable health corollaries.11
In order to develop an effective clinical intervention to address
challenges related to SDOH in primary care, the College of Family
Physicians of Canada (CFPC) collaborated with the Centre for Ef-
fective Practice (CEP) to establish and distribute province-specific
poverty tools across Canada.13 This poverty tool includes three sys-
tematic steps to address poverty in a clinical encounter.
clinical procedures
Step #1. Screen for Poverty. It is imperative to screen every-
one for the poverty risk factor. Brcic et al (2011) developed an ev-
idence-based poverty case-finding tool that can be used by family
physicians to identify patients who are poor. A simple question,
“Do you (ever) have difficulty making ends meet at the end of the
month?”, was identified to be a good screening tool for poverty with
a sensitivity of 98% and a specificity of 64%.11 If the answer is yes,
then the physician can proceed with Step #2.
Step #2. Adjust for Risks. Physicians must acknowledge that
women, Indigenous populations, newcomers, visible minorities,
and the LGBTQ+ communities are among the highest risk groups
for a wide range of chronic conditions.13,14 In addition, family phy-
sicians need to have a general understanding that when it comes
to patients in poverty, regardless of their risk profile, they are at an
elevated risk for health conditions such as cardiovascular disease,
diabetes, depression, and suicidal ideation.14 Experiencing poverty
is also associated with other chronic conditions such as high blood
pressure, inflammatory disorders, and chronic obstructive pulmo-
nary disease.14
Step #3. Ask, Educate, and Intervene/Connect. Family phy-
sicians should ask probing questions to understand the patient’s
living situation, financial burdens, employment, social assistance
and supports, and the remunerations they receive from the gov-
ernment. Depending on the patient’s needs and living conditions,
family physicians can direct patients to allied health professionals
such as social workers to be educated on topics such as tax returns,
income supplements, drug coverages, child and disability benefits,
and non-insured health benefits for First Nations. Physician inter-
vention and the dialogue that this generates with patients and their
families can identify opportunities for additional income and ben-
efits support, and connect patients to government and community
resources.14
The poverty tool places family physicians vis-à-vis with the
threats posed by poverty. Using the poverty tool can empower phy­
sicians to take on more of a leadership and advocacy role within
their clinical encounters, and more importantly, present patients
with opportunities to access appropriate and available resources,
ultimately fostering a more positive socioeconomic environment in
their lives.
implications of poverty tools in medicine
The use of poverty tools to modify clinical decision-mak-
ing reflects a drastic cultural shift in the field of medicine, from a
strict biomedical approach to one that takes into account patient
context.15 In Ontario, the Ontario College of Family Physicians
(OCFP) Poverty and Health Community of Practice, an association
of primary care providers dedicated to reducing health disparities,
continues to mediate discussions related to poverty and associated
adverse health outcomes across the province.14 OCFP has been ac-
tively engaged in anti-poverty advocacy projects, emphasizing the
commitment of medical professionals towards social accountabili-
ty.14,15 OCFP has been accentuating the intensifying duty for family
physicians to regard poverty as an avertible and treatable condition
UWOMJ 86:2 | Fall 2017 Page 63
and that family physicians are in a unique position to combat pov-
erty.14
The CFPC recognizes that aside from advocacy at the mi-
cro-level in the clinic, physicians can also become activists at the
meso-level in the local community and at the macro-level.15 At the
meso-level, family physicians can collect and use community-level
data on SDOH to educate and train health care professionals.15 This
information can also be used to understand the health needs of the
local community and identify gaps in the provision of care. In addi-
tion, physicians can provide on-site healthcare services to patients
that are unable to visit the clinic.15 At a macro-scale, family phy-
sicians can initiate collaborations with organizations to advocate
for improved living conditions for the general Canadian population
and advocate for the transformation of public health policies that
target upstream elements of health such as benefits, social assis-
tance, and affordable housing.15
summary
Poverty has a powerful impact on health outcomes and cre-
ates inequities in health outcomes between the highest- and low-
est-income populations. For decades, what has been considered
as a social issue now needs to be perceived as a health issue. The
poverty screening and intervention tools developed by the CFPC
and CEP empower family physicians to take a stand against pov-
erty, help guide clinical action to provide the best possible patient
outcomes, and tackle the social challenges faced by those who are
living in poverty. Amanda, who was presented in the case study at
the beginning of our article, would have been identified as an in-
dividual of low socioeconomic status by her doctor, who then may
have been able to accommodate Amanda’s work schedule for her
routine appoint­ments. Amanda could have gotten her pap smear
and she could have become educated about tax benefits, income
supplementation, and government grants. She could have survived
and lived a long, healthy life.
While further evidence is required to optimize the screening,
risk-assessment, and intervention practices, integration of poverty
as a clinical tool in medical practice is a step in the right direction
for family physicians to become more socially accountable. With
more family physicians adopting poverty as a health risk, those
from marginalized populations can begin to receive more accessi-
ble and appropriate care.
references
1. McKeown T, Record RG. Reasons for the decline of mortality in
England and Wales during the nineteenth century. Popul Stud.
1962;16:94-122.
2. Logan WPD. Mortality in England and Wales from 1848 to 1947. Popul
Stud. 1950;4:132-78.
3. Raphael D. Social determinants of health: Canadian perspectives, 2nd
edition. Toronto: Canadian Scholars’ Press; 2009.
4. Mikkonen J, Raphael D. Social determinants of health: The Canadian
facts. Toronto: York University School of Health Policy and Manage-
ment; 2010.
clinical procedures

5. Income and Health: Opportunities to achieve health equity in Ontario.

Health Quality Ontario. Toronto: Queen’s Printer for Ontario; 2016.
6. Improving the health of young Canadians. Canadian population health
initiative. Ottawa: Canadian Institute for Health Information; 2005.
7. Wilkins R, Berthelot JM, Ng E. Trends in mortality by neighbourhood
income in urban Canada from 1971 to 1996. Ottawa: Statistics Canada;
2002.
8. Emerson E. Relative child poverty, income inequality, wealth, and
health. JAMA. 2009;301(4):425-6.
9. Currie J, Lin W. Chipping away at health: more on the relationship
between income and child health. Health Affairs. 2007;26(2):331-44.
10. Hamilton Spectator [Internet]. Worlds Apart. Hamilton (ON): Ham-
ilton Spectator; 2010 Aug [cited 2017 May 26]. Available from: http://
www.thespec.com/news-story/2168237-worlds-apart.
11. Brcic V, Eberdt C, Kaczorowski J. Development of a tool to identify
poverty in a family practice setting: a pilot study. Int J Family Med.
2011 May; Article ID: 812182.
12. Willems SJ, Swinnen W, DeMaeseneer JM. The GP’s perception of
poverty: a qualitative study. Family Practice. 2005;22(2):177–83.
13. TheWell [Internet]. Poverty: A Clinical Tool For Primary Care Pro-
viders. Toronto: Centre for Effective Practice; 2016 Nov [cited 2017
Apr 23]. Available from: https://thewellhealth.ca/wp-content/up-
loads/2016/12/Poverty_flow-Tool-Final-2016v4.pdf.
14. Ontario College of Family Physicians [Internet]. Primary Care Inter-
ventions in Poverty. 2016 [cited 2017 Apr 23]. Available from: http://
ocfp.on.ca/cpd/povertytool.
15. Patient’s Medical Home [Internet]. Best Advice – Social Determinants
of Health. College of Family Physicians of Canada; 2015 Mar [cited
2017 Apr 23]. Available from: http://patientsmedicalhome.ca/files/up-
loads/BA_SocialD_ENG_WEB.pdf.

