Early Childhood Development

As an public health epidemiologist, I spend a lot of my time figuring how the best way to measure the population burden of an illnesses. Most of the time we have to use which ever data source is most convenient, often administrative hospital or death records, and occasionally larger population surveys. Understanding population health trends helps planners set priorities and give them confidence that public health interventions are working to reduce disease. The biggest problem with trying to link changes in rates of diseases to specific public health interventions is the difficulty in attribution. The causes of non-communicable diseases are very complicated, and extremely difficult to pin on a single factor. For example, rates of teen pregnancy are decreasing. With the data sources we have it’s impossible to tell if that change is related to public health interventions like free condoms and sex education (there are, of course, so many more as well),   or changes in any number of underlying population characteristics (improving economy, influx of certain immigrant groups, change in religious beliefs, etc.). Public health practitioners would love to claim credit for the decreasing rates, but the data sources we rely on are simply not powerful enough to determine attribution for trends. In reality, it might be that reality shows like Teen Mom, and 16 and Pregnant are scaring teens being more careful.

Diseases that affect people at the end of their life are even more complicated, because the many of the underlying causal factors occurred much earlier in life. This problem often arises when epidemiologists use cross-sectional data (ie data collected at a single point in time, instead of  longitudinally or retroactively over a longer period of time) to try and understand trends. If you are trying to understand the relationship between income and heart disease, knowing the a person’s income at the time of diagnosis or death would not be as helpful as knowing their income level 10 or 20 years earlier, when their income level might have had a much larger impact on their getting heart disease.

Income is widely believed to be one of the single best predictors of disease. It’s far from perfect, but in general, higher income earners are in a better position to access resources which will lead to better health (better housing, healthier food, less stress, more leisure time for physical activity, greater access to physicians and preventative healthcare, and the list goes on…).

The other powerful predictor of health is the effect of early childhood experiences. Poor nutrition during childhood can have lasting biological impacts. Stress and abuse can also leave psychological scars which are even more difficult to detect, and potentially even more damaging. Canadian research Clyde Hertzman developed a theory of biological embedding, which basically describes how early life experiences have a way of literally getting under the skin, and can actually change a person’s DNA. Epigenetics is not really my area, but my understanding is that through biological process such as methylation (help me out here Pat!), the DNA is permanently changed, altering biology and development, and these changes can even be inherited by future generations.

The impact on health is significant. The experiences don’t have to be as violent as abuse, but Dr. Hertzman and others have been able to show that poor child development can have lasting impact on future grades, opportunity, and ultimately long-term health. Canada, unfortunately, ranks last among OECD countries in terms of investing in early child development (usually thought of as before age 5).

Something that really makes me feel encouraged is that interest in investing in early childhood development is an idea that isn’t confined to public health. TD bank has also been supporting investing this area, as a means to foster a healthier and more productive workforce, something that pays big dividends in future economic rewards. I find it so interesting to see other groups addressing this same issue, it’s fascinating to see the issue framed in terms of return on investment instead of improvements in health!


Prevention and Public Health

I told Pat I would write him a response to his post on primary medicine, with an emphasis a public health perspective. I can’t think of a better way to describe prevention from a public health standpoint than the story of “the river”.

Two doctors were walking past a river, when they see a man in the river, shouting for help and drowning. Without thinking, they jump in, pull him out, and save his life. Shortly afterwards, they see another person floating down the river, and jump in to save him too. Soon, another floats by, and another, until before long the river was full of people who needing help. The pair of doctors become overwhelmed and exhausted from pulling person after person out of the river.

Suddenly, one of them gets up, and begins running upstream. “Where are you going? These people need our help!” Shouted the remaining doctor. “You stay here” she responded “I’m going up ahead to see if I can stop them from falling into the river in the first place!”

The purpose of public health, in general, is to be looking upstream, and thinking about making the changes which stop people from ever falling into the river. I suppose this is what Pat referred to in his post as primordial healthcare. Public health then, would be the application of primordial and primary healthcare on the population level, through interventions such as vaccinations, promotion of healthy behaviours, and increasingly, mitigating inequities in social determinants of health, such as income and immigration.

This leads to an interesting question: what is the best way to prevent disease? I’m thrilled that physicians and specialist are taking an interest in preventing disease, but is that the most efficient use of their specialized skill set? Cardiologists are so highly trained, that it seems like a waste to have them spend their time advising smokers to quit, especially when a less skilled practitioner (ie public health nurse (or MPH grad!)) could do it for much cheaper.

Over the past 10 years, smoking rates in Toronto have fallen about 6%, a statistically significant difference. Smoking rates can be very difficult to measure though, and different patterns emerge if you begin to consider occasional smokers vs daily smokers, men vs women, rich vs poor, and low vs high education levels. On the whole, 17% of Torontonians still smoke, and considering that tobacco use is the number one cause of preventable mortality in Ontario, smoking represents a considerable burden on the health system.

