Tag Archives: Kirsten Patrick

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Kirsten Patrick is Deputy Editor at CMAJ

 

Today is a momentous day for physicians in Canada. No matter what your opinion about whether or not physician assisted dying is morally right, it will be a human right henceforth under certain circumstances.

We have aired a broad spectrum of views on this forum in the lead up to the Supreme Court of Canada’s unanimous decision on Carter vs. the Attorney General, released this morning. Even CMAJ’s editors are divided in their personal opinions. We have discussed our personal views in many an editorial meeting, and CMAJ’s Editor-In-Chief, John Fletcher, put me on the spot to declare my position publicly when we were recording the podcast for the November 18th issue of the journal.

Many Canadian physicians will feel unhappy about the decision, perhaps even angry ...continue reading

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Kirsten Patrick is Deputy Editor at CMAJ

 

Yesterday, after a long public consultation by the Human Fertility and Embryology Authority and a heated debate and vote in the English House of Commons, it began to seem likely that the UK will be the first country to allow the practice of mitochondrial transfer (albeit with safeguards). If the House of Lords approves it, this will result in an amendment to the UK’s 2008 law regulating IVF, embryological manipulation and pre-implantation genetic therapies. We’re effectively seeing glimmerings of a green light for the creation of ‘three-parent babies’ in the UK.

I've been following this process closely. Once I understood the reason WHY mitochondrial transfer is important in the prevention of certain serious diseases of mitochondrial DNA, I felt convinced that legalising it was the right thing to do. ...continue reading

Kirsten_headshotKirsten Patrick is Deputy Editor at CMAJ

 

Today, 12/12/14, sees 533 partners in 103 countries participating in events to mark the first ever World Universal Health Coverage Day.

Supported by a grant from the Rockefeller Foundation,  12/12 marks the anniversary of the unanimous UN resolution, 2 years ago, that endorsed Universal Health Coverage as a priority for sustainable development.

The aim is to highlight the need to improve the effectiveness and accessibility of heath care worldwide. Why? As this (slightly UK-focused) video from the London School of Hygiene and Tropical Medicine elegantly illustrates ...continue reading

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Kirsten_headshotKirsten Patrick is Deputy Editor at CMAJ

 

There's a quote from the film 'When Harry Met Sally', (Meg Ryan, Billy Crystal) that I always thought was rather profound. One of the supporting characters, a writer, says,

Restaurants are to people in the eighties what theatre was to people in the sixties.

That dates the movie, and me, but how much more true it is now, I think. In the past three or four decades food has come to define us socially and has evolved into entertainment more and more.

Earlier this week Dr John Fletcher and I published an editorial in CMAJ called 'A political prescription is needed to treat obesity', which garnered some criticism from two high profile Canadian bloggers. Dr Brian Goldman of CBC's "White Coat Black Art", only mildly critical, suggested that the idea of a donut tax was impractical given the ease of cross border shopping for Canadians. Dr Arya Sharma, who writes the daily blog "Dr Sharma's Obesity Notes", was far more derisive . Dr Sharma misinterprets our editorial and suggests that we are naively arguing that taxation and regulation of  high-calorie and nutrient-poor food products is the ONLY viable approach to the obesity epidemic. Which, clearly, it is not. We are in no way in denial about the need for a multi-pronged, multi-generational approach in response to rising obesity.  In fact, perhaps Dr Sharma did not read the whole editorial before pronouncing judgement as we clearly state: "Strategies that include individual interventions, school-based nutrition and activity interventions, incentives for active commuting and changes to thebuilt environment should continue; however, we also need robust ways to restrict portion sizes and reduce the sale of sugar-sweetened beverages and other high-calorie, nutrient-poor food products."

The problem of population level obesity is multifactorial and has been decades in evolution. Political solutions that involve laws and taxation will take years to show benefits - and obviously effective treatment and lifestyle-choice solutions will continue to be necessary. But that does not mean that we shouldn't back political solutions as part of a more comprehensive strategy for treating obesity and NCDs in the longer term. ...continue reading

Kirsten_headshotKirsten Patrick is a deputy editor at CMAJ

 

Health care professionals need to learn to do more to encourage self-expression in healing.

Watching Friday’s TEDMED session entitled ‘Weird and Wonderful’ I was humbled by talks by two non-medics who have done wonderful creative things that have vastly improved the lives of patients.

