“If you’re not studying women at all, you’re biased”

Rehabilitation Science Graduate Students’ Union hosts panel discussion on brain health in women

“If you’re not studying women at all, you’re biased”

The Rehabilitation Science Graduate Students’ Union hosted its inaugural Speaker Series event to discuss women and brain health on March 25. The panel was held at the Rehabilitation Sciences Building.

Kyla Alsbury, PhD student in Rehabilitation Science, explained that the Speaker Series is a reincarnation of what was previously a monthly awareness project.

Mary Boulos, master’s student in Rehabilitation Science, hopes that these events will bridge the gap between research and the community.

“We’re doing research on these different diseases and disorders, but those findings aren’t being shared with the people who are most affected,” said Boulos. 

The goal of the event was to share research and engage with members of the community who are affected and ultimately better their health.

The speakers included Professor Gillian Einstein from the Department of Psychology and adjunct scientist at Women’s College Hospital, who discussed the relationship between sex, gender, and women’s brain health; Reema Shafi, a PhD candidate at the Rehabilitation Sciences Institute, who explained the vulnerability of women’s brain after concussions; and Melissa Biscardi, who recently completed her master’s degree and spoke about the endocrine reproductive health outcomes of women after brain injury.

Mental rotation differences between the sexes

Einstein explained that women’s brain health is important, simply put, because “thinking about… organisms [with XX chromosomes] brings new ideas.” Taking sex into account, Einstein said, “ensures that we can develop effective and safe treatments for  [people with XX chromosomes].”

There are differences in biology, such as phenotypic expression, gene expression and epigenetic signatures, and life experience, when comparing to organisms who possess XY chromosomes to those with XX.

Members of Einstein’s lab created an experiment to determine whether sex plays a role in mental rotation tasks and when transcognition is formed.

Different groups of people were asked to complete a Vandenberg and Kuse mental rotation task. People with XX chromosomes in the follicular and luteal stage of their menstrual cycle, female-to-male transgender people on testosterone hormone therapy, and people with XY chromosomes were asked to complete the task, which shows a 3D representation of an object. The subjects then had to match that impression to another one of the same object from a different angle. 

It was found that people with XX chromosomes at low estrogen states did as well as people with XY chromosomes and people with XX chromosomes on hormone therapy. Therefore, a sex-based difference in performance is seen in the luteal phase. They also discovered that the hormone therapy that female-to-male transgender subjects receive allows them to test as cisgender males.

Concussions and menopause

Biscardi discussed the state of menopause in women who suffered a traumatic brain injury.

She explained that “most women experience new onset of changes in menstruation despite being at least one year post-injury.”

Furthermore, in the tested sample, Biscardi found that menopause symptoms were more intense when compared to the general population.

As the symptoms of menopause and post-concussion are similar, Biscardi noted that investigation is needed to determine which symptoms are due to menopause and which are due to concussive effects.

Shafi explained that there is evidence of females experiencing vulnerability after a concussion due to a combination of factors such as structural disadvantages, which can affect cognitive processing after a concussion.

Following the speakers, there was a short panel discussion with questions from the audience.

Einstein explained that in terms of research funding, she finds a lack of understanding, saying that “if you’re only doing research in females, they really don’t know why you’re doing that.”

“Fifty per cent of the population is women,” said Shafi. “So if you’re not studying women at all, you’re biased [against] women. You have to have a reason to not study sex and gender.”

Moving toward trans-inclusive healthcare in Canada

U of T researchers advocate for affirming and personalized health care practice for LGBTQ+ individuals

Moving toward trans-inclusive healthcare in Canada

Canada’s transgender population continues to face challenges from transphobia and discrimination, which, among other factors, influences their health and development.

Recent efforts by the Canadian government and affiliated agencies address issues that LGBTQ+ communities face.

In 2016, the Canadian federal government passed Bill C-16, which amended the Canadian Human Rights Act to include gender identity and expression as one of the prohibited grounds of discrimination.

In the health care setting, LGBTQ+ individuals face multiple barriers that contribute to the disparities in the management and care of these individuals.

Alex Abramovich, Assistant Professor at the Dalla Lana School of Public Health and Independent Scientist at the Centre for Addiction and Mental Health (CAMH), has been studying the health care needs of LGBTQ+ youth for more than a decade.

From his experience working with young trans people, Abramovich wrote to The Varsity that this population has an unmet need for mental and physical care.

Many transgender individuals are “unable to come out and speak honestly about their identity and healthcare needs because they may not know whether or not it will be safe to do so,” wrote Abramovich, explaining how gender identity affects access to health care.

He added that some trans youth do not even have a family physician due to “previous experiences where their gender identity and sexual orientation were pathologized.”

To address the urgency for improved health care accessibility by trans populations, Abramovich recently co-authored an article in the Canadian Medical Association Journal (CMAJ) that provides comprehensive steps for physicians to follow to become more trans-inclusive and trans-competent.