What’s interesting is that even though it is well known that smoking is harmful, and cessation aids are plentiful and proven to help, many smokers will only begin to attempt to quit after conversation with their doctor. It’s clear that even with repeated public health messaging, advice from a doctor is extremely powerful and motivating, however too many practitioners do not talk to their patients about tobacco use until there is a serious problem. Well done for making it part of your practice Pat!

Primary Prevention

My recent schedule has regrettably made it a bit tricky to write over the past couple of months. After getting home from a long day, seeing friends or going to the gym has usually trumped making a post. Hopefully this will be the first of several to get back on track.

Throughout this past week, a common theme keeps popping-up when I talk to friends – particularly to those not in healthcare. That is, the value of preventative medicine. There are different types of prevention: primary, secondary, tertiary and primordial. Primary prevention deals with stopping an illness from occurring in the first place (e.g. avoiding lung cancer by not smoking). Secondary prevention is to catch a disease after it starts, but before symptoms appear, such as through screening techniques (e.g. colonoscopies for colon cancer). Of course this has to be an illness that can be readily treated at the stage it is diagnosed, and in a non-invasive and affordable way. Tertiary prevention involves rehabilitation after a disease or illness has begun to manifest itself (e.g. pulmonary rehab). Lastly, primordial is making changes on a population level through Health Canada and public health (e.g. banning smoking on public places).

A doctor looks over a patients medical records
“A Doctor looks over a patients medical records” by World Bank Photo Collection is licensed under CC BY-NC-ND 2.0

For the purpose of this post, I will focus on a subject that is close to my heart (no pun intended): cardiovascular health!

Much money and many investments are dedicated into treating pathology of the cardiovascular system. Consider plaque buildup of your coronary arteries (the blood vessels that feed your heart). If these plaques accumulate too much, one becomes high risk for suffering from a heart attack. So much money is spent on treatments for people experiencing a heart attack, either through stents (angioplasty) or a more invasive alternative, such as open-heart surgery. Additionally, there is an entire market of pharmaceuticals focused on the management of people who have had a heart attack: Plavix, beta-blockers, alpha-blockers, diuretics, and many more. In fact, statins (often used to lower bad cholesterol in the blood) are the most commonly prescribed medications on the market.

With a greater focus on primary prevention, this burden can be shouldered. Despite this, only 1% of healthcare costs are devoted to primary prevention and promoting healthy lifestyle. Most of this is done through family physicians and regular check-ups, but some specialists are starting to emphasize it as well (such as preventative cardiologists). Central to this is the issue of time management, inadequate primary literature, and poor remuneration. Efforts are being put towards stressing primary prevention, albeit slowly. This is something that I am looking forward to pursuing once I start practicing, and that I have already begun to push with many of my patients. I am excited to see what direction our system will go regarding the value of primary prevention.

Job Market…?

One of the major advantages of going into medicine has traditionally been job security. Fortunately and unfortunately, there are always going to be sick people who need to be looked after. When I first started schooling, I remember hearing all these rumors about the declining job market for doctors. Initially I shrugged it off, accepting that certain surgical specialists, such as cardiac surgeons and orthopedic surgeons will have trouble, but that the majority should be okay. As I continued preclerkship, it became clear that many medical specialists (e.g. nephrology, ICU, etc.) are also struggling for jobs. Two years back, a group of students including myself met various MPPs and brought this issue forward. Our goal was to begin collaboration between the CMA and provincial government to create a database outlining specifics on job openings around Ontario. As an added bonus, this could potentially help to fill-in gaps in certain areas and fields. It was unanimously agreed upon… but will unfortunately be ready after I have already chosen my ultimate path. It was still a fun weekend though.

I have also heard some of the older docs say that this has always been an issue, but it is not really as bad as everyone makes it seem. On the contrary, others argue that the 2008 mortgage crisis cost many physicians their investments, ultimately leading to them working well into their 70s and 80s. It’s hard to decipher what the actual scenario is… maybe it’s a combination of everything.

So where will this lead us? I would love to hear other people’s opinions (this is something that my counterpart can provide a more informed answer!). Will this unsustainability ultimately shift Canada into more of a two-tier system, mirroring Australia? Or is there an alternate solution? Timing is also important. Will these inevitable changes be implemented by the time I graduate?

Fortunately, I have yet to be overly excited by fields like cardiac surgery and neurosurgery. However, things still aren’t terrific for the fields that I am considering. Nevertheless, I will try my best to not let it impact my decision (too greatly at least). I have always been a believer that if you want something badly enough, there is almost always a means to achieve your dreams.

Feel free to share any input!