First up was Bob Carey. I had never heard of Bob Carey before – WHY had I never heard of Bob Carey before? – so I was surprised to see a middle-aged man standing on the TEDMED stage in a pink tutu and nothing else. He said, “I’m a commercial photographer …and I have been photographing myself for over 20 years as a form of self-therapy because that’s what I do; when things get hard I go take pictures of myself…and it’s a lot cheaper than real therapy...” He transforms himself through photography into something that he is ‘not’ and that helps him to get out of himself, he says. In 2003 his wife, Linda, was diagnosed with an aggressive form of breast cancer and Bob started to take pictures of himself wearing a pink tutu in beautiful landscapes. What started out as a way of expressing his inner discomfort and difficult feelings and sharing his wife’s experience, grew, through self-publication of a book, into the Tutu Project. ...continue reading

Kirsten_headshotKirsten Patrick is deputy editor at CMAJ

Breastfeeding? Really? At TEDMED? C’mon breastfeeding is as old as humanity and we know everything there is to know about its benefits (just not how to make moms stick to it), right? How did breastfeeding end up as a topic of a TEDMED talk in a session called ‘TURN IT UPSIDE DOWN’ that I live-streamed this morning?

Well, as the speaker, Eleanor 'Bimla' Schwarz, pointed out we’ve been missing a trick in our thinking and communicating about the benefits of breastfeeding. We’ve been talking all about the benefits for the baby but we've failed to move beyond "it helps you lose the baby weight" when it comes to talking up the benefits for mom. ...continue reading

Kirsten_headshotKirsten Patrick is a Deputy Editor at CMAJ, currently at the IEA World Congress of Epidemiology in Anchorage, Alaska

 

The 20th International Epidemiology Association World Congress being held in Anchorage, Alaska, this week is focusing on global epidemiology in a changing environment, and particularly, delegates are discussing and learning about the epidemiological effects of climate change. While much research being presented in concurrent sessions and posters is the usual mix of national and regional epidemiology (infectious diseases, nutritional diseases, cancer…), and epidemiological methods research (always interesting to a journal editor), the ‘circumpolar perspective’ is the subject of many sessions. What is happening in the world’s frozen regions as a result of climate change?

It may or may not surprise you to hear that people who live in areas that are frozen year-round aren’t high-fiving each other about the mean increase in temperature of 3°C. They aren’t throwing off their traditional fur clothing in celebration. This is because communities are being destroyed by warming in polar regions. ...continue reading

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Kirsten Patrick is a Deputy Editor at CMAJ

I’ve come back to competitive swimming in the last couple of years, as a Master. Although I enjoyed a youth spent in the water, I can't fully identify with the T-shirt slogan I've seen this week, “I used to be faster; now I’m a Master!” I didn't find myself motivated to set competition goals when I was 14, sadly. Having had a pretty good 2013/14 training season I am about as fast as I was when I last competed as a teen. Last week I had the opportunity to compete in the 15th FINA World Masters Swimming Champs in Montreal, Canada, which someone told me is the largest aquatic event to be held in the Americas, ever.

While some things do not change – e.g. familiar anxiety, with its negative consequences – aches and pains are more worrisome than they were 25 years ago, ‘recovery’ is slower, and, since improving as you age is pretty unlikely, my main (and realistic) aim is to slow the rate of decline rather than to ride a trajectory of gradual improvement.

That said, this week, I’ve seen some truly inspiring swims, and also some nigh-unbelievable race times achieved by swimmers who are a lot older than me. The oldest participant in the 3km open water event was an incredible 87. The oldest participant in the pool swimming division was a 97 year old lady who had traveled from New Zealand! She looked 75. There were women in the 90+ category in all the swimming events INCLUDING the 400m individual medley and the 200m butterfly (in which one aged 90 set a new world record of 8min 52sec ....I couldn’t swim 200m fly NOW so the thought of swimming fly for nearly nine minutes at the age of 90 boggles the mind!). There were two 95-year-old men and there were men in the 90+ categories in most events. A lovely 87 year old man from my club competed and won a pair of silver medals. There were some pretty old participants in the diving category too. Scary to watch.

Looking at the results I can dream that if I work really hard at slowing the decline (to a rate of zero…okay who am I kidding?) I could, for example, swim the 200m individual medley in my current time at this meet in 20 years time – and medal!

Clearly these inspiring seniors are a healthy lot, enjoying the benefits of partaking in regular aerobic and strength-building exercise over many years. Yet it seemed to me that there are benefits of competitive/club exercise, aside from direct cardiovascular health related ones, when you are growing older. If you are introverted like me, being in a sports club helps you to connect with people in a less-stressful way than regular socializing. I see the power of the swim club in the way that the older members of my own swim club care for and encourage each other. I’ve seen it at the Masters Champs. Most people are not there to win, or to medal. Most are team mates who have made a journey half way around the world together. They have fun with each other and support each other, cheer each other on, say ‘Good job!’ even if a swimmer comes in way off their PB. At other, more accessible, events I have seen swimmers in the over-80-&-90 years age categories that are in wheelchairs on poolside, who can still swim a race and may hope to set a new record.

