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A town of about 20,000, Collingwood, Ont. is fairly small. By comparison, Toronto—the closest, large, metropolitan city—has a population of nearly three million.
Community hospitals like Collingwood’s have many advantages. They’re relatively small, which may make them less intimidating. There’s also a sense of community. In fact, small, local hospitals can even feel friendly. However, unique challenges exist too. One of these is privacy and patient confidentiality. In Toronto, or New York City for example, it’s common to care for people and never see them again. Or, if one’s paths do cross at a later date outside the hospital setting, it’s likely that patients and care providers won’t recognize each other. With such a small population, it’s different in Collingwood. This makes protecting patients’ privacy and confidentiality that much more challenging in certain situations. For example, I often run into patients in the community, including at the grocery store, the pharmacy, the gym, or the local coffee shop and we recognize each other. This can make it difficult to separate one’s personal and professional life, because encounters like this commonly happen several times a week, or maybe even more than once a day. It’s obviously not appropriate to ignore one’s patients in the community. Nor is it proper to blur the professional line and be too friendly. Nonetheless, despite its challenges, working and living in the same small community is a privilege that’s also rewarding. Perhaps it comes down to striking a balance between being a professional, yet, at the same time, a caring, compassionate human being in the hospital, as well as in one’s community.
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The statement “mental illness is like any other illness” has largely become an accepted truth. This implies that mental disorders, like other medical conditions, all have biological origins.
Aside from mental health complications, because of neurological illnesses, medical conditions like Type 2 diabetes do not typically alter one’s core self significantly. However, mental disorders do by occurrences that change one’s thinking, perception and consciousness of the self, others and the world. Neuroscience advancements have taught us that several mental illnesses develop as a result of underlying biological differences. Yet, many of the behaviours and experiences that form mental disorders’ core presentations still can’t be explained by neurobiology. Even if this changes in the future, it will still be necessary to understand the experiences of people with mental illness psychologically. Likening mental disorders to medical conditions confines them to an organ, namely the brain, within one’s biology, but fails to recognize their uniqueness in terms of how they affect the self. This can’t be justified based on our current understanding, nor does it adequately serve patients, or the general public. Equating mental illnesses with medical conditions can be helpful clinically, particularly in the context of acute crises where medication often plays an essential role. This can become problematic later, however, because it often compromises compliance with crucial psychological and social treatments. The statement “mental illness is like any other medical illness” is, at its best, an over simplification of a complex human problem and, at its worst, harming patients, families and the field of mental health. Instead, this conversation needs to integrate the complexities of human thinking, behaviour and memories, including the ideas of the self and consciousness. I recently started working at Collingwood General & Marine Hospital’s Community Mental Health Services. There’s no question that this clinic is making a positive difference in the lives of many residents in the area. In fact, one of our top priorities is keeping patients in the community as long as they’re safe. However, the harsh reality that faces seniors without family support who are no longer able to live independently confronted me face-to-face this afternoon during a visit to a local nursing home.
In Canada, elderly people who can’t live alone have some choices if family support isn’t available. These include retirement homes, nursing homes, also know as long-term care facilities, or hospice care for those who are very ill and nearing the end of life. There are drastic differences, however, depending on whether or not you can afford care that is privately funded. Most of my patients can’t, which means their only option is government funded care. This is the kind of place I visited today and it was heartbreaking. During the day, there are two registered nurses and four personal support workers at this 95-bed facility, which becomes one nurse and two support workers over night. My first thoughts were, ‘What if there was a fire? How would three workers get 95 seniors, most of whom can’t get themselves out of bed, never mind walk, out safely?’ Most of the rooms are shared, which means there are two to four residents using the same bathroom. Many of these people are incontinent and most of them have walking aids. I didn’t get the sense that anyone was really making an effort to get to know these seniors, or what they were like premorbidly, either. There were no histories or photo albums by their beds. When I asked about this the nurse said, “We don’t do that here.” She wasn’t concerned about this though and didn’t give me any indication that they might consider it in the future. There’s also no autonomy. Routine is important, but what if getting up at 7 a.m. and eating breakfast at 8 a.m. were never part of your routine and now, at 80 or 90 years of age, they have to be, because that’s the regimented schedule? All of this made me wonder why we’ve come to accept this and how we justify it? It seems many of our elderly citizens are falling through the cracks and we’re largely letting it happen. I’ll do my part to keep my patients in the community as long as safely possible. However, when they have to be institutionalized there should be better public options. I don’t have a practical answer to this problem yet. What I do know is we need to address it now, because we wouldn’t consider these circumstances acceptable for any other age group. Although there are many exceptional physicians in the world who listen, ‘Doctor knows best, don’t challenge me’ still features prominently in medicine’s culture.