UWOMJ 86:2 | Fall 2017 Page 64

diagnostic review
Radiology wait times
Impact on Patient Care and Potential Solutions
Logan Van Nynatten, Ariel Gershon
Faculty Reviewer: Ilanit Ben-Nachum, MD (Department of Medical Imaging)
abstract
As diagnostic imaging becomes a more prevalent tool in
medicine, radiologists must increasingly be concerned with re-
source management. Wait times represent an important qual-
ity of care issue in medicine, especially in Canada, where the
number of MRI and CT scanners is limited compared to other
countries. Longer wait times have been shown to worsen med-
ical outcomes in a number of different settings, including head
and neck cancers, as well as costing patients emotional and
financial resources. Accordingly, a number of strategies have
been undertaken to reduce waiting times. Teleradiology, which
is the assignment of diagnostic interpretation of images to dis-
tant radiologists, has worked in the context of reduced staff ra-
diologists in PEI. There may also be a role for encouraging only
appropriate indications for imaging. In conclusion, the authors
suggest that good radiologic practice consists of considering
appropriate use of diagnostic imaging to reduce wait times.
introduction
The perception that the radiologist’s only job is diagnostic
interpretation of medical imaging is outdated. Radiologists not
only provide medical imaging interpretation, but are increasingly
involved with resource management and quality of care improve-
ment.1 Wait times are an important quality of care issue, especially
in Canada, which has lagged behind other developed countries in
efficient utilization of Magnetic Resonance Imaging (MRI) equip-
ment per capita. In Organisation for Economic Co-operation and
Development (OECD) countries the median number of MRI scan-
ners per million people is 6.1. Canada’s is 4.6 per million people,
which is considerably lower than Japan (35.3) or the United States
(19.5), which have the highest MRI per capita in the OECD.2 The
expanding indications for imaging combined with inappropriate
ordering, and delays in reporting, has led to poorly managed wait
lists and unnecessarily long wait times.
diagnostic imaging in canada
Canada has seen an increase in medical imaging utilization.
In Ontario, the number of MRI scans performed increased by over
300%, and the number of Computerized Tomography (CT) scans
increased 3-fold between 1993-2003. This rapid increase in use of
technology raises the questions of whether the indications for CT
and MRI have expanded, or if physicians are using diagnostic imag-
ing appropriately. The average Canadian waits 3.7 weeks for CT and
11.1 weeks for MRI scans.3 In contrast, the Canadian Association
UWOMJ 86:2 | Fall 2017 Page 65
of Radiologists (CAR) has recommended that the maximum wait
times for non-urgent CT or MRI scans to be no more than 60 days
(or 8.6 weeks). The same report outlines the need for better data to
monitor wait times.4
impact of radiology wait times on patient care
Wait times pose a significant problem to many areas of medi-
cine. Wait times have an impact on quality of care, inconveniences
the patient, increases cost of care, and also have material conse-
quences on the medical issues the patient faces.5 A study by Byrne
et al demonstrated the effect of wait times in patients with non-
small cell lung cancer (NSCLC). Biopsies from patients in a New-
foundland centre who required CT guided lung biopsies in 2009
were compared to biopsies taken in 2011 as there were significantly
shorter wait times in 2011. The authors showed longer wait times
correlated with an increase in the tumor size and stage found on
imaging, which worsens the prognosis of NSCLC.6 Jensen et al, sim-
ilarly, showed that wait times negatively impacted disease course in
the context of head and neck cancers.7 In this cohort, the authors
compared initial diagnostic scans with the treatment planning scan
of patients diagnosed with squamous cell carcinoma of the head
and neck, and measured changes in tumor volume and in disease
stage. The average wait time was 4 weeks, with a range of 5 to 95
days, and most (62%) of the patients had an increase in tumor size,
and many others developed serious complications of tumor growth
including new lymph node metastases (20% of patients) and pro-
gression in the TMN classification (10% of patients).
Wait times have an economic impact as well. A report by Barua
and Ren estimated that 973,505 Canadians waited an average of 10.6
weeks in order to access treatments in 2016, and that on average
each patient lost between $1,759 to $5,360, depending on whether
the analysis only included loss of work hours, or included loss of
weekends and evenings as well. The total estimate borne by indi-
viduals waiting for treatment is between $1.7 billion or $5.2 billion.
This estimate does not include the cost of loss of productivity in the
family members of the patients, and also does not include mental
anguish or worsening medical issues.8
solutions to reduce wait times in diagnostic imaging
The problem of long wait times has many contributing fac-
tors. The total radiology waiting time is measured as both the time
between referral and examination, and the time between the ra-
diologic examination and the production of the clinical report. A
systematic review by Olisemeke et al studied a number of service
delivery initiatives targeted at reducing wait times in radiology.
diagnostic review
For this review, while the heterogeneity across studies was large, a
number of approaches have shown decreases in wait times.9 Some
promising avenues in the literature include technological tools to
increase radiologist productivity such as speech recognition soft-
ware, teleradiology, and increasing radiographic technician’s scope
of practice to assist with image interpretation.9 The introduction of
teleradiology improved the number of reports completed within 40
minutes from 34 to 43.
Teleradiology has been particularly successful in Canada when
the primary problem is a paucity of staff radiologists. Teleradiolo-
gy is the practice of interpreting radiographic images at a distance.
In Prince Edward Island, a number of changes were implemented
that resulted in wait times for elective or non-urgent CT scans de-
creasing from 22 weeks in January 2009, to under 3 weeks in 2011,
and MRI wait times decreasing from 33 weeks to 8 weeks. In order
to achieve this improvement in wait times, a quality improvement
committee implemented a number of upgrades to their existing
procedures, but attributed much of their success to the implemen-
tation of teleradiology. Teleradiology practises allow scans to be
interpreted by highly skilled radiologists in neighboring provinces,
thus reducing the time between radiologic examination and clinical
reporting.9 Hence, this allows for the corresponding primary care
physicians or specialists providing care to the patient (depending
on the results of imaging scans) to do so in a more timely manner.9
The province of PEI has a shortage of staff radiologists relative to
the needs of the population, so the PEI Department of health con-
tracted radiologists working in Halifax, Nova Scotia to commit to
reviewing a number of cases per day, with a predetermined amount
of time to return a report.10
Yet another global method of improving wait times is to ensure
that only appropriate diagnostic examinations are ordered. A re-
port estimated that 10 to 20% of MRI or CT scans are unnecessary.
There are many potential sources of inappropriate scans including
patients’ demands for imaging when not indicated, lack of knowl-
edge of up-to-date guidelines by the referring physician, and poor
communication between physicians.11 Despite the high estimated
rate of inappropriate diagnostic examinations, very few centres
have programs to reduce this inefficiency. The authors of this re-
port suggest that physicians should stay abreast of the appropriate
imaging guidelines and to foster a culture of quality within radiol-
ogy departments. Indeed, it has been demonstrated on a local level,
that appropriate use of guidelines by general practitioners reduced
inappropriate radiology referrals by 23%.12 The standardization of
imaging guidelines and workflow processes will help to shorten
wait times and lead to improved quality of patient care.
conclusion
Wait times for imaging remains a significant issue in the Cana-
dian healthcare system. While this is widely considered a trade-off
for our presumably otherwise successful single-payer system, wait
times are not benign. Delays in patient imaging can negatively im-
pact patient care in a number of ways, including reducing the quali-
ty of care and causing worsening of medical conditions and progno-
UWOMJ 86:2 | Fall 2017 Page 66
sis. In addition, there are economic impacts associated with waiting
for medical care. Wait times is a complex issue and there are many
possible approaches to reduce it including appropriate use of imag-
ing, having validated guidelines, increasing radiologist productivity
through more efficient workflows, increasing the number of staff
radiologists, teleradiology, or increasing the number or operational
hours of CT or MRI machines. Different approaches may be suc-
cessful to different extents in different centres. The PEI example
serves as a reminder that drastic changes in this area are possible,
and that we need not accept that long wait times are inevitable in
our system. We suggest that dedicated task forces investigate the
many causes and possible solutions to the problem of lengthy wait
times in diagnostic imaging. As mentioned above, although a num-
ber of individual research groups have investigated the role of ra-
diology wait times on patient outcomes there is no uniform body
in Canada that currently works to address such issues on a national
level (other than individual academic health science centre quality
improvement projects). Ideally, we suggest this task force commit-
tee could be a subset of the Canadian Society for Radiology who
already have the nation-wide contacts and capacity to investigate
and mediate quality improvement within radiology departments
across Canada.
references
1. European Society of Radiology. The future role of radiology in health-
care. Insights Imaging. 2010;1:2–11.
2. Stein LA. Making the best use of radiological resources in Canada.
Healthc Pap. 2005;6:18-23.
3. Barua B. and Feixue R. Waiting Your Turn Wait Times for Health Care
in Canada, 2016 Report [Internet]. Fraser Institute; 2016 [cited 2017
Sep 11]. Available from: https://www.fraserinstitute.org/sites/default/
files/waiting-your-turn-wait-times-for-health-care-in-canada-2016.
pdf.
4. Canadian Association of Radiologists. National Maximum Wait Time
Access Targets for Medical Imaging (MRI and CT) [Internet]. Canadi-
an Association of Radiologists; 2013 [cited 2017 Sep 11]. Available from:
http://www.car.ca/uploads/standards%20guidelines/CAR_Nation-
al_Maximum_WaitTime_Targets_MRI_and_CT_2013_EN.pdf.
5. Oostrom T, Einav L and Finkelstein A. Outpatient office wait times
and quality of care for Medicaid patients. Health Aff (Millwood).
2017;36:826–32.
6. Byrne SC, Barrett B and Bhatia R. The impact of diagnostic imag-
ing wait times on the prognosis of lung cancer. Can Assoc Radiol J.
2015;66:53–7.
7. Jensen AR, Nellemann HM and Overgaard J. Tumor progression in
waiting time for radiotherapy in head and neck cancer. Radiother
Oncol. 2007;84:5–10.
8. Ren F. and Bacchus B. The Private Cost of Public Queues for Medically
Necessary Care, 2017 [Internet]. Frasier Institute; 2017 [cited 2017 Sep
11]. Available from: https://www.fraserinstitute.org/sites/default/files/
private-cost-of-public-queues-for-medically-necessary-care-2017.pdf.
9. Olisemeke B, Chen YF, Hemming K, et al. The effectiveness of
service delivery initiatives at improving patients? Waiting times in
clinical radiology departments: a systematic review. J Digit Imaging.
2014;27:751–78.
10. Macdonald JE and MacPherson G. Teleradiology to Solve Wait Times
[Internet]. Accreditation Canada; 2011 [cited 2017 Sep 11]. Available
from: http://accreditation.ca/sites/default/files/qq-2011-december.pdf.
11. Morrison A. Appropriate Utilization of Advanced Diagnostic Imaging
Procedures: CT, MRI, and PET/CT [Internet]. Canadian Agency for
Drugs and Technologies in Health; 2013 [cited 2017 Sep 11]. Available
from: https://www.cadth.ca/media/pdf/PFDIESLiteratureScan_e_es-
.pdf.
12. De Vos Meiring P and Wells IP. The effect of radiology guidelines for
general practitioners in Plymouth. Clin Radiol. 1990;42:327-9.
ethics and law
Evaluation of supervised injection facilities as an ethically
sound approach to treatment of injection drug abuse
Katherine Fleshner, Matthew Greenacre
Faculty Reviewer:Jacob Shelley, LLB, LLM, SJD(c) (Faculty of Law)
abstract
Novel approaches are needed to address the issue of injec-
tion drug use in Canada, which can have negative consequences
for drug users and society. Supervised injection facilities (SIFs)
are legally sanctioned facilities in Canada where drug users can
receive sterile drug paraphernalia, referral to cessation pro-
grams and timely medical care if necessary. SIFs operate under
the principle of harm reduction, which aims to reduce rates of
infection and death due to overdose among drug users. SIFs are
largely driven by the utilitarian ideal of maximizing benefit for
the greatest number of people, through supervision of active
drug users and appropriate referral for those wishing to quit.
Deontological theory may support SIFs depending on how one
applies the categorical imperative. Studies of the first SIF in
North America, Insite, have shown demonstrable reductions in
adverse health and societal consequences of injection drug use,
rationalizing their implementation under consequentialism.
SIFs are, therefore, suitable for greater adoption by the health-
care system.
introduction
Injection drug abuse in Canada is a pressing public health is-
sue. Frequently injected drugs include heroin, cocaine, amphet-
amines and prescription opioids.1 Recent data estimate that there
are 75 000 to 125 000 intravenous drug users in the country.1 Injec-
tion drug use is problematic due to its association with addiction,
fatal overdose, contraction of chronic infections such as Human
Immunodeficiency Virus (HIV) or Hepatitis C, social isolation and
criminal behaviours.1 Novel approaches to facilitating cessation of
intravenous drug use are needed to ameliorate this issue.
Supervised injection facilities (SIFs) are legally sanctioned
medical facilities within which individuals may consume illicit
drugs under the supervision of healthcare workers. These centers
operate under the principle of harm reduction, which aims to cir-
cumvent the adverse effects of drug consumption rather than ab-
solutely discourage use altogether.2 They provide sterile injection
equipment to prevent the spread of infection often seen with nee-
dle-sharing and using unsanitary drug paraphernalia, including
needles, cookers and tourniquets. Opiate antagonists such as nalox-
one are available on site to be administered in the event of an over-
dose. SIFs staff includes social workers and mental health workers
who provide services including counseling and information about
and referral to rehabilitation programs.
The first SIFs were established in the Netherlands in the 1970s
as a result of changing attitudes towards deviant youth behaviours
UWOMJ 86:2 | Fall 2017 Page 67
including drug use.3 These centres were designed as a communal
meeting place and drop-in facility where individuals could con-
sume drugs. Some basic health services were also provided onsite.3
In following years, similar centres were established in Switzerland
and Germany.3
In 2003, Insite, the first SIF in North America, opened in
Downtown Eastside, Vancouver as a pilot project for a novel harm
reduction approach to substance abuse. Downtown Eastside is the
poorest urban neighbourhood in Canada with an estimated 5 000
injection drug users.4 Insite was initially granted a special three-
year exemption from Section 56 of the Controlled Drugs and Sub-
stances Act, which prohibits possession and trafficking of illicit
drugs, on the condition that its effects on the community be stud-
ied.5 The exemption was extended until 2007, after which a con-
stitutional challenge to Section 56 was filed to the Supreme Court
of British Columbia. Plaintiffs argued that it is unconstitutional to
prohibit possession and trafficking of illicit drugs as it restricts drug
users’ access to SIFs such as Insite.6 The Supreme Court of British
Columbia and, subsequently, the Supreme Court of Canada ruled in
their favour, granting Insite a constitutional exemption of Section
56 to allow them to continue operation.7 In 2017 thus far, Health
Canada has approved the opening of three new SIFs in Montreal
and three in Toronto, and they are currently reviewing applications
for additional SIFs in Surrey and Vancouver.8,9
SIFs are controversial. While other drug therapy practic-
es such as methadone clinics are funded by provincial healthcare
systems, many question whether the Canadian healthcare system
should subsidize or even simply condone a practice that facilitates
drug consumption rather than seeking to abolish it.10,11 This article
will demonstrate that utilitarianism and consequentialism provide
an ethical foundation for the Canadian healthcare system to adopt
SIFs as a complementary approach to treatment of injection drug
abuse.
utilitarianism, consequentialism and deontology
Ethical examination of a practice typically consists of two
schools of thought: utilitarianism and deontology. Utilitarianism,
pioneered by Jeremy Bentham and John Stuart Mill, teaches that
an action is moral if it maximizes the happiness within a society.12
Utilitarianism is sometimes considered under the broader theory
of consequentialism. In judging the morality of an action or policy,
consequentialism considers the widespread impact of an action on
all stakeholders as well as society at large.13 Consequentialism and
utilitarianism justify an action based upon the goodness of the re-
sults it produces, regardless of the optics or inherent righteousness
of the action itself.12
ethics and law
In contrast to utilitarianism, deontological theory as put forth
by Immanuel Kant states that humans are rational beings, and ra-
tional beings cannot be used as a means to an end.14 Therefore, de-
ontology judges morality by inherent goodness and whether actions
are motivated by duty, irrespective of the consequences.12 Inherent
goodness is often evaluated by whether an action or policy can
conform to the categorical imperative, which poses that inherently
moral actions could be prescribed as a universal law.12
supervised injection facilities maximize good for
more drug users
An ideal utilitarian approach to the issue of substance abuse
would bring about the most happiness for the greatest number of
people. However, many of the current approaches to treatment
for substance abuse are rooted in an abstinence-only philosophy
whereby help is provided to those willing to completely cease use.
These programs only benefit a subset of drug users: those who are
willing, ready and able to stop using. A significant proportion of
drug users do not fall under those categories for a multitude of rea-
sons, such as a desire to continue using or an inability to quit. These
individuals are therefore unaddressed by the abstinence-only ap-
proach.1
In contrast, harm reduction programs such as SIFs provide
more holistic care for drug users. In addition to the services pro-
vided in association with supervised injection, SIFs employ on-site
counselors, physicians and mental health workers to assist individ-
uals who express a willingness to quit. Some SIFs either have ad-
jacent detoxification facilities or are closely affiliated with similar
facilities in the community.15 Therefore, SIFs help more people than
would a strict cessation program, and therefore are more utilitarian
in nature.
deontological theory may conflict with harm
reduction principles
The deontological approach to substance abuse would con-
form to the categorical imperative, which states that a truly moral
action could be prescribed as a universal law. However, drug users
comprise a rather small subset of the population, and so it is hard
to delineate whether the categorical imperative should consider a
proposed policy as universal law only for those who consume drugs
or for all members of society. In the case of SIFs, if one considered
all of society, a possible universal law might be, ‘everyone should
consume drugs in SIFs’. However, as intoxication and/or addiction
eliminate an individual’s autonomy and free choice,14,16,17 if everyone
were to consume drugs, it would impair all individuals’ ability to act
as rational beings – a central tenet of deontological theory. There-
fore, this cannot align with a deontological viewpoint. However, if
the categorical imperative instead applied only to drug users, and
the universal law became, ‘all drug users should consume in SIFs’,
then a rationale becomes evident. If all drug users consumed in
SIFs, then the rates of fatal overdoses and injection-related infec-
tions would be markedly reduced – the result of close surveillance
and education by medical personnel. In addition, public drug use
UWOMJ 86:2 | Fall 2017 Page 68
and drug litter would be virtually eradicated since everyone would
only consume within SIFs.
consequentialist evaluation of supervised injection
facilities supports their adoption
Rampant drug use detrimentally impacts the communities in
which it occurs. Oftentimes, communities with significant popula-
tions of drug users have associated high rates of public drug use and
public discarding of syringes, which can put other citizens at risk
for needle-stick injuries.1,4,18 The presence of drug dealers and high-
er rates of petty crime may also pose safety issues.1 In the neigh-
bourhood of Downtown Eastside, Vancouver, the rates of Hepatitis
C and HIV infection are 90% and 30%, respectively,1, 19 and rates of
fatal overdose and emergency care use are exceedingly high relative
to surrounding communities.20
Two years after Insite opened in Downtown Eastside, rates of
syringe sharing declined among individuals who injected within
the facility, whereas no change in syringe sharing patterns were
noted in individuals not injecting at Insite.21 Insite users also re-
ceived education about how to inject to avoid infection and subse-
quently adopted sterilization regimens prior to injection.21 Utiliza-
tion of Insite facilities was also associated with decreased syringe
lending by HIV-positive drug users and decreased syringe borrow-
ing by HIV-negative drug users.21 Downtown Eastside also noted
decreases in public injection of drugs and in publicly discarded sy-
ringes and other forms of injection-related litter.21 With respect to
medical complications of injection drug use, Insite has prevented
approximately 35 new cases of HIV and 3 deaths due to overdose
each year – a net societal benefit of almost $6 million per year.22
Furthermore, rates of overdose at Insite were remarkably low and
the majority that did occur were managed onsite by in-house staff,21
subverting the need for external emergency care. The overall over-
dose rate in the community surrounding Insite fell by 35% in the
two year period following its opening.23 Suspected drug dealing and
drug-related crime also did not increase during this time.21 Insite
has led to positive outcomes within the community of Downtown
Eastside, justifying its operation under consequentialist ideals.
conclusion
As demonstrated, SIFs find footing on utilitarian and conse-
quentialist bases by minimizing the harms associated with ongoing
drug use and assisting those who are ready to quit. Unlike previous
approaches that stress abstinence from drugs, SIFs promote indi-
vidual freedoms and also prevent further harm through distribu-
tion of clean drug paraphernalia and timely medical attention in
the case of an overdose. On a societal level, the implementation of
SIFs can lead to both subsequent decreases in public drug injec-
tion and public discarding of syringes with no associated increase in
drug-related crimes. SIFs are, therefore, well suited for adoption by
the Canadian healthcare system for treatment of drug abuse.
ethics and law