Heavy picOn the last weekend of #FINAMasters2014, we shared Parc Jean Drapeau with festival-goers attending the Heavy Montreal event. It made for an interesting contrast. Hundreds of lean, older, healthy, lightly clad athletes drinking fruit smoothies, alongside thousands of heavy metal fans wearing heavy jackets in the hot sun, arriving on Harleys, drinking mainly copious alcohol and filling the air with tobacco and marijuana smoke. Populations drawn from different demographics.

That got me thinking about the older competitive swimmer demographic, or at least the crowd that managed to get themselves to the World Champs. We’re looking at a privileged bunch – that much is clear. They have enough money to travel a long way to compete. They have enough leisure to put in hours and hours of training; many can afford to hire personal trainers to help them with land training as well as pay fees that come with Masters swim club membership (registration with a Masters club was a requirement for entry). Some could afford to bring their spouses and kids along too. I noticed that the only competitors who came from Africa were from South Africa and Egypt. The majority came from Canada (‘home country’) and the United States, with large contingents from wealthier European countries, Japan and Australia. South American countries were quite well represented. I didn’t see a single black person competing (although I’m not saying I saw every competitor), which seemed odd.

Kirsten competing in a relay event (centre)

Kirsten competing in a relay event (centre)

So when admiring the obviously superior health and wellbeing of Masters Swimmers, it is prudent to remember what’s known about the associations between socio-economic advantage, good health and longevity. I’m still in awe of the 80+ and 90+ year old swimmers who came to compete at Worlds this year. They are an inspiration. I hope to be a 90-year-old competitor myself someday. That’s a good intention to have. “If you can’t beat ‘em outlive ‘em,” they say 😉 Yet I recognize that alongside all effort of training hard and eating healthily, the long term health of my body depends on other factors, too, like my income, many childhood advantages, education, genetic factors, and luck. I’d like to develop another intention, too – to encourage people who don’t think swimming is ‘for them’ to try it. Hopefully, by the time I’m competing in the 80+ age groups, Masters swimming will represent a broader demographic.

Dr Patrick in action as a newly qualified physician working in an obstetric unit in rural South Africa

Dr Kirsten Patrick is Deputy Editor at CMAJ

Last week I was fortunate enough to be invited to a great workshop, organized by the CMA’s Public Health division, aimed at developing a unified policy and advocacy platform for humanitarian medicine. As the background reading material pointed out, many Canadian physicians are interested in participating in humanitarian medicine initiatives and work or volunteer abroad at different stages of their life and career. The problem is that many such activities are ad hoc, not optimally planned, fragmented, and undertaken without due consideration of their impact. The CMA hopes to co-ordinate efforts in Canada to explore and delineate best practices, and to optimize the way that global health activities are coordinated among NGOs, physicians, residents and medical students.

I’ve had some experience with developing guidelines for best practice during short term experiences in global health. In 2010 I was part of a group led by Jeremy Sugarman, professor of bioethics and medicine at Johns Hopkins, and John Crump, a professor at Duke’s Global Health Institute, that produced the first Open Access guidelines on Ethics and best practice guidelines for training experiences in global health. The first decade of the new century saw an explosion of global health programs that would send students and graduates for short term experiences, usually from a developed country to a less developed country (without much traffic in the other direction). To quote Sugarman, we now have a “stunning  prevalence  of  initiatives covering  a  broad range  of  activities,  institutions,  and  countries”, offered by “Governmental, Non-­‐governmental, Religious, Humanitarian relief, Academic and Professional [organizations].”

In the early 1990s, as a medical student in Johannesburg, South Africa, I spent some clinical rotations in Baragwanath Hospital in Soweto. There I met many foreign medical students (mainly German and British) who came to get 'developing world experience' (mostly of performing surgery that they would not get to perform at home). If they were keen and hung around long enough sooner or later they’d get to do an appendectomy, or a circumcision, or excise a lipoma the size of a baseball. Ethically sound behavior? Mmmm. Not so much.

But it isn't just students. Trained physicians from wealthy countries also go to less well developed areas to offer their skills. Historically the pattern was for physicians to pack up their lives and go to live and work in an under-served area for many years. Yet in the last few decades the ease with which air travel and temporary accommodation can be arranged has changed this pattern. Now the opportunity exists for physicians to keep their ‘developed world lives’ relatively intact while taking a short trip to ‘do good’ somewhere else.