Even if patient safety is on the line, most medical students and residents won’t challenge their senior colleagues. This is because they think their opinion will be ignored, they’ve been warned by people they respect not to, they fear that doing so could damage their career, or they have friends whose jobs have been destroyed by such behaviour. In his book, Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out, Dr. Peter Pronovost, an intensive care physician at Johns Hopkins, discovered that in 90 per cent of serious, harmful patient safety events, at least one team member knew something was wrong but either didn’t say anything, or spoke up and got ignored. We know that groups do better than expert individuals, yet we don’t get enough training about how to work this way in medical school. We spend countless hours looking at slides under microscopes to improve our individual knowledge, but very little time learning how to work as a team or how to resolve conflict. Medicine’s culture of intimidation is slowly changing, however, because we’re starting to talk about it. This matters since it’s the first step towards making hospitals safer for patients, as well as constructive learning environments for doctors. As the days get longer, and the snow continues to melt, spring seems like it’s finally here. Yet, many of us won’t treat the risks of sun exposure as seriously as we should. This is part of the reason why skin cancer rates have actually risen in the last 20 years, especially among people over 50.
Lax sun safety habits seem to be a combination of an aversion to sunscreen’s greasiness, fashion concerns and a generally blasé attitude about the possibility of getting skin cancer. However, rising skin cancer rates are mostly because of increased sun exposure. In fact, the sun's dangerous ultraviolet (UV) rays are responsible for 90 per cent of melanoma cases. More sunburns In the 1930s, the chance of getting melanoma was one in 1,500. Now, it's one in 50. The main reason for this change is that we bare more skin than we used to. Yet, despite greater awareness about melanoma risk, there's still a lot of resistance to using sunscreen. Another problem is that many of us don't know how to put it on properly—in order for sunscreen to work, people need to use a sun protection factor (SPF) of at least 30, and re-apply it every two hours. Moreover, whether it's using sunscreen, long sleeves, or a hat, because these tend to be unfashionable, we generally refuse them. Popular culture’s images make us think that bronzed skin is more attractive, which is why many of us are willing to risk greater sun exposure. The vanity aspect also explains tanning salons’ popularity. And, although parents are normally vigilant about using sunscreen on their children, these habits readily disappear when kids are old enough to put it on themselves. Untrained doctors Doctors who don’t promote sunscreen to their patients are another factor. In fact, a 2013 study of U.S. physicians between 1989 and 2010, involving more than 18 billion consults, found that sunscreen was mentioned less than one per cent of the time. Perhaps even more striking is the fact that dermatologists reviewed it with fewer than two per cent of patients. Interestingly, when discussing the sun’s dangers, warning people about the risk of melanoma seems less effective than appealing to their fear of aging, because most of us don’t think we will be that person who gets skin cancer. Let’s make 2015 different and not ignore literacy about sun safety. It's been 13 days since Germanwings Flight 9525 slammed into the French Alps and killed everyone on board. As the details behind this story develop, alongside the perplexing tragedy, the media repeatedly reports on one part: the co-pilot, Andreas Lubitz’s, mental health.