program on numbers of discarded needles: a 2-year follow-up. Am J

references Public Health. 2000;90(6):936-9.
1. Supervised Injection Facilities (SIFs): FAQs [Internet]. Canadian 19. Tyndall MW, Kerr T, Zhang R, et al. Attendance, drug use patterns, and
Centre on Substance Abuse; [cited 2017 Mar 11]. Available from: http:// referrals made from North America’s first supervised injection facility.
www.ccsa.ca/Resource Library/ccsa-010657-2004.pdf. Drug Alcohol Depend. 2006;83(3):193-8.
2. Erickson PG. Harm reduction: what it is and is not. Drug Alcohol Rev. 20. Palepu A, Tyndall MW, Leon H, et al. Hospital utilization and costs in a
1995;14(3):283-5. cohort of injection drug users. CMAJ. 2001;165(4):415-20.
3. Dolan K, Kimber J, Fry C, et al. Drug consumption facilities in Europe 21. Wood E, Tyndall MW, Montaner JS, et al. Summary of findings from
and the establishment of supervised injecting centres in Australia. the evaluation of a pilot medically supervised safer injecting facility.
Drug Alcohol Rev. 2000;19(3):337-46. CMAJ. 2006;175(11):1399-404.
4. Wood E, Kerr T, Small W, et al. Changes in public order after the open- 22. Andresen MA, Boyd N. A cost-benefit and cost-effectiveness anal-
ing of a medically supervised safer injecting facility for illicit injection ysis of Vancouver’s supervised injection facility. Int J Drug Policy.
drug users. CMAJ. 2004;171(7):731-4. 2010;21(1):70-6.
5. Wood E, Kerr T, Lloyd-Smith E, et al. Methodology for evaluating 23. Marshall BD, Milloy MJ, Wood E, et al. Reduction in overdose mor-
Insite: Canada’s first medically supervised safer injection facility for tality after the opening of North America’s first medically supervised
injection drug users. Harm Reduct J. 2004;1(1):9. safer injecting facility: a retrospective population-based study. Lancet.
6. Makin K, Dhillon, S, Peritz, I. Supreme Court ruling opens doors to 2011;377(9775):1429-37.
drug injection clinics across Canada [Internet]. The Globe and Mail.
September 30, 2011 [cited 2017 May 25]. Available from: http://www.
theglobeandmail.com/news/british-columbia/supreme-court-ruling-
opens-doors-to-drug-injection-clinics-across-canada/article4182250/.
7. Canada (Attorney General) v. PHS Community Services Society, 2011
SCC 44, [2011] 3 S.C.R. 134. Cited 2017 May 24. Available from: https://
scc-csc.lexum.com/scc-csc/scc-csc/en/item/7960/index.do.
8. Woo A, Perreaux, L. Health Canada approves three supervised con-
sumption sites for Montreal [Internet]. The Globe and Mail. [cited
2017 May 25]. Available from: http://www.theglobeandmail.com/
news/politics/federal-government-approves-three-supervised-injec-
tion-sites-in-montreal/article33914459/.
9. Woo A, Gray, Jeff. Federal government approves three supervised-in-
jection sites in Toronto [Internet]. The Globe and Mail. 2017 Jun 02
[cited 2017 Jun 13]. Available from: http://www.theglobeandmail.com/
news/national/federal-government-approves-three-supervised-injec-
tion-sites-in-toronto/article35189403/.
10. Stueck W. The arguments for and against Vancouver’s supervised
injection site [Internet].2011 [cited 2017 Mar 11]. Available from:
http://www.theglobeandmail.com/news/british-columbia/the-ar-
guments-for-and-against-vancouvers-supervised-injection-site/arti-
cle596153/.
11. Strike C, Watson TM, Kolla G, et al. Ambivalence about supervised
injection facilities among community stakeholders. Harm Reduct J.
2015;12:26.
12. Christie T, Groarke L, Sweet W. Virtue ethics as an alternative to de-
ontological and consequential reasoning in the harm reduction debate.
Int J Drug Policy. 2008;19(1):52-8.
13. Sinnott-Armstrong W. Consequentialism [Internet]. 2003 [cited 2017
Jun 13]. In: The Stanford Encyclopedia of Philosophy [Internet]. Meta-
physics Research Lab, Stanford University. Available from: https://
plato.stanford.edu/cgi-bin/encyclopedia/archinfo.cgi?entry=conse-
quentialism.
14. Kant I. The Doctrine of Virtue. Ethics. 1965;75(2):142-3.
15. Small W, Van Borek N, Fairbairn N, et al. Access to health and social
services for IDU: The impact of a medically supervised injection facili-
ty. Drug Alcohol Rev. 2009;28(4):341-6.
16. Leshner AI. Addiction is a brain disease, and it matters. Science.
1997;278(5335):45-7.
17. Lyvers M. “Loss of control” in alcoholism and drug addiction: a neuro-
scientific interpretation. Exp Clin Psychopharmacol. 2000;8(2):225-49.
18. Doherty MC, Junge B, Rathouz P, et al. The effect of a needle exchange

UWOMJ 86:2 | Fall 2017 Page 69

health promotion
An analysis of the French healthcare system
in the context of geriatric care
How does Canada compare and what can we learn
Hong Yu (Andrew) Su, Lilian Jade Robinson
Faculty Reviewer: Monidipa Dasgupta, MD, FRCPC (Division of Geriatric Medicine)
abstract
The geriatric population occupy a progressively greater
portion of the Canadian demographic spectrum. They often
present with multiple comorbidities and utilize a dispropor-
tionate amount of healthcare resources per capita. Keeping
current Canadian healthcare practices may become unsustain-
able in the long run, and comparison with the French health-
care system may help with the identification of current short-
falls. The Canadian healthcare system lags behind the French
counterpart in several key healthcare indicators, including per
capita spending, growth in expenditure, and specialist wait
time. The French healthcare system is characterized by a mix
of public and private healthcare choices, greater emphasis on
preventative health and an nationwide integration. All of these
may have contributed to the French healthcare system’s bet-
ter fiscal spending practices and healthcare outcomes. The
Canadian healthcare system should take note of these differ-
ences and integrate positive elements to create a model better
prepared for geriatric care in the foreseeable future. More in-
depth studies may be needed to better assess the extent of ad-
aptation for each of the aforementioned areas.
geriatric care challenges – an introduction
Effective management of the aging Canadian population is an
increasing societal concern and will remain so for years to come.
Individuals over 80 are the fastest growing age group,1 and will
account for a quarter of the total population by 2036, based on
data from the Canadian Institute of Health Information.2 This in
turn presents many unique challenges to the currently established
healthcare system.
Firstly, the geriatric population present more commonly with
vulnerability resulting from a combination of frailty, disability and
multiple chronic conditions (MCCs). These individuals suffer from
more than 2 comorbidities and no longer fit the one-problem-per-
visit model currently practiced in Canada, which is partly incen-
tivized by the way physician billings are structured.3,4 Furthermore,
due to the array of health problems presented by a standard geri-
atric patient, the level of care can be subjected to much greater
intra- and inter-provider variability, leading to iatrogenic errors
such as polypharmacy.5-7 Finally, the geriatric population has much
higher rate of utilization of healthcare resources compared to their
younger counterparts. For instance, individuals above 65 account
UWOMJ 86:2 | Fall 2017 Page 70
for over 60% of the primary care spending,8 suggesting that the sys-
tem would eventually become unsustainable as more fall into this
age category.
With that in mind, this article will shift focus onto another
healthcare system—that of France, arguably one of the best in the
developed world. Some of the strongest features of French health-
care will be examined, and based on those, recommendations will
be made that may help alleviate some of the current major challeng-
es faced by the Canadian healthcare system.
rationale for selecting the french healthcare
system
The French healthcare system is reputed for its accessibility,
broad consumer selection and quality of care. It has topped the
World Health Organization’s list since 20009 and has consistently
received positive evaluation from the general populace.10
A side-by-side comparison further emphasizes the French sys-
tem’s superiority over the Canadian counterpart in select key ele-
ments. Based on the annual reports published by the Organization
for Economic Cooperation and Development (OECD) for instance,
while both Canada and France have similar per capita spending,
sitting at $4611.30 and $4407.20 respectively, France had notice-
ably lower annual growth in governmental expenditure, averaging
2.6% over the course of 2000-2010. Meanwhile, Canada’s annual
growth over the same period, sitting at 4.5%, is significantly above
the OECD average and trails only behind countries such as United
Kingdom and the United States.11 France also performs noticeably
better in areas such as physicians per 1000 population (3.3 vs. 2.4)
and avoidable mortality caused by deficient healthcare per 100,000
discharges (63.6 vs. 87).
Meanwhile, the International Health Policy Surveys for the
Commonwealth Fund reports similar findings with different indi-
cators assessed. Canada scored particularly low in comparison in
2 key areas: accessibility and cost effectiveness. Canadian patients
need to wait on average 68 days before seeing a specialist of any
kind, while that number drops down to 44 days for the French.
Similarly, only 7% of patients in France had to wait 4 months or
more for an elective surgery, compared to 25% in Canada. Mean-
while, the average Canadian hospital spends on average $14,000 per
discharge, while the French spend less than half of that, sitting at
$5,204.12
To summarize, the French healthcare system appears to have
comparatively lower adverse outcome, better long-term sustain-
ability and better access despite similar per capita spending, all of
health promotion
which are significant advantages in the context of geriatric care.
Given these observations, recognizing and integrating strengths of
their model into the Canadian healthcare system certainly seems a
logical approach to address future shortfalls.
characteristics of the french healthcare system
One of the central characteristics of the French healthcare sys-
tem involves a mixed public and private insurance model, both of
which are available for patients. This is consistent with the French
medical philosophy of medicine liberale which advocates maximiz-
ing free choice.13 The model contains both elements of nationalized
care and those of a competitive market-based system as in the case
of the United States.14 At initial glance this approach may jeopardize
the universal access epitomized by socialized medicine. However,
the method of coverage is incremental in nature based on the indi-
vidual’s financial, insurance and health status, so uninsured indi-
viduals and those falling below an income threshold would receive
extra coverage from the government up to 100%.15
The French healthcare providers also engage in a different cul-
ture of care with much greater focus on primary prevention. For in-
stance, when considering cardiovascular diseases alone, the French
are 30% less likely to die than Americans even after adjusting for
MCCs.16 When the French physicians were polled regarding this is-
sue, 53% cited a greater focus on patient education regarding both
lifestyle and dietary habits.17 While subjective in nature, this study
does show primary prevention being a critical aspect of care, espe-
cially in the context of elderly care. With so many geriatric patients
plagued with a diverse set of MCCs, creating unifying treatment
guidelines may prove unfeasible, and shifting focus onto preventa-
tives tactics may be a better alternative leading to better improve-
ment on health outcome.
Finally, the French healthcare system’s success may be at-
tributed to its highly integrated nature. The “carte vitale” is the
official health insurance card possessed by virtually every citizen.
The card contains all the necessary demographic information, and
patients can expect treatment after a single swipe.17 The payment
details are subsequently sent to the insurers, which are usually a
mix of both public and private insurance providers.14 This highly
integrated approach helps reduce repetitive collection of the pa-
tients’ information, as well as streamline the entire payment pro-
cess so physicians can spend more time with patients rather than
administrative inefficiencies.
discussion and conclusion
Through review of the French system’s strengths, this article
proposes the following recommendations which may alleviate the
fiscal burdens of future geriatric care. Firstly, the government can
adopt a mixed system where both public and private care are avail-
able. As demonstrated previously, this may have a dramatic impact
on the current long wait times for both primary and specialty ser-
vices plaguing Canadian hospitals. The challenge to this is to avoid
over-privatization and compromise the principles of universal ac-
cess. Population-based studies may be needed to elucidate the per-
UWOMJ 86:2 | Fall 2017 Page 71
fect balance.
Secondly, Canada should strive for a greater focus on primary
care initiatives. The French are known for their three-meals a-day
routine and high greens consumption, a practice that has been rel-
atively well preserved despite globalization of fast-food chains. Ad-
ditionally, Europeans walk and bike much more than their North
American counterparts.18 The health benefits of such lifestyle prac-
tices cannot be unduly emphasized, and should be considered of
equal, if not greater, importance than treatment guidelines in the
context of health policy development. Hence, programs should be
created to enable greater access to physical activity and better diet-
ing practices amongst the geriatric population.
Finally, there should be a similar endeavor in Canada to cre-
ate a universal payment and information storing system. Similar
initiatives are underway in Canada but are scarce and comprise of
numerous locally integrated systems lacking capacity for nation-
wide integration.19 This is likely the most challenging area from a
feasibility standpoint. Not only does Canadian healthcare fall under
provincial jurisdiction, making a national initiative extremely hard
to administer, Canada is also bigger with physicians practicing over
a broader geographic spectrum, which may hinder technology up-
take especially in remote, sparsely populated regions.
Several limitations exist for this article. Firstly, many compar-
isons were made between France and Canada without accounting
for geographical, economic, and sociocultural differences. For in-
stance, while Canadians do bike less, the difference may be partly
due to the sparser layout of North American cities which discour-
ages nonautomotive transportation—an issue that cannot be ame-
liorated by healthcare advances alone. Furthermore, some of the
comparisons made in this article address the United States or all of
North America and may not accurately reflect Canadian statistics.
Consequently, more in-depth studies are needed to assess whether
making changes to the current healthcare system is the most prag-
matic approach.
France has created a unique healthcare structure where its
citizens do not want universal coverage at the expense of individ-
ual choice, and this practice has stood the test of time as one of
the strongest models today, one that is more prepared to face the
explosive growth in geriatric population already underway. While
Canada does indeed have a very strong socialized healthcare, com-
placency is dangerous and stagnation may lead to an unsustainable
model. A brighter outlook relies critically on reciprocal learning be-
tween these 2 great healthcare systems.
references
1. The Canadian Population in 2011: Age and Sex. Statistics Canada.
http://www12.statcan.gc.ca/census-recensement/2011/as-sa/98-311-
x/98-311-x2011001-eng.cfm Published 2011. Updated December 21,
2015. Accessed March 6, 2017.
2. Vogeli C, Shields AE, Lee TA, et al. Multiple Chronic Conditions:
Prevalence, Health Consequences, and Implications for Quality, Care
Management, and Costs. J Gen Intern Med. 2007;22:391-395.
3. Fullerton M. Understanding and improving on 1 problem per visit.
CMAJ. 2008;179:623, 625-623.
health promotion