Burnout at the Clipsal 500

Burnout at the Clipsal 500 by Australian Department of Defence CC BY-NC-ND

Put simply, burnout can be described as exhaustion and a decreased interest in work. It is a triad of emotional and physical exhaustion; depersonalization (cynicism); and a loss of sense of accomplishment. Although it is possible to develop burnout in a number of professions, physicians are the prototypical victims.

Since the medical field is the environment that I know best, I can only really comment on it here. We were taught about this in several of our lectures during the first two years of medical school. This is what we learned. Burnout is largely due to perfectionism, and what was called the “compulsive triad.” This triad consists of 1) self doubt; 2) guilt; and 3) sense of responsibility. This compulsive triad materializes into a difficulty with setting limits → never doing enough → not ever pursuing pleasure → decreased self-awareness → numbing. This I have seen within myself, as well as those around me. We never set limits on ourselves, and especially when tired, begin to ignore the inner voice telling us to slow down and focus more on our own wellness. We development an absence of mindfulness, which may ultimately lead to burnout.

Burnout has been shown to have a negative impact on professional behaviors, altruism, knowledge scores, risk of medical errors and collateral damage. Over 90% of medical professionals who are assessed for unprofessional behavior, are not bad people, rather, they are depressed and at risk of burnout. 50% of medical students experience burnout symptoms in year 2, and up to 80% of residents at some point in their training.

That’s the bad news… but fortunately there are things that can be done to prevent/manage burnout. One way is by showing resilience. Resilience means that you are able to bounce back, as well as adapt positively in the face of adversity. The following have been shown to make a person more resilient:

1) Positive attitudes and emotions
2) Meaning making – this can be very personal. For some, it is forming connections with patients. For others, it is intellectual stimulation.
3) Social support – surrounding oneself with friends, family, and people who have a positive outlook on life.

Also, having the flexibility to enjoy leisure-time activities, such as sports or music doesn’t hurt either. This is very valuable, which explains why lifestyle factors heavily into so many people’s decisions on which specialty to ultimately pursue. I have recently gone through a short, but impacting bout of what I think is some form of burnout. When we had this lecture series last year, I didn’t give it much thought. But reading it over now, it’s amazing how much of it mirrors exactly what has been going-on in my head these past couple weeks. The three aforementioned defense mechanisms, and others, have really helped. Nevertheless, I am still counting down the days until my well-earned Christmas break!

Six weeks at the Clinical Teaching Unit

CTU, or the clinical teaching unit, has earned the reputation of being the toughest rotation in the third year of medical school. This is due to a combination of 80-120 hour work weeks, the excess of scut work that has to be done, the sudden responsibility of having our own patient’s to look after, and the constant barrage of questions that we likely don’t know the answer to in front of a large audience (AKA pimping). I have just finished my six-week block of CTU, and I can’t believe how fast the time went by.

CTU is like a less glamorous version of JD’s life on the show Scrubs. The details vary in location, but I think most places share the same basic format.

The days start at 7:30AM, where students often drop-in to pre-round on their patients. From 8:00-9:00, there is morning report. The team then meets from 9:00-10:00 to catch everyone up on their patients. From 10:00-12:00, you see your patients, until 12:30, when instead of lunch you have an hour of teaching. The rest of the afternoon consists of more rounding on patients, teaching, and team meetings. Usually you get to go home at 6:00PM, unless you are on call, which means you are staying until about 12:30PM the next day. That’s the quick and dirty.

Overall, it really wasn’t as bad as everyone made it out to seem. In fact, a lot of it I enjoyed. There is really cool stuff to learn, I loved the people I worked with, and I made some great connections with my patients. The biggest set-back was having all of our exams at the end of the block, so we often had to spend the evenings (or between rounding) studying.

For anyone reading this who has a CTU rotation coming-up, there are a few survival tips that can really make life easier. They seem pretty obvious, but you’d be surprised how greatly things can change when you’ve been on call for 30 hours strait, and being paged at 4:30AM about a patient’s oxygen mask falling off.

Tip number one: always be super friendly. To everyone. You are going to be working long hours, usually with the same people. Everyone will be tired and overworked, and everyone will appreciate having a genuine and kind person to work with. Trust me, not only will it make your day better, but people will repay your kindness by making your life easier. Number two: be prepared to work long and hard hours. Do what you can to help make the life of your residents easier. This is one of the few rotations where you can actually help, as opposed to mostly being a hazard. Number three: make the most of learning opportunities. You will get the opportunity to not only gain huge amounts of knowledge, but also to master physical exam skills. This is one of the few rotations where you can do this, and nothing is expected from us at this point. I would much rather admit to not finding someone’s JVP now, than at 3:30AM as a resident. Lastly, don’t give-up on your hobbies/social life. It is a challenging six weeks, but having something to look forward to when you get home is key. Medicine is a marathon, not a sprint!