A jumble of facts, assumptions and speculations, this desperate coverage continues to make statements like: “New information about Germanwings co-pilot Andreas Lubitz. Prosecutors now saying [he] was undergoing medical treatment.” “Several newspapers in Germany reporting that Lubitz had been undergoing psychiatric therapy. Not quite a smoking gun, but a whiff of gunpowder in the air if nothing else.” “The co-pilot in the Germanwings crash reportedly had a history of depression. Andreas Lubitz was even treated at this clinic in Düsseldorf within the past two months. For what we do not know.” “He once told a girlfriend that the entire world would someday know his name. Lubitz [said] he was in psychiatric treatment and was planning a spectacular gesture.” “Why on earth was he allowed to fly? Suicide pilot had a long history of depression.” I think there’s agreement that we need to discuss Lubitz’s mental health since 150 lives were lost and everyone deserves answers. However, sensationalizing stories that intertwine mental health and disaster is damaging. We’ve come a long way in terms of de-stigmatizing mental illness, but this kind of coverage brings us back to square one. Stigma is the biggest reason people avoid treating mental illness, and attitudes don’t change quickly. One badly reported example by the media drives people away from seeking treatment for illnesses like depression. Public safety is critical, but how many people will be hurt, because of how this story is being covered? Mental health + 24/7, instantaneous news Germanwings Flight 9525 is breaking news. However, we’re misinforming the public about the role mental health issues play in the lives of those afflicted with mental illness. Most depressed people don’t hurt others. Nor do they typically plan a “spectacular gesture.” The truth is we cover mental health badly most of the time. That’s dangerous because it distorts peoples’ understanding of mental health. Events need to be explained. In this case though, we’re rushing to explain a story we barely know anything about. We don’t know if Lubitz was depressed. What we know is that he suffered depression previously, which isn’t the same thing. In this story for example, we’re using depression as another word for dangerous, which simply isn’t true. Fear of saying what we don’t know The known is that Lubitz was treated for depression in 2009. The unknowns are what kind of treatment he was receiving when this plane went down, whether the mental health system’s accountability failed here, and what kind of psychological testing he actually endured as a pilot. Knowing the answers to these questions would change the context of the few facts we do know. Yet, we generally have a tendency to use small pieces of information to explain way more than we should allow them to. We don’t diagnose diabetes and heart disease based on incomplete information, nor should we diagnose depression and psychosis before we know the facts. Potent prescription opioids like oxycodone can be lifesaving for people with pain. However, these drugs also cause serious problems. Addicts obsess about getting their next fix to avoid the unbearable withdrawal symptoms.
There have been pharmacy thefts, illegal street sales and desperate pleas by criminal’s families for prison time so their loved one can get addiction counselling. These stories aren’t going away. Oxycodone is a huge problem for addicts. Moreover, newborn babies are being innocently caught up in opioids’ power too. Prescription drug abuse is not infrequent among moms-to-be. In fact, rates are increasing. Infants born to addicted mothers suffer from neonatal abstinence syndrome where baby is effectively in withdrawal after birth, craving the opioid taken by mom. These newborns are irritable, jittery, breathing quickly and feverish. First, doctors try non-pharmacological interventions like keeping baby in a calm, dark, quiet room with soothing by mom. Sometimes, they also have to use morphine to manage baby’s pain and distress until it’s weaned off its craving, mom’s opioid. These infants are monitored closely in the neonatal intensive care unit. This has crept up on physicians over the last decade, many of whom didn't have any medical training in this area. Now, they’re gaining expertise and even getting used to seeing pregnant women in this situation. Methadone, another opioid, offers some optimism through harm reduction programs. Ideally, mom wouldn't be on any opioids, but at least methadone gives her a chance for a healthy pregnancy. For addicts, oxycodone withdrawal can mean vomiting, unremitting tummy pain, severe agitation, insomnia and the unending quest for more oxycodone. Methadone can treat these symptoms, and expecting moms enrolled in harm reduction programs get it regularly from pharmacists who dispense doctors’ prescriptions. The idea is that instead of spending every day looking for the medication, and wondering how she’ll get and pay for it, mom knows exactly when she’ll have her next dose. This means women can focus on staying well. Fear of losing her family Now, some methadone moms are having healthy pregnancies and healthy babies who go home with them and breastfeed. The challenge however, is getting more mothers to admit their problem and then ask for addiction help. This isn’t an easy step though, since it’s attached to guilt and shame. Moms with other children may fear losing them, and worry about how they'll be viewed. It takes a lot of strength to see beyond peoples’ negative reactions and judgments, and make baby’s health the top priority. Hospitals are supposed to promote health, but are they actually sending mixed messages when it comes to human vice? Burgers, fries and soda have inundated North America even in the most unlikely places.