4. Boult C, Wieland GD. Comprehensive Primary Care for Older Patients

With Multiple Chronic Conditions: “Nobody Rushes You Through”.
JAMA. 2010;304:1936-1943.
5. Mortazavi S, Shati M, Keshtkar A, et al. Defining polypharmacy in the
elderly: a systematic review protocol. BMJ Open. 2016;6:e010989.
6. Drewes YM, Blom JW, Willem J et al. Variability in Vulnerability
Assessment of Older People by Individual General Practitioners: A
Cross-Sectional Study: e108666. PLoS One. 2014;9.
7. Cantlay A, Glyn T, Barton N. Polypharmacy in the elderly. InnovAiT.
2016;9:69-77.
8. Healthcare Cost Drivers: The Facts. Canadian Institute for Health In-
formation. https://secure.cihi.ca/free_products/health_care_cost_driv-
ers_the_facts_en.pdf Published 2011. Accessed March 6, 2017.
9. World Health Statistics 2016: Monitoring Health for the SDGs. http://
www.who.int/gho/publications/world_health_statistics/2016/en Pub-
lished 2016. Accessed March 8, 2017.
10. Roth M. “Liberty, Solidarity, Fairness”: A Personal View of the French
Healthcare System. Camb Q Healthc Ethics. 2010;19:329-333.
11. Health Statistics 2016. Organization for Economic Cooperation and
Development (OECD). http://www.oecd.org/health/health-systems/
health-data.htm Published June 30, 2016. Updated October 12, 2016.
Accessed March 9, 2017.
12. International Health Policy Surveys 2016. The Commonwealth Fund.
http://www.commonwealthfund.org/interactives-and-data/interna-
tional-survey-data Published November 16, 2016. Accessed March 9,
2017.
13. Rodwin VG. The Health Care System Under French National Health
Insurance: Lessons for Health Reform in the United States. Am J Pub-
lic Health. 2003;93:31-37.
14. Doty P, Nadash P, Racco N. Long-Term Care Financing: Lessons From
France. Milbank Q. 2015;93:359-391.
15. Grignon M. Quel filet de sécurité pour la santé? Une approache
économique et organisationelle de la couverture maladie universelle.
Rev Fr Aff Soc. 2002;2:145–176.
16. Cardiovascular diseases (CVDs). World Health Organization (WHO).
http://www.who.int/mediacentre/factsheets/fs317/en/index.html.
Updated November 2016. Accessed March 11, 2017
17. Cherry CO, Steichen O, Mathew A, et al. A culture of care: The French
approach to cardiovascular risk factor management. J Am Board Fam
Pract. 2012;25:477-486.
18. Bassett Jr DR, Pucher J, Buehler R, et al. Walking, cycling, and obesity
rates in Europe, North America and Australia. J Phys Act Health.
2008;5:795-814.
19. Steffen M. Universalism, Responsiveness, Sustainability - Regulating
the French Health Care System. NEJM. 2016;374:401-405.

UWOMJ 86:2 | Fall 2017 Page 72

history of medicine
ECT: Examining a controversial therapy
in the armamentarium of psychiatry
Nirushan Puvanenthirarajah, Asma Amir Ali
Faculty Reviewer: Shelley McKellar, PhD (Department of History)
abstract
Historically, treatments for severe psychoses and affec-
tive disorders were nonexistent, and patients with mental
disorders were transferred to asylums for public safety. This
deficiency in treatment inspired the inception of somatic ther-
apies, of which electroconvulsive therapy (ECT) was the most
efficacious. This paper will outline the birth of ECT, the con-
troversies leading to its decline, and the subsequent resurgence
back into practice.
introduction
Before the 20th century, psychiatry as a field of medicine of-
fered little to individuals suffering from severe psychoses or af-
fective disorders. Treatments for mental illness were scarce, the
public perceived the mentally ill as dangerous, and individuals
with mental disorders were involuntarily transferred from their
homes into dirty, overcrowded public institutions, supposedly for
treatment and public safety.1,2 Individuals who experienced mild
psychotic episodes were typically locked into isolation and, if the
episodes became too severe, they received sedation to control their
behaviour.3 Since few individuals could afford the handful of pri-
vate asylums that existed, most patients were admitted to public
institutions, referred to as insane or lunatic asylums. These were
harsh, ill-equipped facilities with underpaid staff who often treated
patients cruelly.2
The first feasible breakthrough in treating psychiatric illnesses
arose from advancements in psychodynamic therapies, notably the
work of Sigmund Freud. Although this approach proved fruitful for
neuroses and milder mental disturbances, treatment development
for individuals suffering more severe psychoses remained stag-
nant.1,4 This impasse in the treatment of mental illness sparked the
inception of somatotherapies – treatments by chemical or physical
means.5 During the early decades of the 20th century, 3 unsubstan-
tiated procedures were proposed as methods to shock the patient
out of illness: insulin shock therapy, chemical convulsion shock
therapy, and electroconvulsive shock therapy.5 Today, only electro-
convulsive therapy remains in the armamentarium of psychiatrists,
but not without its share of controversy.
discovery of ect and early application
Lacking modalities for treating severe psychoses, Hungarian
physician Ladislaus von Meduna turned to the medical histories
and autopsies of mentally ill patients in search of a solution.5 What
came of this search was the discovery that schizophrenia and epi-
UWOMJ 86:2 | Fall 2017 Page 73
lepsy seldom occurred together, a phenomenon he coined biologi-
cal antagonism.5 This phenomenon set the foundation for a belief
that inducing convulsions could be used as a therapy for psychotic
disorders. Stimulating convulsions through metrazol, a pharmaco-
logic agent, Meduna showed the potential of convulsive shock in
reducing psychosis symptoms.5 But there was a disturbing response
in witnessing conscious patients endure painful convulsions that
reduced the appeal of this particular treatment.3
On the heels of Meduna’s discovery, neurologist Ugo Cerletti
extended the induction of convulsion to electric shocks. Having
specialized in epilepsy, Cerletti understood that electric shocks ap-
plied to the cranium of pigs would create a transient epilepsy-like
convulsion.5 In contrast to pharmacological induction of convul-
sions, electrical induction had the added benefit of retrograde am-
nesia, which increased its desirability as a treatment since patients
would not remember the pain associated with convulsion.4 Similar
to pharmacologic convulsion therapy, ECT reduced symptoms in
patients suffering from depression compared to other treatments.4
The transition of electroshock therapy from animal models to
human subjects raised serious ethical problems. The first test on a
human patient occurred in April of 1938 when patient S.E., who had
been diagnosed as paranoid schizophrenic, was institutionalized
against his will and, as doctors later recounted, received treatment
without understanding what was about to happen.5 S.E. later pub-
lished a letter retroactively praising the doctors for curing him of
his illness, which instilled the belief that convulsive shock could be
used to treat mental illness in humans.5 The immediate improve-
ment and short-term convalescence observed in this patient and a
handful of patients thereafter led Cerletti and his team to believe
that ECT was a panacea for psychiatric illness.6 In fact, eager physi-
cians began recommending the procedure for nonpsychiatric con-
ditions like psoriasis and ulcers.5 While these preliminary human
tests revealed the potential for ECT in treating mental illness, the
excitement quickly faded soon after.
rise and fall of a somatic therapy
With minimal ECT regulations during the early 1940s, patient
safety was a problem, which contributed to a rapid decline in ECT
popularity. The first patients to undergo this treatment suffered
spine fractures and joint dislocations due to the violent convulsions
they experienced, which created further medical problems for phy-
sicians and a fear of ECT treatment for patients.3,5 Furthermore, ad-
equate empirical research was minimal due to ethical limitations,
with the majority of case information derived from anecdotal ev-
idence.4 Understandably, this lack of appropriate regulation pro-
history of medicine
voked improper ECT practice and therefore a poor reputation of
the treatment in the eyes of the public.6 Therapy without proper
indication, inadequate adjuvant therapy, and technical inconsisten-
cies rendered the practice of ECT problematic.
After addressing initial problems of patient injury, practitioners
continued to provide ECT therapy through to the 1960s until social
backlash and alternative therapies caused ECT treatments to de-
cline.4 Methodology of ECT practice incorporating anesthesia, oxy-
gen, and muscle relaxants reduced therapy-related injuries and side
effects to improve patients’ desirability of this treatment.4 Still, pub-
lic perception of ECT remained tainted due to the flaws observed in
its early practice. These troubles became compounded by the abuse
of ECT in psychiatric hospitals, which would later inspire the an-
ti-ECT movement. Reports of ECT being used to punish patients
in psychiatric institutions, as heavily publicized in the movie “One
Flew Over the Cuckoo’s Nest,” added to the public’s disapproval
of ECT.7 Visuals of involuntary patients being strapped down and
forced into convulsions propagated the belief that the practice was
inhumane. The suicide of Ernest Hemingway, who after multiple
ECT sessions to ease his depression shot himself because he found
the memory loss that came with the treatment simply unbearable,
added fuel to the anti-ECT movement.7 It also led to an increasing
number of lawsuits against ECT professionals by former patients.3,8
During the mid-20th century, ECT remained the predominant
somatic therapy available for psychiatric disorders, however the
concurrent discovery and development of psychotropic medica-
tions reduced the need for convulsions.7 Medications were proving
their efficacy against placebos, and pharmacotherapy was seen as
more humane regardless of the side effects that coexisted.7 Con-
sequently, pharmaceuticals emerged as the standard therapy for
preliminary management of psychiatric disorders by medical pro-
fessionals, driving ECT towards obsolescence.7 Unfortunately, pa-
tients with disorders resistant to pharmaceutical therapy were left
lacking a proper alternative.
resurgence of ect and incorporation
The renaissance of electroconvulsive therapy in North Ameri-
ca was led by the American Psychiatric Association (APA) as greater
empirical evidence surfaced illustrating its benefit. After nearly dis-
appearing from practice, a surge of research and press releases from
the APA helped standardize the methodology of ECT, with appro-
priate indications and contraindications.7,9 ECT re-entered the ar-
mamentarium of psychiatrists for incapacitating mental disorders
such as major depression, bipolar disorder, and catatonia, where
pharmacotherapy alone lacked effectiveness.9 Further research re-
vealed nonpsychiatric potential in Parkinson’s disease and epilepsy,
thereby increasing its therapeutic value.4,9 Coincidentally, ECT has
re-emerged as an efficacious therapeutic modality for psychiatric
and nonpsychiatric disorders, as was alleged by physicians during
its inception.
Since Cerletti’s innovative discovery of ECT in the 1930s, the
procedure has undergone a complete transformation. The tech-
nique itself has undergone changes in the equipment used to in-
UWOMJ 86:2 | Fall 2017 Page 74
duce the electric stimulation, and concomitant therapies have been
integrated to mitigate side effects and potential injury.4,7 Likewise,
policy has adapted to prioritize the health of the patient, ensuring
patient safety and other issues that had plagued the therapy earlier
in its history. In contrast to the unknowing patients that ECT was
tested on, patients now undergo rigorous testing by physicians to
ensure that treatment is the ideal option, and are well informed of
the procedure and risks.4
Still, public perception remains skewed in judging ECT as an
inhumane treatment, and many individuals think the procedure is
unlawful. This prevailing misconception elucidates the necessity
to educate the public about the benefits of this treatment, and ex-
plains the regular press releases from the APA educating doctors.7
Currently, most patients with major depression still reject ECT as a
possible treatment, despite medical literature and patient testimo-
nials reporting positive outcomes.7 Interestingly, even 7% of physi-
cians in 2005 believed ECT to be obsolete.7 Consequently, the APA
has designated a task force of professionals to tackle ECT misinfor-
mation through press releases, workshops, and published reports.
Accordingly, this effort has created an initiative to reclassify ECT as
a low risk procedure.10,11
conclusion
Although electroconvulsive therapy is back in the psychiatry
toolkit, its controversial history has left it entrenched in public
doubt and skepticism. The misconceptions surrounding the prac-
tice are deep-rooted and will require extensive education of phy-
sicians and the public to dismantle. Organizations such as the APA
have made it a priority to better educate the physicians offering
ECT treatment and to eliminate the stigma associated with ECT.
Psychiatric disorders are a major burden to society, both eco-
nomically and socially, and so it is critical that we continue to strive
for better treatments and ultimately a cure. Consequently, research
regarding the mechanisms of ECT have now yielded more effective
and less invasive techniques. Newer brain stimulating techniques
such as transcranial magnetic stimulation and deep brain stimula-
tion have sprouted from the knowledge of ECT, and now provide
better alternatives to convulsive therapy.12 Despite being less than
a century old, ECT has survived a controversial and tortuous life,
and the future may be just as uncertain. But regardless of what the
future may bring for the treatment of psychiatric disorders, it is im-
portant to appreciate the influence of ECT in the present era, and
the undeniable effect it has had on the treatment of mental illness
in the past.
references
1. Shorter E. History of psychiatry. Current Opinion in Psychiatry.
2008;21(6):593-597.
2. American Psychological Association. A home away from home [In-
ternet]. 2012. Available from: http://www.apa.org/monitor/2012/03/
asylums.aspx
3. The History of Shock Therapy in Psychiatry [Internet]. Library.law.
columbia.edu. 2017. Available from: http://library.law.columbia.edu/
urlmirror/CJAL/14CJAL1/shock_i.htm
history of medicine

4. Payne N, Prudic J. Electroconvulsive Therapy: Part I. A Perspective

on the Evolution and Current Practice of ECT. Journal of Psychiatric
Practice. 2009;15(5):346-368.
5. N.S. E. The origins of electroconvulsive therapy (ECT). Convulsive
Therapy. 1988;4(1):5-23.
6. Ottosson J. Use and misuse of electroconvulsive treatment. Biological
Psychiatry. 1985;20(9):933-946.
7. Payne N, Prudic J. Electroconvulsive Therapy: Part II. A Perspective
on the Evolution and Current Practice of ECT. Journal of Psychiatric
Practice. 2009;15(5):346-368.
8. Journal of the American Medical Association. Consensus conference.
Electroconvulsive therapy. 1985.
9. Canadian Psychiatric Association. Electroconvulsive Therapy. 2001.
10. American Psychiatric Association. APA Task Force Report on Electro-
convulsive Therapy. APA; 1995.
11. American Psychiatric Association. Time is Now to Support the ECT
Reclassification Effort. 2016.
12. George M, Nahas Z, Li X, et al. Novel treatments of mood disorders
based on brain circuitry (ECT, MST, TMS, VNS, DBS). Seminars in
Clinical Neuropsychiatry. 2002;7(4):293-304.