Do they do good? That's the million dollar question. While they may be motivated by good intentions there is no clear evidence that such activities are beneficial in an enduring way to the host countries. An oft-quoted paper points out that there IS benefit for physician who goes abroad for the brief stint, both for that physician personally and for his/her home country (because such people are more likely to work in under-served areas back home in their future careers). Trainers from leading humanitarian organizations acknowledge that one thing we DO know for sure is that there is always some harm that comes from even the most well-intentioned of humanitarian missions (see list of resources below).

Some of the ethical considerations and potential negative consequences of short term global health experiences were outlined in an influential 2008 JAMA article. The cynical term ‘voluntourism’ is perhaps a realistic descriptor of such activities, given their clear benefit for the traveler and much less clear benefit for the receiving community.

I think there is a particular difficulty for many who are fired up by the noble desire to ‘do good’ or ‘make a difference’ to stop and think about potential negative consequences of their well-intentioned behavior. Because how could giving up one’s time for the good of others be bad? Yet it is probably ‘placebo’ at best as some have argued “don’t go”. But realistically, without some Icelandic volcanic ash scenario in which all airplanes out of North America and Europe are grounded, physicians will continue to go abroad on global health ‘missions’. The only thing that we can do is increase awareness of ethical concerns, encourage physicians and students to think about scenarios ahead of time and endeavor to educate, educate, educate…. in the hope that the harm done by people going on global health experiences and humanitarian missions can be minimized.

The CMA meeting’s participants were top notch, representing all the main stakeholders leading the way in humanitarian activities and global health electives in Canada and some international players, perhaps with the notable exception of experts from countries who receive medical humanitarian missions and voluntourists. The CMA will produce an official report at the end of the process. In the mean time here are some educational and support tools that may be helpful to those who are thinking of going abroad to ‘do good’ in a medical way.

  • The Johns Hopkins Berman Institute of Bioethics collaborated with the Stanford Center for Innovation in Global Health to produce an excellent case based online course on Ethical Challenges in Short-Term Global Health Training. [This course is based on the guidelines on Ethics and best practice guidelines for training experiences in global health I mentioned earlier; it is widely understood that case studies are the best tools to teach applied ethics…best for pre-departure training, but also useful as an in-field resource and to assist debrief after return.]
  • HumEthNet, a website that developed out of empirical research on the ethical dilemmas faced by humanitarian healthcare professionals working in humanitarian crises, disasters or areas of extreme poverty.
  • The McGill Humanitarian Studies initiative, which offers the Canadian Disaster and Humanitarian Response Training Programs that range from an introductory course to an advanced program that includes simulation training.
  • The 53rd week, a non-profit organization that aims to maximize the benefits derived from short-term volunteer initiatives using innovation, education, and research.

 

Kirsten_headshotby Kirsten Patrick, Deputy Editor, CMAJ, in Victoria, BC

Human beings are often difficult to fathom. In a lecture about the health effects (present and expected) of climate change, David Fisman, infectious disease physician and epidemiologist from the University of Toronto, pointed out that getting people to care about – and take action to reduce – climate change is tough. This is because human beings tend not to like long time horizons. We are consistently happier to have things now and make ‘payment’ later. Even when anyone with rudimentary imagination can, after being shown a little climate change data, see the likely catastrophic cost to human health of not pumping huge amounts of money into mitigating the effects of climate change NOW, we still collectively choose to do very little. The answer would seem to lie in learning how to influence deep-seated psychological desires, rather than trying to beat folks over the head with more data. Needless to say, Fisman’s lecture was scary, but he was preaching to the converted, at least with me. I was more scared when I learned about something I didn’t know a lot about: the nature of antibiotic use in animals.

Some would have us believe that rampant and indiscriminate use of antibiotics in the farming and veterinary sector is the reason we have such bad problems with antibiotic resistance. But it’s much more complex than that. According to Scott Weese of Guelph, ON, Professor at the Ontario Veterinary College and a Zoonotic Disease/Public health Microbiologist at the University of Guelph’s Centre for Public Health and Zoonoses. Weese cautioned against playing the futile cross-discipline blame game when talking about the problems facing antibiotic stewardship.

Antibiotics are widely used in animals for therapeutic indications, prophylaxis, disease control, growth promotion, and feed efficiency. Widely doesn’t cover it, though. We are talking tonnes and tonnes of antibiotics used in animals each year. Yet that doesn’t mean that the use of antibiotics in animals is always inappropriate. There are particular problems.