In fact, there’s always time to fuel your ‘Big Mac’, ‘large Coke’, or ‘Double Cream Double Sugar’ addictions, including inside hospitals. The irony is, fast-food outlets don’t force their way in. McDonald’s and Dunkin’ Donuts (or Tim Horton’s in Canada) wouldn’t be there without hospital approval. If you didn’t know you were in a hospital, you certainly wouldn’t be able to tell from the food court. Actually, you would probably think you were at the mall. Paradoxically, hospitals are where we go to get healthy; to conquer diseases like cancer, diabetes and obesity. The food we eat plays an important role in our health. This is particularly true for children whose bodies are still developing. However, paediatric hospitals are among the worst offenders. Florida’s Shands Children’s Hospital has five fast-food restaurants. Hospitals are often upsetting places, but don’t we have an obligation to behave more responsibly than this? Why are we comforting patients and their families with unhealthy comfort food that we know is directly linked to the diabetes and obesity epidemics plaguing our country? Fast-food places keep hospitals in the black, but isn’t this a conflict of interest? It’s a very mixed message that you’re not supposed to eat Wendy’s or McDonalds, but when doing so helps your local hospital’s budget it’s okay. In other words, we want you to curb your unhealthy impulses, but we’ll look the other way when it’s good for the bottom line. Sometimes we’ll even endorse your vice if that’s the lesser of two evils. There’s no place for fast-food in hospitals because these chains aren’t interested in health. They’re profit driven instead. The recent measles outbreaks in Canada and the U.S. raise some important questions.
What are the responsibilities of editors and journalists when it comes to science-based topics? Those, like vaccines, rooted in scientific fact? Do they too deserve the balance we conventionally consider our journalistic standard? After all, are such stories really a debate? The scientist in me wishes media outlets would stop giving anti-vaxxers opportunities to broadcast untruths to others. The vaccine “debate” is an example of a dialogue where both sides should not be given equal podium time and benefit of doubt. Vaccines need to be framed differently. Rather than, ‘We are going to hear from someone in favour of vaccination’—which is like believing in Thursdays if they are something you have to believe in—and then, ‘We are going to hear from someone against vaccination’—which makes it seem like this is an even-handed subject—we should instead discuss it as a human-interest piece; ‘Why do anti-vaxxers think this way? Why don’t they immunize their children? What are the risks?’ Putting the “pro-vaxxers” and the “anti-vaxxers” head-to-head establishes an inaccurate equivalence. Editors strive to create balance and avoid bias. Vaccination is not a question of equilibrium however, because there is nothing to equalize. One side is a thousand-ton brick, and the other a feather. Creating parity between them is impossible. Newspapers and the radio think they are engaging lively debate by including different opinions, but sometimes there is no debate. Often, journalists’ role is to question the status quo. Despite the public’s right to do so, in the context of science, sometimes we should simply accept the facts. Vaccines are one of medicine’s greatest accomplishments. They have eradicated contagious, disfiguring and often deadly diseases like smallpox that plagued humans for thousands of years. Hard evidence over decades exists that is easy to access. If you google, ‘Does the MMR vaccine cause autism?’ and open any evidence-based health page, the answer is a resounding ‘No.’ If you then dig deeper, into someone’s personal Facebook page or blog perhaps, you will find the anecdotal evidence to the contrary. To me, those things are not equivalent. Vaccination is science, not a political debate. Vaccines are not like discussing foreign policy where one or two or seven or nine opinions might be equally valid. Scientific consensus exists, and then there is anecdotalism that blatantly deviates from that consensus. It is not that I do not want to debate. When considering vaccines however, it is about how and what to debate. When someone gets cancer we want to know why. We want to believe there's a reason.
However, according to a study by oncologist Dr. Bert Vogelstein and biomathematician Cristian Tomasetti at Johns Hopkins published in the journal Science last month, the explanation is more like losing the lottery—often the real reason is not because you didn't behave well or were exposed to something harmful in your environment, it's just because you were unlucky. In fact, Vogelstein and Tomasetti found that two-thirds of cancers could be attributed to bad luck rather than heredity or our environment. This bad luck presents itself as random DNA mutations, which accumulate in our bodies as our cells divide and appear to be responsible for several cancers. Actually, 22 of the 31 these researchers looked at, including leukemia, bone, brain, ovarian, pancreatic and testicular cancer, were essentially due to biological bad luck (random mutations). Heredity and environmental factors like carcinogen exposure played a more significant role in the other nine types, including colorectal, skin and smoking-related lung cancer. Early detection in research Overall, Vogelstein and Tomasetti attributed 65 per cent of cancer incidence to these random gene mutations, which can drive cancer growth. There’s no particular reason for these harmful mutations aside from randomness as our stem cells divide. These results suggest that lifestyle changes like quitting smoking might help prevent some cancers, but may not affect others. Therefore, more research and resources need to focus on finding ways to detect these cancers early when they’re still curable. Vogelstein and Tomasetti did not cover all cancers. They excluded breast and prostate because of unreliable stem cell division rates. |
AuthorDr. Clea Machold Archives
March 2016
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