UWOMJ 86:2 | Fall 2017 Page 75

medicine & technology
Machine learning in medicine
Chloe Gui, Victoria Chan
Faculty Reviewer: Daniel J Lizotte, MSc, PhD (Department of Computer Science)
abstract
Machine learning (ML) is a powerful and flexible tool that
can be used to analyze and predict outcomes from biological
and clinical data. ML models have the potential to improve
healthcare efficiency in a number of ways. Algorithms that
predict prognosis empower healthcare officials to allocate re-
sources optimally and physicians to select better treatment op-
tions for patients. Diagnostic models can be used in screening,
in risk stratification, and to recommend appropriate testing
and treatment. This would decrease the burden on physicians,
increase and expedite patient access to care, save resources, and
reduce costs. However, despite the research advances of ML in
medicine, its role in the clinic is currently limited. Model build-
ing and validation may require large amounts of high-quality
data that can be difficult and expensive to obtain, and diag-
nostic models must be individually built for each disease, a
lengthy process. The psychological aspect of trusting black box
algorithms may also be challenging to accept. Continued ML
research, however, may enable the use of smaller datasets and
the development of more transparent models. Careful trials in
the clinic will need to be conducted before the more impactful
uses of ML, such as diagnosis, can be implemented.
introduction
Machine learning (ML) is a branch of artificial intelligence
(AI) that has become ubiquitous in many fields. Essentially, from
an initial training dataset of features and outcomes, an algorithm
learns how the features relate to and are predictive of the outcomes.
On subsequent data, the ML model can predict outcomes when pre-
sented only with the features.1-4 Models are currently used by banks
to detect fraudulent transactions,1 by email servers to filter spam,2
and by astronomers to analyze galaxy images.3 ML especially ex-
cels at identifying patterns in large and noisy datasets, making it
useful for analyzing complex biological data. As a simple example,
an algorithm may be trained to predict outcomes such as whether
a tumour is benign or malignant from features such as tumour size.
The model could then make predictions on new tumours whose
outcomes are unknown. Data on which ML can be trained range
from numerical data of blood biomarkers to medical images. Thus,
ML is a versatile and powerful tool that potentiates personalized
medicine, providing a more precise understanding of individual pa-
tients and their needs. Here, we examine how ML can improve the
efficiency of our healthcare system in areas of prognostics, diagnos-
tics, and increasing access to medical care.
UWOMJ 86:2 | Fall 2017 Page 76
predicting prognosis
Prognosis prediction includes approximating outcomes such
as a patient’s disease susceptibility, disease recurrence likelihood,
life expectancy, and response to treatment. The factors involved
are complex and multifactorial, and thus, it is difficult to provide a
definitive prognosis for many conditions.5,6 Accurate prognosis pre-
diction is valuable as it helps healthcare providers make informed
decisions about resource allocation and best treatment practices.7
A tool to predict response to treatment, for instance, would allow
physicians to tailor treatments to individual patients. Such a tool
would enable physicians to identify which patients would benefit
from adjuvant or alternative therapies and which patients would
not, sparing the latter from treatment risks and side effects.
The field of oncology in particular has been extensively study-
ing the use of ML methods in predicting prognosis. One review re-
ported that ML improves cancer prognostic predictions by 15-25%.8
The rise of high-throughput sequencing has pushed the consider-
ation of genetic markers in treatment decisions, and ML is useful for
modeling complex genetic data. For example, a classification ML al-
gorithm trained on microarray data of breast tumour tissues found
different genetic signatures associated with metastatic phenotypes
and with certain treatment prognoses.9 These patterns could serve
as clinical indications for different treatments, leading to better
patient outcomes. A study on hepatitis B virus-positive metastatic
hepatocellular carcinoma also used ML to identify signatures from
153 genes to predict metastasis and survival.10
screening, diagnosis, and access to care
AI has the potential to streamline healthcare diagnostics by re-
ducing cost and time to diagnosis. ML has been demonstrated to
be capable of screening patients, stratifying patients by risk, and
assisting physicians in decision making. Screening models have
been built to detect diseases such as congenital cataracts,11 skin
cancer,12 heart disease,4 hepatitis disease,13 and autism.14 Given the
high stakes of medical decisions, a model built with particularly
high sensitivity could be an inexpensive tool to rule out diagno-
ses, leaving potentially positive cases for physicians to investigate.
These models could also be distributed to patients for preliminary
evaluation and to prioritize patients at risk. For example, Esteva et
al trained algorithms to classify skin lesion images as cancerous or
benign at an accuracy that matched dermatologists.12 Mobile-based
evaluation of other diseases could also be feasible. For instance,
Wall et al developed a highly accurate model to assess and diagnose
autism.14 Given that the incidence of autism is increasing and eval-
uation involves analysis of candidates’ home videos, mobile tools
could be valuable in assessing a wider population.14 Indeed, models
developed for many diseases could potentially be deployed on mo-
medicine & technology
bile devices for greater access to care.
Screening could be particularly advantageous for rare diseases.
Rare diseases are typically difficult to identify, and this may lead to
delayed or incorrect treatment, possibly with harmful consequenc-
es to the patient. Because specialists are usually concentrated at
larger health institutes, patients with rare diseases may have diffi-
culty accessing expertise for diagnosis and care.11 Thus, Long et al
examined whether AI could provide a unique management system
for rare diseases. They built ML models to screen patients for con-
genital cataracts, perform risk stratification, and suggest treatment.
In fact, the models performed to the same level as ophthalmolo-
gists.11 A widely accessible system of such models could increase ac-
cess to the expertise required to identify and care for patients with
rare diseases.
changing the role of the physician
As ML algorithms improve and their applicability to health-
care broadens, ML will be gradually introduced to the healthcare
system. In fact, ML already forms the basis of radiology tools such
as image segmentation to isolate areas of interest.15 Increased ca-
pabilities of ML, however, may displace physicians from some of
their roles. For instance, image-reading specialties such as radiolo-
gy involve identifying patterns from medical images. Such tasks are
suitable for ML as the data are consistent in format, and diagnoses
often can be made from the images alone. Given equal accuracy to
human assessment, algorithms would be advantageous in provid-
ing immediate results while reducing cost. One study, for instance,
found that computer-aided detection could replace the traditional
second reader in detecting small breast cancers.16 The increasing
use of imaging due to technological advances has also escalated the
workload for radiologists.17 ML would reduce the burden and pro-
vide consistent 24-hour service, whereas human radiologists may
make errors in circumstances such as overnight shifts. Models that
have been built for computer-aided diagnosis include those that de-
tect pulmonary embolisms,14 polyps in CT colonography,15 and pat-
terns of mild cognitive impairment in brain scans that precede Alz-
heimer’s disease.15 By extension, physicians of other image-based
specialties, such as pathology, may also perform fewer image analy-
sis tasks as ML algorithms improve.
challenges to translation
Despite its widespread use in other fields, ML has failed to
make an equivalent impact in the healthcare system. One of the big-
gest challenges is the enormous amount of high-quality data often
required to build and validate ML models. Though patient data is
increasing in abundance, they may be incomplete for ML purpos-
es. One model that aimed to predict the survival of postmenopausal
women using electrocardiogram biomarkers, clinical factors, and
demographic variables performed worse than the current standard,
the Framingham Risk Score.18 This was at least partly because the
data lacked information known to be important to the outcome,
such as blood biomarkers. Another possible problem in applying
ML to healthcare data is that predictive variables may be infre-
UWOMJ 86:2 | Fall 2017 Page 77
quently tested in clinic or only tested in limited patient subgroups
and thus are generally unavailable. Therefore, there may exist im-
portant predictive features that ML would fail to recognize. Fur-
thermore, some lesions, such as in cardiac and vascular tissues, are
generally not biopsied, which limits the availability of molecular
and histological information.19 Aside from the data needed to build
the model, data must also be acquired from multiple independent
populations to validate the model. As biological data is expensive
to acquire and not typically shared among researchers, quality and
quantity of information is a major inhibitor of ML progress in med-
icine. The study that used electrocardiogram markers to predict
mortality in postmenopausal women, for instance, failed to find
an appropriate external dataset on which to validate their model.18
These issues are currently being addressed by research that aims to
build models from smaller datasets.20
Another challenge to translation is the psychology in-
volved in using machines to manage patients. A human error rate
is generally accepted in healthcare, but machine error that carries
health consequences may be difficult to accept. Some powerful ML
methods are also black box models where the algorithmic mech-
anism is unknown, and the medical community may feel uncom-
fortable with this lack of transparency. However, ongoing research
efforts to improve model transparency are promising,21 and if ML
performance eventually exceeds that of a physician for a task, it
may be considered inefficient and unethical not to defer to ML. Ad-
ditional clinical trials will be required to determine the appropriate
and responsible use of AI in healthcare.
conclusion
ML shows tremendous promise in increasing the efficiency of
our healthcare system. It has demonstrated the ability to predict
prognoses, provide diagnoses, and increase the reach of medical
care. As novel predictors of health-related outcomes are discov-
ered, ML findings will also contribute to research developments
and our understanding of disease. However, because ML generally
requires large quantities of high-quality data, progress is costly and
time-consuming. Nonetheless, advances suggest that this technol-
ogy may grow to be a fundamental part of our healthcare system,
decreasing the burden on physicians and improving the speed and
depth to which patients can be attended. As domain knowledge is
necessary to interpret ML findings, physicians will continue to be
key in providing empathetic care.
references
1. Perols J. Financial statement fraud detection: An analysis of statis-
tical and machine learning algorithms. Auditing-J Pract Th. 2011
May;30(2):19-50.
2. Guzella TS, Caminhas WM. A review of machine learning approaches
to spam filtering. Expert Syst Appl. 2009 Sep;36(7):10206-222.
3. Kuminski E, George J, Wallin J, et al. Combining human and machine
learning for morphological analysis of galaxy images. Publ Astron Soc
Pac. 2014 Oct;126(944):959-67.
4. Magoulas GD, Prentza A. Machine Learning and Its Applications.
Berlin Heidelberg: Springer; 2001 Sep. 300-7 p.
medicine & technology

5. Christakis NA, Lamont EB. Extent and determinants of error

in physicians’ prognoses in terminally ill patients. BMJ. 2000
Feb;320(7233):469-72.
6. Clément-Duchêne C, Carnin C, Guillemin F, et al. How Accurate Are
Physicians in the Prediction of Patient Survival in Advanced Lung
Cancer? Oncologist. 2010 Jun;15(7):782-9.
7. Ohno-Machado L. Modeling Medical Prognosis: Survival Analysis
Techniques. J Biomed Inform. 2001 Dec;34(6):428-39.
8. Kourou K, Exarchos TP, Exarchos KP, et al. Machine learning applica-
tions in cancer prognosis and prediction. Comput Struct Biotechnol J.
2014 Nov;15(13):8-17.
9. Van ‘t Veer LJ, Dai H, Van de Vijver MJ, et al. Gene expression
profiling predicts clinical outcome of breast cancer. Nature. 2002
Jan;415(6871):530-536.
10. Ye QH, Qin LX, Forgues M, et al. Predicting hepatitis B virus–positive
metastatic hepatocellular carcinomas using gene expression profiling
and supervised machine learning. Nat Med. 2003 Apr;9(4):416-23.
11. Long E, Lin H, Liu Z, et al. An artificial intelligence platform for the
multihospital collaborative management of congenital cataracts. Nat
Biomed Eng. 2017 Jan;1(1):0024.
12. Esteva A, Kuprel B, Novoa, RA. Dermatologist-Level Classifica-
tion of Skin Cancer With Deep Neural Networks. Nature. 2017
Jan;542(7639):115-8.
13. IEEE Neural Networks Society. Proceedings of the International Joint
Conference on Neural Networks, 2003. 2003 Jul 20-24; Portland, OR.
New York City: IEEE; Aug 2003.
14. Wall DP, Kosmicki J, DeLuca TF, et al. Use of machine learning to
shorten observation-based screening and diagnosis of autism. Transl
Psychiatry. 2012 Apr;2:e100.
15. Wang S, Summeres RM. Machine learning and radiology. Med Image
Anal. 2012 Jul;16(5):933-51.
16. Gilbert FJ, Astley SM, Gillian MGC, et al. Single Reading with Comput-
er-Aided Detection for Screening Mammography. N Engl J Med. 2008
Oct;356:1675-84.
17. Smith-Bindman R, Miglioretti DL, Johnson E, et al. Use of diagnostic
imaging studies and associated radiation exposure for patients en-
rolled in large integrated health care systems, 1996-2010. JAMA. 2012
Jun;307(22):2400-9.
18. Gorodeski EZ, Ishwaran H, Kogalur UB, et al. Use of hundreds of elec-
trocardiographic biomarkers for prediction of mortality in postmeno-
pausal women: the Women’s Health Initiative. Circ Cardiovasc Qual
Outcomes. 2011 Sep;4(5):521-32.
19. Deo RC. Machine Learning in Medicine. Circulation. 2015
Nov;132(20):1920-30.
20. Boulicaut JF, Esposito F, Giannotti F, et al. Knowledge Discovery in
Databases: PKDD 2004. 8th European Conference on Principles and
Practice of Knowledge Discovery in Databases; 2004 Sep 20-24; Pisa,
Italy. Berlin Heidelberg: Springer; 2004 Sep. 161-172 p.
21. Henao R, Lu JT, Lucas JE, et al. Electronic Health Record Analysis via
Deep Poisson Factor Models. 2016 Apr;17(186):1-32.