For one thing, there are many different groups involved in the 'veterinary’ sector, including farmers, food producers, owners and vets. So who drives or directs antibiotic use in animals? The answer is that all those stakeholders do. Economic factors drive food production, which mean that some antibiotics are preferred over others. For example, a dairy farmer will favour using a cephalosporin to treat illness in a herd because there will be no ‘milk withdrawal’ (prohibition of sale of milk for a month after treatment) as there is with other antibiotics. Farmers sometimes rely on heavy use of antibiotics as a crutch to support ‘factory farming’ and that is to be discouraged. That’s difficult to control, though, because antibiotics for animals are widely available for sale over the counter in North America.

Did you know that you can buy antibiotics for fish in a pet store? What’s more, if you want to avoid going to the vet for your sick dog you can buy fish antibiotics and then find an online tool to calculate the dose that you should give your dog! In the U.S. farmers can easily buy antibiotics for animals without limitation (as long as they use them according to label dosage). Conversely, the Canadian federal government controls the sale but, critically, not the use of antibiotics in animals. Canadian farmers can drive across the border, load up on over-the-counter antibiotics and feed them to their animals back home without fear of legal retribution. In fact the Ontario Medical Association called on the federal government to close this loophole last year.

Even the legal requirement for farmers to feed only the ‘on-label’ dose of antibiotic to animals in the U.S. is unhelpful. The ‘on-label’ dose is archaic, calculated when bugs were more sensitive to antibiotics than they are today. Farmers are forced by law, if they buy over-the-counter, to feed their animals sub-therapeutic doses of drug, which comes with its own set of problematic contributions to antibiotic resistance.

Much worse, though, is that many antibiotics marketed to farmers for animals come with claims to promote growth. Recently, however, the FDA released a list of companies and their antimicrobial products that will no longer be allowed to claim growth promotion, the administration of which will require veterinary oversight. This is welcomed by the American Veterinary Medical Association, yet the AMVA website still states that “There is little to no evidence that restricting or eliminating the use of antimicrobials in food-producing animals would improve human health or reduce the risk of antimicrobial resistance to humans”.

Scott Weese disagrees with this statement. The truth is that it is not clear, he says. Some drugs, some animals, some situations...but not all. We might balk at the sheer tonnage used, and without doubt we should try to use many fewer antibiotics in farming, but animals are different and looking only at antibiotic quantities used is not helpful. There are scant good data. There are conflicting data... conflicting claims, between bacteriae, between animal species, between drugs. What everyone seems to agree on now is that there is a need for more data – specifically good species-specific and drug-specific data that go beyond quantities of antibiotics used in animals.

We should not assume that the direction of travel of bacterial resistance is always from animals to humans. Weese described cases he had seen of companion animals picking up resistant bacterial infections from their humans, often owners who have been on long term antibiotics or who are immunocompromised. Bacterial resistance is a problem for all species and joined up efforts to control development of resistance are needed.

So what does Weese recommend? Don’t blame, either other stakeholders or poor data. Everyone can assume responsibility for good antibiotic stewardship, and everyone can be judicious with prescribing. Close legal loopholes, take growth promotion claims off labels, and collect decent epidemiological and usage data. Influence farmers to avoid using antibiotics as a crutch to support poor animal farming practice.  In Canada, a federal approach to regulating antibiotic use (rather than provincial policy-making) would help to facilitate working together across medical-agricultural-farming sectors.

Yes, I hear those of you who are shouting at the screen about how people successfully farm animals for meat that is ‘antibiotic free’ … people are happy to pay a higher price for this option so why not promote antibiotic-free farming? Weese pointed out that ‘antibiotic-free’ animals are routinely pumped full of zinc to control infections. Zinc is also antimicrobial, though, and has been associated with MRSA selection. And the effect of banning prophylactic tetracycline in food animals would be a bit like squeezing a balloon. If incident infection rates increased in animals as a result, more important drug classes would need to be used for treatment.

All of which brings me back to climate change and an obvious conclusion…. IF farming animals using routine antibiotics in feed worsens the problem of development of antibiotic resistant bacterial strains – and we don’t know for sure that it does because the data aren’t generally good – and IF tightly controlling and reducing antibiotic use in animal farming would drive up the cost of meat, then wouldn’t it seem obvious to put a lot of energy into convincing humans to eat Much Less meat? ...Which would also help a lot to reduce greenhouse gas emissions…? I’m just saying.

I know. It’s not about finding logical solutions. It’s about managing and influencing deep-seated psychological fears related to lost profits, lost livelihoods, and the perceived lowering of standards-of-living.