UWOMJ 86:2 | Fall 2017 Page 78

profiles
The complexity of cross-sector healthcare teams
An interview with Dr Shannon Sibbald
Alice Yi, Dino D’Andrea
Faculty Reviewer: Shannon L Sibbald, PhD (Department of Family Medicine)
introduction
Dr Shannon Sibbald is a health systems researcher specializing
in implementation science, the study of factors that affect the im-
plementation and success of new practices, as well as interprofes-
sional teamwork in healthcare settings. She also spends time teach-
ing students in the Masters of Public Health program and has held
faculty positions in the Department of Family Medicine, Schulich
Interfaculty Program of Public Health, and School of Health Stud-
ies since 2013. We were able to sit down with Dr Sibbald for our
interview to discuss her work in health systems and policy.
UWOMJ: Can you tell us about your educational background
and how you became a part of the Western faculty?
Dr Shannon Sibbald: I did my undergrad in Bachelor of Health
Sciences program here, at Western. When I was here I had the op-
portunity to work with phenomenal mentors and faculty, and one
of my mentors, Dr. Louis Charland, really helped me understand
how much I enjoyed research. Like many students who start the
BHSc program, I thought I wanted to be a doctor! My interests
changed as the program allowed me to look at health from a dif-
ferent perspective—as a holistic concept as opposed to just a bio-
medical concept. I spent summers working at the University of
Toronto Joint Centre for Bioethics, and that’s where I ended up
doing both my Masters and PhD. I was in the Institute of Health
Policy, Management, and Evaluation, with a subspecialty in Bio-
ethics. I returned to Western to work with Dr Anita Kothari and
Dr Nadine Wathen and did a three-year postdoctoral fellowship,
during which I began focusing my time more on cross-systems
and intersectoral work. So while my graduate studies were heavily
focused in acute care in hospitals, I started looking more at other
sectors like public health, primary care, and long-term care, and
began to understand truly how complex our health system is. Af-
ter then, I did a six-month post-doc with the International Center
for Health Innovation and Leadership out of Ivey, and at that time
a position came up that involved working with the Department
of Family Medicine, the Schulich Interfaculty Program of Public
Health, and the School of Health Studies. It was perfect—it was
everything I’d been doing up until this point all wrapped up into
one perfect role! The job allows me to continue working in interdis-
ciplinary and cross-sector research, and I’ve been here since 2013.
What drew you towards interdisciplinary health systems re-
search?
I really want to help people—to help patients, but knowing
that I didn’t have a clinical interest made me think, “What can
UWOMJ 86:2 | Fall 2017 Page 79
my contribution be instead?” And I think I’m good at research; I
enjoy it, whether it be coming up with a research question on my
own or being involved with integrative knowledge translation.
I try to be involved with knowledge users—policy makers, physi-
cians, people who are using the knowledge on the ground—and
come up with research questions that will ultimately and hope-
fully impact their day-to-day practice, which then in turn im-
pacts patient care. I’m drawn to new, innovative, changing, and
dynamic systems, and that’s what healthcare is. There’s always
new policies, new legislations, grey papers, or political promises.
There’s always something going on that’s affecting the health of
Canadians, so to be a part of that but at the same time use my own
strengths was what really drew me into health systems research.
Could you tell us about your current research?
In order to understand the complexity of the health system, it
is necessary to understand each of the working pieces and how they
function. My goal right now is to try and understand how teams
function within healthcare. Whether or not teams are the best
approach to handle a scenario is kind of up to debate. Dr Natalie
Allen, a great researcher here on campus, has a paper called “The
Romance of Teams,”1 where she says teams aren’t always the best
approach; it depends on a number of factors. In healthcare though,
it’s the reality—whether or not teams are the best from an evidentia-
ry point of view, we do a lot of things using teams, and that largely
comes down to the right mix of health professionals along with task
complexity and financial costs. We know that a service delivered by
a personal support worker is going to be more cost-effective than a
service offered by a physician, so we need to figure out how to best
deliver care in a team-based way. With that in mind, I am trying
to understand what team-based care looks like across primary care
and hospital care.
I’m looking at patients with complex care needs, like with
COPD. These patients need a team that can work across the sectors.
They need a primary care team, an acute care team for when they
need to be in the hospital, and many of them also have long term
and home care needs. We’re getting really good at team based care
in a hospital, with a classic example being a surgical team. Those
teams have in some ways learned how to do it really well. Even in
primary care we’re getting better at understanding what a team
should look like. But what does a team look like that has to navigate
across those sectors?
We’re looking at what we are calling high-performing
teams. They have the right mix of health professionals, and
they’re working in a way that’s effective and efficient. How
have they figured it out, and what’s the secret? We hope we
profiles
can understand their secret to success and share those les-
sons with other teams who are trying to do a similar task.
What does the current average cross-sector team for COPD
care look like?
The answer is we don’t know yet; there’s not a lot of consisten-
cy. We have 14 Local Health Integration Network (LHINs) in On-
tario, and in just our LHIN alone we’re trying to categorize all the
different COPD programs available. And COPD is complex because
there are multiple stages. Something that might work for someone
with early stage COPD in the community would not work for some-
one who has late stage COPD and needs care in the home.
There are some exemplars out there. For example, I’ve done
work with the Canadian Foundation for Health Care Improve-
ment and they recently did a quality improvement collabora-
tive project called the INSPIRED COPD Outreach Program.2
That was their attempt at a cross-sector, inter-professional, in-
ter-disciplinary, patient-centered team. We’re in the process of
evaluating the impact of those teams. What happened to allow
some teams to do so well, while others never got off the ground?
Are there any countries or provinces other than Ontario that
has a successful intersectional teamwork model?
The example I gave you earlier of INSPIRED actually comes
from Nova Scotia. But in terms of what’s really happening, we don’t
know yet. My goal is to reach out to colleagues in other provinces
to start those discussions. Even in London, there is so much diver-
sity. I think that’s a good thing, because that means that patients
potentially have access to this diversity of programs. But the chal-
lenge comes when there’s not a program in their area that’s right
for them, and this can be because of many factors like disease stage,
access, or patients’ wishes. So the multitude of programs can be
seen as a good thing, but the fact that those programs are not well
coordinated is where we have a challenge.
What is the biggest barrier to creating an effective integrated
system?
We have historically provided healthcare in silos, and unfor-
tunately the silos are perpetuated by the way they’re funded. It be-
comes really challenging to make a change when at the end of the
day you still have to pay for the services somehow. Who owns this
intersectoral healthcare team? Acute care probably doesn’t think
they own it because it’s not happening in the hospital, even though
these patients eventually end up at their front door! Primary care is
often willing to own it but they need the support of other sectors.
It’s really difficult to coordinate when the systems are not very in-
tegrated. I think that’s one of the biggest challenges, but I also think
we currently have an opportunity with changes coming down the
pipe with Patients First Act.3,4
What’s the current state of education in terms of interprofes-
sional, team-based learning?
I’m very interested in team-based learning. I have this hypoth-
UWOMJ 86:2 | Fall 2017 Page 80
esis that if we are training all of our health professionals in a team-
based learning approach, they’ll work better at point-of-care in a
team based case approach. Another long-term goal of mine is to test
out this hypothesis. It’s important to educate people on the com-
plexities of the systems, but we also need to teach people how to
function within a complex system. We’re not going to change how
complex the system is, so we need to teach people how to work
within it.
Here at Western, all the learning in the MPH program is
team-based. We have a strong competency-based and case-
based curriculum, and we are using it as a living laboratory to
test out some of those assumptions. There’s a lot of literature
around inter-professional education, but oftentimes that liter-
ature focuses more on inter-professional education once peo-
ple are already working. What I’m suggesting is maybe we need
to start evaluating inter-professional education a little earli-
er in the classroom in graduate and undergraduate training.
Do you have any advice for medical students or students in
general who are interested in health systems?
Don’t be afraid to challenge the system. No matter what area
you go into, as a doctor there’s always an open door to challenge
the system. If you see something that’s not right in the system, or if
you see a way to make it better, to do it because you have that cred-
ibility to make things happen. And that’s why I feel very fortunate
to be jointly appointed in the Department of Family Medicine, be-
cause I have the ability to sit down with family doctors and find out
what is actually happening on the ground. I can only speak from my
research perspective and what I see happening is from a systems
point of view, whereas the clinicians actually live it.
further reading
1. Allen NJ, Hecht TD. The “romance of teams”: Toward an understand-
ing of its psychological underpinnings and implications. Journal of
Occupational and Organizational Psychology. 2004;77:439-61.
2. Nova Scotia Health Authority. The INSPIRED COPD Outreach Pro-
gram [Internet]. Nova Scotia Health Authority. [Cited 2017 Apr 30].
Available from http://www.cdha.nshealth.ca/chronic-obstructive-pul-
monary-disease-copd/patients/inspired-copd-outreach-program.
3. Legislative Assembly of Ontario. Bill 41, Patients First Act, 2016 [In-
ternet]. Legislative Assembly of Ontario; 2016 Dec 6 [Cited 2017 Apr
30]. Available from: http://www.ontla.on.ca/bills/bills-files/41_Parlia-
ment/Session2/b041ra.pdf.
4. Ontario Ministry of Health and Long-Term Care. Patients First: Action
Plan for Health Care [Internet]. Ontario Ministry of Health and Long-
Term Care; 2017 Apr 19. [Cited 2017 Apr 30]. Available from: http://
www.health.gov.on.ca/en/ms/ecfa/healthy_change/.
thinking on your feet
A series of unfortunate events
How should a health system react after preventable medical errors?
Jamie Riggs, Carlos Muzlera
Faculty Reviewer: Merrick Zwarenstein, MBBCh, Msc, PhD (Department of Family Medicine)
case introduction
Mr. B presents to the ED with a 4 day history of dyspnea. He is
a smoker, and was diagnosed one year ago with systolic heart fail-
ure (NYHA II). He has a history of hypertension, and is on enal-
april 10mg PO BID and labetalol 200mg PO q12h. Physical exam
reveals bilateral crackles and moderate peripheral edema. The ED
physician orders a chest X-ray, and observes signs of pulmonary
edema. A decision is made to admit Mr. B, but it proves difficult to
diurese him, and the decision is made to insert a Foley catheter on
the ward. On the third night of his stay, he complained to a member
of the cleaning staff of severe pain in his right leg. The staff member
subsequently notified the nurse, who was able to contact the resi-
dent on call. A bedside ultrasound was performed, and confirmed
the presence of a DVT. The resident also noted that the patient
had not been started on DVT prophylaxis. After morning rounds
the patient was started on anticoagulation, and his pain resolved
within a few hours. Now on his 4th day in hospital, the nurse noted
that Mr. B was now febrile, and that he was producing cloudy urine.
The catheter is removed and Mr. B is started on empiric antibiotic
therapy, and a few days later the infection resolves. However, Mr. B
spent 5 extra days in hospital and was discharged feeling extreme-
ly displeased with his care. You are the hospital director of quality
improvement, and have been asked to review the case and suggest
solutions.
what is quality improvement and why should we
bother?
Quality improvement (QI) is defined as “the combined and un-
ceasing efforts of everyone-healthcare professionals, patients and
their families, researchers, payers, planners and educators, to make
the changes that will lead to better patient outcomes (health), bet-
ter system performance (care) and better professional development
(learning).”1 The Institute for Healthcare Improvement, a leading
QI organization based in the United States, advocates for the use
of a systematic QI process, outlined in Figure 1. In order to create
change, the problem must be rigorously defined, including the pa-
tient population and health systems that will be affected by the pro-
posed interventions. Quantitative measures must be defined prior
to implementing any changes in order to determine whether a spe-
cific change has improved the outcome of interest. Ideas for inter-
ventions should be solicited from healthcare professionals, others
working in the system, and those who have previously completed
successful changes. It is important to note that traditionally, QI has
been distinguished from research by it’s focus on local problems
and it’s use of Plan-Do-Study-Act cycles of rapid data collection and
UWOMJ 86:2 | Fall 2017 Page 81
refinement of interventions. QI was also normally not carried out
with the intention of publishing scholarly papers.2 This distinction
is currently being blurred, with the advent of QI-focused journals,
as well as QI work published in prestigious traditional research
journals leading some to question whether QI projects should be
subject to similar oversight as other research programs.3-6
Preventable complications in hospitalized patients represent
an enormous burden on our healthcare system. The WHO has re-
ported that 7% of hospitalized patients in developed countries will
acquire a healthcare associated infection, with rates as high as 30%
in patients in intensive care units.7 The Canadian Patient Safety In-
stitute reports that about 8,000 Canadians die each year from hos-
pital acquired infections, and that in 2010 $129 million was spent
treating these infections.8 A meta-analysis of hospitalized patients
in Vancouver, BC, found that infection with vancomycin-resistant
enterococci (VRE) increased the length of stay by an average of
68%, or 13.8 days, and increased costs by 61.9% or $17,949 in abso-
lute terms.9 For these reasons, reducing hospital-acquired infection
has been a major goal of quality improvement efforts. In the Unit-
ed States a program aimed at reducing central-line infections has
been adopted in at least 45 states, contributing to a 63% decrease in
these infections between 2001 and 2009. The program uses a mod-
el focused on collaboration both within and between states and is
supported by centralized data collection and a distribution tool that
provides each participating hospital with real-time reports of their
infection rates.10
Although national level estimates of hospital acquired DVT
are not available, Canadian data suggests that DVT also represents
a serious cost to our system, with each case averaging $5180.11 At a
large US teaching hospital, a QI effort based around provider edu-
cation, reminders, decision support tools, data audits and feedback
was implemented over a 3 year period to improve adherence to
DVT prophylaxis guidelines. Over this period of time, adherence to
the guidelines increased from 63% to 96%, while rates of hospital
acquired DVT fell from 2.6 per 1,000 discharges to 0.2 per 1,000
discharges.12 Clearly, avoiding preventable complications should be
a goal for hospitals as well as our healthcare system, and well-con-
ceived QI measures represent an important method for achieving
this goal.
evaluation of the current case
What are the possible lapses that have contributed to Mr. B’s
complications? At multiple points throughout this case, break-
downs in communication contributed to the eventual outcomes.
Evidence has shown that handover procedures are frequently in-
thinking on your feet

complete, and that in some cases information considered important up to 50%.3

by physicians and nurses is omitted,13 and that ineffective commu-
nication is one of the leading causes of medical error.14
Although this case does not specify whether standard protocols
for DVT prophylaxis or catheter insertions are used at this hospital,
it is possible that both complications may have been avoided by the
use of “bundled” care.15 Electronic medical records often have these
bundled orders that are implemented automatically upon the initi-
ation of certain procedures.
It is important to recognize what went well during the course
of Mr. B’s stay in order to acknowledge and learn from these posi-
tive actions. Well trained housekeeping staff were able to quickly
alert the nursing staff to Mr. B’s problem, and he was subsequently
able to get treatment quickly. Additionally, despite his complica-
tions, Mr. B was able to be discharged to home with no long term
consequences. Finally, the fact that the hospital initiated a QI effort
is a crucial step towards creating positive change in this system.
strategies for improvement
A first step for initiating any QI initiative is to involve the right
people in the effort. This team includes members with expertise in
the technical details of the case, a day-to-day leader of the initia-
tive, representation from allied healthcare professions affected by
the proposed changes, as well as a sponsor or champion in hospital
management to advocate for the project.16 Once established, this QI
team should actively solicit ideas for improvement initiatives, some
of which are detailed below. Before undertaking any changes, quan-
titative outcome measures must be defined in order to track the
success of the intervention. These measures will vary based on the
aspect of care being targeted, but must be relatively easily tracked
over time and must be meaningful in the context of the goals of the
QI project. Potential strategies for change in this case include:
Bundles of Care: Bundles are sets of evidence-based practices
designed to prevent complications. Bundles may be designed by the
QI team, in collaboration with other content experts, or taken from
existing literature. In one study, implementation of care bundles
along with multi-disciplinary rounds resulted in significant reduc-
tions in nosocomial UTIs, including four consecutive months with-
out a catheter associated UTI in an ICU setting.15
You form a working group consisting of the unit charge nurse,
an infection control expert, a consultant internist on the same unit
and yourself as hospital administration champion. Over the course of
three meetings, the team reviewed the case and identified areas for
improvement. Initially, two measures were selected: the rate of cathe-
ter associated infections on the unit, and nursing staff ’s self-reported
knowledge of the assessment and treatment plan for patients under
their care. After baseline data was collected, the team implements
two changes. First, goal oriented multi-disciplinary rounds will occur
on a daily basis. Additionally, an evidence based bundle of care is put
in place through the hospitals electronic medical record for patients
receiving urinary catheters. Data collection will continue throughout
the trial period, lead by the unit charge nurse, and both interventions
will be re-evaluated after one month.
Set Aims
What are we trying to accomplish?
Establish Outcome Measures
How will we know that our change made an improvement?

Standardized communications: The Situation, Background,

Select Changes
Assessment, Recommendation (SBAR) method has been proposed
as a method to ensure that all team members are on the same page.14 What change can we make that will result in improvement?
Using this method, all members of the healthcare team frame their
communications around four questions: What is going on with
the patient? What is the clinical background or context? What do
I think the problem is? What do I think needs to be done for the
•Modify the •Develop a
patient? intervention plan to test
Team huddles: Implementing focused ‘huddles’ with all mem- according to your change
the data
bers of the care team at the beginning of every shift in order to set
out the goals and action items to be attended to has been shown to Act Plan
reduce the need for interruptions in order to seek clarification later
in the shift.17
Goal oriented multi-disciplinary rounds: Daily rounds in-
cluding all members of the healthcare team are focused using a pa- Study Do
•Track
tient centered approach, where the aim is to ensure that all mem- quantitative •Implement
bers of the team are clear on what the goals of care are for that day.17 measures the change
and observe for a period
Evidence suggests that these rounds can significantly increase the results of time
proportion of nurses and physicians who understand the goals of
care for that day, and can reduce the length of stays in the ICU by Figure 1. The systematic process of Quality Improvement. Adapted from the
Institute for Healthcare Improvement’s Model for Improvement.18

UWOMJ 86:2 | Fall 2017 Page 82

thinking on your feet

Available from: http://www.ihi.org/resources/Pages/HowtoImprove/

conclusion ScienceofImprovementFormingtheTeam.aspx.
This case has illustrated only a few of the nearly limitless op- 17. Dingley C, Daugherty K, Derieg MK, et al. Improving Patient Safety
portunities for change in healthcare. QI, as a systematic cycle of it- Through Provider Communication Strategy Enhancements. In: Hen-
erative changes based on locally generated data, is a template that riksen K, Battles J, Keyes M, editors. Advances in Patient Safety: New
may be applied in many other healthcare settings. By using a sys- Directions and Alternative Approaches (Vol 3: Performance and Tools)
tematic approach, we are better able to evaluate changes that have [Internet]. Rockville, MD: Agency for Healthcare Research and Quality
the potential to tackle the many challenges facing our healthcare (US); 2008. p. 1–18. Available from: https://www.ncbi.nlm.nih.gov/
books/NBK43663/.
systems and allow others to learn from our work.
18. IHI. Science of Improvement: How to Improve [Internet]. [cited 2017
Feb 17]. Available from:http://www.ihi.org/resources/Pages/Howto-
references Improve/ScienceofImprovementHowtoImprove.aspx.
1. Batalden PB, Davidoff F. What is “‘quality improvement’” and how can
it transform healthcare? Qual Saf Healthc. 2007;16:2–3.
2. Bellin E, Dubler NN. The Quality Improvement – Research Divide and
the Need for External Oversight. Am J Public Health. 2001;91(9):1512–
7.
3. Pronovost P, Berenholtz S, Dorman T, et al. Improving communication
in the ICU using daily goals. J Crit Care. 2003 Jun;18(2):71–5.
4. Palevsky PM, Washington MS, Stevenson, et al. Improving compliance
with the dialysis prescription as a strategy to increase the delivered
dose of hemodialysis: an ESRD Network 4 quality improvement proj-
ect. Adv Ren Replace Ther. 2000 Oct;7(4 Suppl 1):S21–30.
5. Cretin S, Keeler EB, Lynn J, et al. Should patients in quality-improve-
ment activities have the same protections as participants in research
studies? JAMA. 2000 Oct 11;284(14):1786; author reply 1787–89.
6. Lynn J. When does quality improvement count as research? Human
subject protection and theories of knowledge. Qual Saf Health Care.
2004 Feb;13(1):67–70.
7. WHO. Health care-associated infections: Fact Sheet. 2014. Available
from: www.who.int/gpsc/country_work/gpsc_ccisc_fact_sheet_en.pdf.
8. CPSI. Healthcare Associated Infections [Internet]. 2016 [cited 2017
Feb 18]. Available from: http://www.patientsafetyinstitute.ca/en/Top-
ic/Pages/Healthcare-Associated-Infections-(HAI).aspx.
9. Lloyd-Smith P, Younger J, Lloyd-Smith E, et al. Economic analysis of
vancomycin-resistant enterococci at a Canadian hospital: assessing
attributable cost and length of stay. J Hosp Infect. 2013 Sep;85(1):54–9.
10. Provonost P, Marsteller J, Goeschel, C. Preventing Bloodstream Infec-
tions: A Measurable National Success Story in Quality Improvement.
Health Aff. 2011 Apr;30(4):628-34.
11. Guanella R, Ducruet T, Johri M, et al. Economic burden and cost de-
terminants of deep vein thrombosis during 2 years following diagnosis:
a prospective evaluation. J Thromb Haemost. 2011 Dec;9(12):2397–
405.
12. Bullock-Palmer RP, Weiss S, Hyman C. Innovative approaches to
increase deep vein thrombosis prophylaxis rate resulting in a decrease
in hospital-acquired deep vein thrombosis at a tertiary-care teaching
hospital. J Hosp Med. 2008 Mar;3(2):148-55.
13. Siddiqui N, Arzola C, Iqbal M, et al. Deficits in information transfer be-
tween anaesthesiologist and postanaesthesia care unit staff: an analysis
of patient handover. Eur J Anaesthesiol. 2012 Sep;29(9):438-45.
14. Leonard M, Graham S, Bonacum D. The human factor: the critical im-
portance of effective teamwork and communication in providing safe
care. Qual Saf Health Care. 2004 Oct;13 Suppl 1:i85–90.
15. Jain M, Miller L, King D, et al. Decline in ICU adverse events, nos-
ocomial infections and cost through a quality improvement initia-
tive focusing on teamwork and culture change. Qual Saf Heal Care.
2006;(15):235–9.
16. IHI. Science of Improvment: Forming the Team [Internet]. 2017.

UWOMJ 86:2 | Fall 2017 Page 83

health economics
OECD single-payer policy review
Adam Beswick
Faculty Reviewer: Kelly K Anderson, PhD (Department of Epidemiology and Biostatistics)
abstract
The Canadian national public healthcare system is feder-
ally funded and delivered within provincial and territorial ju-
risdictions. While this system is a source of national pride, the
limitations of this mode of healthcare delivery are an import-
ant point of consideration in light of the changing demographic
and social factors upon which this system’s ongoing economic
viability will depend. The Organization for Economic Co-op-
eration and Development aggregates and reports on measures
of national health statistics, and therefore provides a valuable
point of comparison between Canada and similarly economi-
cally developed nations with public healthcare options. A num-
ber of salient public policy differences between Canada and
other nations are discussed they relate to healthcare delivery.
Two broad health policy areas are emphasized as potential
areas of improvement with regard to efficient, cost-effective
healthcare delivery: access to primary care, and integration of
care between primary and specialist services.
introduction
Since the implementation of the Medical Care Act of 1966, Ca-
nadians have been justifiably proud of the universal healthcare sys-
tem in our country. The Canadian single-payer healthcare system,
and the tacit implication of national values with which it has been
associated, has for many embedded itself into the very identity of
what it means to be Canadian.
The Organization for Economic Cooperation and Development
(OECD) is an intergovernmental agency that collects economic
data among developed nations.1 Among the 35 member countries
regularly included in its analysis, the Canadian healthcare system
stands relatively average as compared to similarly structured sin-
gle-payer systems. National healthcare spending ($4608 per capita)
is not substantially different than the majority of European, Austra-
lian, and South American counterparts.1 Among other measures of
health outcomes reported by the OECD, the Canadian healthcare
system reports falls below the top ten nations in a number of mea-
sures, including: life expectancy (79.4 years), percentage of popula-
tion over the age of 15 who are overweight or obese (52.5%), and the
number of hospital beds per 1000 people (2.7).2 Overall, the Cana-
dian single-payer healthcare system is falling behind international
best practices. Within the context of healthcare systems delivery, it
is therefore imperative to identify both potential areas of improve-
ment.
access to primary care
Access to primary care is an essential component of a robust
UWOMJ 86:2 | Fall 2017 Page 84
and economically efficient healthcare system. In Canada, primary
care include services such as mental healthcare, palliative and end
of life services, health promotion, healthy child development, pri-
mary maternity care and basic rehabilitation services.3 Overall, the
benefits of primary care service in Canada are evident: this form of
healthcare delivery is cost-effective, allows patients access to rap-
id treatment, reduces burden on specialist services, and improves
disease prevention and health outcomes for patients.4 However,
the proportion of Canadians who have access to same-day primary
care (41%) lags behind similar nations like New Zealand (72%) and
Germany (76%).5 This is a consequential reality within the Cana-
dian healthcare system. Patients who do not use primary care are
driven to more expensive points of access. For example, a study
from Ontario found that over half (57.4%) of patients in the emer-
gency department would have chosen to use primary care if it had
been available to them.6 This problem is not exclusive to Canada,
as many single-payer healthcare economies grapple with the issue
of “inappropriate” emergency department (ED) use. This is char-
acterized broadly as visits that could otherwise be attended to by
community-based primary care services.7 However, Canada seems
to be unique in the extent to which this problem exists, with a re-
ported 25% of ED visits in Canada are patients who could otherwise
be seen in a primary care setting, as compared to 12% in the United
States, 20% in Italy4, and 15% in the United Kingdom.8
The benefits of improving primary care access are enormous,
and healthcare systems that achieve success in this realm realize
benefits across a variety of health and economic measures. New
Zealand is a global leader in this regard, having entirely restruc-
tured their healthcare policy approach to primary care in 2001. The
New Zealand government finances all health expenditures for all
hospital and specialist care for patients referred by a primary fam-
ily practitioner. The Primary Health Care Strategy was a program
which decentralized healthcare provision from the federal govern-
ment into the control of 82 District Health Boards (subsequently re-
duced to 46 in 2008) representing unique districts of the country.9
These District Health Boards are composed of elected board mem-
bers from the communities themselves, and the mandate of the
boards is to take the responsibility for their communities’ unique
needs in an entirely non-profit context. This initiative was wide-
ly lauded for its success – today the proportion of New Zealanders
with access to primary care is 94%.10
integration of care
In so far as primary care access is an important measure of
healthcare system deliverability, integration of specialist care ser-
vices is an essential component in the continuation of primary
care service. Failure to integrate services remains a ubiquitous and
health economics
obstinate barrier to healthcare in Canada. Nowhere is this lack of
integration more pronounced than at the junction of primary and
specialist care: a 2016 study of primary care physicians in Canada
found that 71% of doctors reported not receiving relevant patient
information following a specialist appointment, including changes
to patient prescriptions and care plans.11 Patients also recognize the
lack of integration of care in Canada – a survey of Ontario residents
found that 18% reported that their doctor “did not seem informed”
about the care they had received from a specialist appointment.12
By virtue of the compartmentalization of service, and without
incentive to achieve maximum efficiency in integration of care, it
is easy for single-payer healthcare systems to fall victim to health-
care integration problems. The German healthcare system com-
bines public and private insurance for healthcare delivery – with
the majority of the population (88%) accessing healthcare through
the public stream. This system of delivery was at the height of in-
efficiency in the year 2000, where the majority (68%) of German
primary care physicians worked in solo practice, more than 50% of
whom reported that it took more than 14 days to receive full re-
ports of their patients upon discharge from hospital.13 Coordination
of care with community services such as long-term care, support
services, and residential environments for patients with physical or
mental deficiencies were criticized as being ineffectual. These fail-
ures were largely attributable to disconnected financing streams of
the country’s medical and social services. In response to these chal-
lenges, the German government set a large-scale policy overview
with a view to remove inefficiencies and improve integration be-
tween primary care, specialist care, and community services. These
policies included a number of reforms including improving the gate
keeping mandate of primary care physicians within the healthcare
system, investing in preventative disease management programs
and medical care centers, and developing integrated care contracts
— a system through which care is provided within a network of care
providers that are overseen by independent management organiza-
tions.13 German healthcare integration is now regarded as one of the
most efficient in the world, 90% of patients reporting that their pri-
mary care physicians were aware of their hospital admission care,
as compared to 75% of patients in Ontario.12
conclusion
It is important to recognize that no healthcare system will ever
be perfect. Healthcare delivery is unique in its economic viability –
it does not follow many of the basic economic assumptions that can
be applied to other sectors. Furthermore, every system of healthcare
delivery is a microcosm of the demographic, political, economic
and social values of a society. That being said, it is important to rec-
ognize benchmarks of comparable single-payer healthcare systems
in order to generate new ideas to improve Canadian health services.
By acknowledging varying provision practices and objectively mea-
suring their success, governments and health advocates can more
effectively improve healthcare within our own communities.
UWOMJ 86:2 | Fall 2017 Page 85
references
1. OECD [Internet]. Paris (France); c2017. Health Statistics, Health Status
Data Sheet; c2016 [cited 2017 Jan 17]. Available from: http://www.
oecd.org/els/health-systems/health-data.htm.
2. OECD [Internet]. Paris (France); c2017. Health Statistics. Health
spending (indicator); c2017 [cited 2017 May 23]. Available from:
https://data.oecd.org/healthres/health-spending.htm.
3. Canadian Institute of Health Information. [Internet]. c2015. How Can-
ada Compares: Results from the commonwealth fund 2015 Interna-
tional health policy survey of primary care physicians [Press Release].
c2015. [cited 2017 Jan 16]. Available from: https://www.cihi.ca/en/
cmwf/media_release_commonwealth_2015.
4. Canadian Nurses Association. [Internet]. c2012. Evidence Synthesis for
the Effectiveness of Interprofessional Teams in Primary Care. Ottawa:
Canadian Health Services Research Foundation. c2012. [cited 2017 Jan
16]. Available from: https://www.cnaaiic.ca/~/media/cna/files/en/syn-
thesisinterprofteams_jacobson-en-web.pdf.
5. Kiran T, O’Brien P. 2015. Challenges of same-day access in primary
care. Can Fam Physician. 61; 399-400.
6. Wong WB, Edgar G, Liddy C, et al. Survey of ambulatory patients seek-
ing after-hours care. Can Fam Physician. 2009 Nov; 55(11): 1106–1107.
7. McHale P, Wood S, Hughes K, et al. Who uses emergency departments
inappropriately and when a national cross sectional study using a
monitoring data system. BMC Medicine 2013 Sep; 11:258.
8. Wise J. Most emergency attendances at hospital are appropriate, finds
study. BMJ 2014; (348):3479.
9. New Zealand Ministry of Health [Internet], c2017. Overview of Health
System. [cited 2017 May 18]. Available from: http://www.health.govt.
nz/new-zealand-health-system/overview-health-system.
10. World Health Organization Primary health care the New Zealand. Bull
World Health Organ. 2008;86(7): 505-6.
11. Canadian Institute of Health Information [Internet] c2017. Canadian
Patient experiences; c2015 [cited 2017 May 23]. Available from:
https://www.cihi.ca/en/pia_cper_2015_en.pdf.
12. Health Quality Ontario [Internet] c2017. Emergency department per-
formance in Ontario; c2016. [cited 2017 May 23] Available from:
http://www.hqontario.ca/portals/0/Documents/system-performance/
under-pressure-report-en.pdf Accessed Dec 1st, 2016.
13. Schlette S, Lisac M, Blum K. Integrated primary care in Germany: the
road ahead. Int J of Integr Care. 2009;9:e14.
zebra files
Chikungunya virus in Canada
A case report highlighting the need for increased global health education
Herman Bami, Jason L Elzinga
Faculty Reviewer: Javeed Sukhera, HBSc, MD, DABPN, FRCSC (Department of Psychiatry)
abstract
This article presents a previously reported case involv-
ing the first Canadian patient to acquire Chikungunya virus
(CHIKV) infection after travelling to a newly endemic region
in the Americas. The specific history and clinical presentation
of this patient is examined, including the treatment and com-
plete resolution of the patient’s symptoms. A brief overview of
the general disease course and diagnosis of CHIKV is provided.
This case emphasizes the importance of global health educa-
tion in Canadian medical curricula. The current standards of
global health education in Canadian medical schools are briefly
reviewed and recommendations based on expert opinions are
provided. Although such programs exist, their implementation
was found to be variable between schools and increased atten-
tion and standardization is currently required.
case presentation
A 57-year-old Caucasian male with no previous medical histo-
ry travelled to Martinique, an island in the East Caribbean, from
mid-January to early February 2014.1 Around 3 days after his return
to Quebec, he presented with several symptoms including fever, my-
algia, and increasingly progressive headaches.1 The patient sought
medical attention with his primary complaints being arthralgia in
his extremities, joint swelling and a nonpetechial rash on his tho-
rax.1 Upon further questioning, the patient reported that while in
Martinique, he resided in a villa close to the mountains.1 Although
the villa itself was reportedly well maintained, the patient reported
mosquito bites, mostly during the first few days of his approximate-
ly 2-week stay.1 The patient did not experience episodes of fever,
gastrointestinal or respiratory illness during his trip.1 He was evalu-
ated for renal and liver anomalies with no significant results.1
Serological testing for dengue virus was ordered on paired sera
samples with negative results for the anti-dengue IgM and IgG anti-
bodies.1 The patient was treated supportively with nonsteroidal an-
ti-inflammatory drugs.1 Upon treatment, the fever subsided, howev-
er musculoskeletal symptoms persisted for an additional 2 weeks.1
Four weeks after the initial symptoms, the patient received fol-
low-up blood tests.1 The patient reported gradual improvement in
symptoms, although arthralgia and residual morning joint stiffness
were both still present.1 Physical examination displayed no signs of
synovitis and a presumptive diagnosis of arbovirus infection was
given.1 Additional serological testing for Rickettsia spp. and chiku-
ngunya virus (CHIKV) was conducted with a positive CHIKV IgM
enzyme-linked immunoassay found.1,2 The positive finding was lat-
UWOMJ 86:2 | Fall 2017 Page 86
er confirmed by a CHIKV plaque neutralization test.1 Amplification
of the CHIKV envelope EI gene from the samples was initially at-
tempted by reverse-transcriptase polymerase chain reaction.1,3 Suc-
cessful amplification of the targeted genome resulted in a product
that could be sequenced.1 These results were consistent with initial
findings related to an Asian strain circulating in the Caribbean.1
Eight weeks following his first patient visit, the patient report-
ed returning to his previous state of health with a lack of residu-
al febrile syndrome, and absence of both hand stiffness and other
symptoms.1
description of chikv: pathogenesis and epidemiology
Chikungunya is an RNA alpha virus of the Togaviridae fam-
ily that is transmitted by the Aedes aegypti and Aedes albopictus
mosquitos.4 Although the virus is endemic in nonhuman primates,
humans can also serve as primary hosts during periods of acute
illness that allow for infection of biting mosquitos.5 The virus was
first isolated in Tanzania in 1953 but spread to Thailand in 1958.6 In
2004, an outbreak sparked a transmission to Mozambique, India,
Sri Lanka and other parts of Southeast Asia.7 The virus first reached
the Western hemisphere in late 2013 with transmission to the Ca-
ribbean island of St. Martin.6 Since then, it has reached up to 44
countries including the United States and Canada.1,8
CHIKV infection is characterized by an acute onset of high fe-
ver in addition to symmetric and severe polyarthralgia in the small
distal joints.4 Other possible symptoms include headache, myalgia,
and vomiting with further examination potentially revealing ar-
thritis, lymphadenopathy, and conjunctivitis.5,9 The most common
laboratory finding is lymphopenia, the severity of which correlates
with the extent of viremia.9 CHIKV has an incubation period of 2 to
12 days with the subsequent viremia lasting between 4 to 7 days.4 Al-
though acute symptoms typically do not last more than 2 weeks, up
to 60% of patients can experience relapsing and severe arthralgias
for months to years after the infection subsides.5,7 While CHIKV has
a low mortality rate, elderly and immunocompromised patients are
at a higher risk for life-threatening disease including meningoen-
cephalitis, hepatitis, myocarditis and nephritis.5 Differential diag-
noses often include dengue virus, which carries similar symptoms
(see Figure 1) and is transmitted by the Aedes mosquito in similar
locations.10 Additionally, chronic arthralgia may mimic rheumato-
logic conditions including rheumatoid arthritis, underscoring the
need a comprehensive history upon initial presentation.10
Although malaria is still the most common cause of fever in
travellers returning to Canada, a broader spectrum of other vec-
tor-borne and viral infections are being detected over time includ-
ing measles, CHIKV and dengue virus.11 Since early 2014 and the
zebra files
initial transmission of the CHIKV to the Caribbean islands, a dra-
matic increase in CHIKV cases diagnosed in Canada has been seen,
emphasizing the need for increased awareness and education for
Canadian clinicians and healthcare providers.12
Figure 1. Clinical presentations of CHIKV and dengue virus including overlap-
ping and distinguishing clinical signs.10
global health education
Need for increased training
Due to trends in globalization and travel bringing previously
foreign pathogens to North America, students and medical edu-
cators should maintain a global perspective on infectious illness
needs to mitigate the potentially negative societal impact of global-
ization. Globalization is a multifaceted phenomenon with a myriad
of potential and critical health impacts, ranging from direct impacts
on individuals through healthcare delivery to indirect impacts via
economic and other social factors.13 For instance, globalization re-
sulted in liberalization of the airline industry, leading to a dramatic
increase in global air travel, thus enabling the rapid spread of com-
municable disease.13 In the past 5 years, numerous emerging infec-
tive agents such as Zika virus, Ebola virus, Enterovirus D68, and
CHIKV have spread broadly and rapidly. These infections empha-
size the need for increased training and awareness of global health
issues. Furthermore, the rapid influx of newcomers due to inter-
national conflict, especially considering the recent crisis in Syria,
highlights the importance of such training.
While “global health” can be an evasive term, especially when
used with terminology such as “international health” or “tropical
medicine”, it is increasingly being used to denote the health issues
that transcend national borders, race, ethnicity, income or culture.14
Although significant differences exist between disease patterns
based on geography, the factors that perpetuate disease states -
which include poverty, political instability, limited access to care
and genetic determinants - are often quite related.14 This similarity
can perhaps be best exhibited by the rise of chronic conditions such
as cardiovascular and lung disease in developing countries due to
increased risk of smoking, poverty and educational factors.14 In or-
der for medical students to be able to address these complex and
nuanced issues, there has to be a clear and comprehensive integra-
tion of global health in medical school curricula.
UWOMJ 86:2 | Fall 2017 Page 87
Current status and recommendation
The past few years have brought a substantial increase in
medical students interested in global health.14,15 In a recent study
conducted on American medical schools, it was found that many
matriculating students had prior international experiences, and up
to 30% chose to partake in international electives during their stud-
ies.15 Additionally, up to 68% of schools had active student global
or international health groups.15 In a similar study in Canada, 53%
of the medical schools had either specific global health lectures
or modules as part of the mandatory courses.16 As a caveat, there
is significant variation across schools in the material covered, the
amount of information provided, and the year in which this training
is offered.16 While all schools offer the opportunity to take part in
international electives, there has historically been poor consistency
in the pre-departure training provided, as well as the financial and
organizational support provided by the school.16 Despite the grow-
ing interest exhibited by medical students and the increased need
for global health training, medical school curricula have yet to de-
liver a sufficient and coherent response.15,16
Recommendations have been made for the foundations of
global health curricula in undergraduate medical programs. In a
2010 update to guidelines released by the Association of Faculties
of Medicine of Canada Resource Group on Global Health/GHEC
joint committee, the group proposed all medical graduate should
have competency in the following areas: global burden of disease,
health implications of travel, social and economic determinants of
health, population health, globalization of healthcare, healthcare in
low-resource settings, and human rights in global health.15 Another
study based on work from the American Society for Tropical Med-
icine and Hygiene Committee on Medical Education consolidated
the core competencies of global health education into 3 domains:
burden of global diseases, traveller’s medicine, and immigrant
health.15 Despite these consensus competencies, tremendous vari-
ability remains.
Despite the difficulty of incorporating novel elements into
medical school curricula, and ensuring that these newer offerings
are available in learning formats accessible to all students, it is crit-
ical to ensure that physicians graduating today have the skills to
make them competent and effective practitioners. While standard-
ized curricula of a specific length or format may be impractical for
all medical schools to accommodate, increased student interest in
global health and the increased demands on today’s medical practi-
tioners require action.
conclusion
This report presents the first case of a Canadian acquiring
CHIKV after travelling to a newly endemic region in the Western
hemisphere. The clinical picture of this disease is also examined.
While other potential causative infectious agents can confound di-
agnoses, it is important for clinicians to be aware of the different
presentations of emerging infections. In addition, this case high-
lights the continual need for global health education in its varied
formats for medical trainees. There is ongoing debate regarding
zebra files

standards for global health education in Canadian medical schools,

with a number of recommendations being put forward from expert
opinion groups.

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