One of the recommendations listed in the article was to privately ask all patients what name and pronoun they go by, instead of making assumptions based on perceptions of their voice, appearance, or name and sex listed on their health card.

Another key recommendation made in the article was to ensure that patients are addressed with a gender-affirming approach that does not view gender variance as pathological.

“These are just some of the things that health care professionals can implement immediately,” wrote Abramovich, expanding on the purpose of publishing such health care recommendations.

Staff Physician and Adolescent Medicine Specialist at St. Michael’s Hospital, Joey Bonifacio, argues in a review article recently published in CMAJ that adolescents’ mental health improves when they receive gender-affirming care.

Bonifacio mentions that primary care providers are equipped with some published medical guidelines on providing care for the transgender population. However, practice is hampered by a lack of experience and training in trans health issues.

He suggests that primary care providers support trans adolescents with gender dysphoria by facilitating discussions about the “timing of social transitioning, reviewing and overseeing the potential use of medical management, and connecting them with local community resources and supports.”

Besides improving the management and care of trans individuals, U of T-affiliated researchers suggest that routine data collection can “contribute to evolving norms in Canadian society regarding sexual orientation and gender identity.”

Currently, there is a lack of national and territorial data on trans populations, mainly because there is no standardized way of collecting and analyzing data about gender identity.

Andrew Pinto, Assistant Professor in the Department of Family and Community Medicine at U of T and Staff Physician at St. Michael’s Hospital, tackled this challenge with his research group by examining how Canadian patients react to being asked routinely about sexual orientation and gender identity.

By administering a sociodemographic survey of all patients in the waiting rooms of St. Michael’s Hospital on a regular basis and later conducting semi-structured interviews with 27 patients, Pinto and his research group found that the majority of patients appreciated the variety of options available for both the sexual orientation and gender identity questions.

However, some patients felt discomfort in answering such questions, and some felt that their identities were not reflected in the options despite efforts to provide diversity in survey responses.

Based on these research findings, the authors suggest that an open-ended option such as Identity not listed (please specify) could be included in addition to prespecified options. They also suggest that health care organizations should set the stage for asking these questions by explaining how the data will be used and ensuring that clinics are LGBTQ+-positive spaces.

Pinto and his colleagues hope that further research will be done in a variety of Canadian and international settings in consultation with LGBTQ+ communities, as such data can help organizations identify health inequities and build a framework with improved and inclusive care.

Bridging the technological divide in Canadian health care

Electronic Medical Records and patient care

Bridging the technological divide in Canadian health care

In Canada, a battle rages in health care. On one side stands a relatively stagnant health care system, already expensive but comparatively effective, with a legacy of poor technology integration. On the other side, investment in technology has the potential to not only reduce costs but also produce better patient care.  

Initially, further tech-focused investment would make health care even more expensive for the government. In Ontario alone, health care spending equates to 43.2 per cent of all provincial expenditures. Across Canada, health care amounts to about 11 per cent of gross domestic product (GDP), or $4,919 per year per person, as of this year. As a percentage of our GDP, we have the fourth most expensive social health care system of 28 comparatively wealthy countries, falling short of only Switzerland, France, and Norway. However, our above-average spending nets above-average results.

Compared to other wealthy nations, Canadians experience an above-average quality and quantity of health care. Canada consistently ranks highly on the majority indices that measure efficacy, despite having fewer physicians, long wait-times, and less equipment. Canada is ranked first at preventing and reversing debilitating illness, and also boasts above average cancer survivorship rates, above average healthy-age expectancies at 73.2 years, and above-average life expectancies at 81.9 years. These accomplishments have been achieved with our existing low-tech system. For example, we are without a consistent system and centralized database for recording personal medical information or automatically communicating medical files, at times even at the same hospital.

The adoption of Electronic Medical Records

To learn more about Canada’s relationship to health care technology, I investigated Canada’s partial adoption of Electronic Medical Records (EMRs). I spoke with Dr. Muhammad Mamdani, Director of the Li Ka Shing Centre for Healthcare Analytics Research and Training at St. Michael’s Hospital in Toronto; corresponded with Christina Christodoulakis, a PhD candidate in computer science at the University of Toronto; and interviewed Davey Hamada, a registered nurse in British Columbia.

According to Mamdani, “there seems to be a general consensus that the adoption of tech [into health care] is a good thing.” Christodoulakis’ U of T-based research reflects this: she found that in Canada, about seven per cent of tests are ordered because practitioners are unaware of already relevant results. A central database of EMRs that is used and updated consistently would solve this problem. The benefits of EMRs include improved speed of finding records, prevention of handwriting illegibility, aid in the early identification of diseases, assistance in targeting services based on risk, help with long-term monitoring of patients, and improved immunization consistency.

Hospitals and smaller family practices have been slowly and irregularly integrating EMRs for the past 30 years. Most of these earlier databases were designed by software engineers with little input from medical professionals. This meant that their software was not functional for practitioners — sometimes queries were too rigid or irrelevant information was readily displayed while critical information was hard to find. According to Christodoulakis, “some physicians reported that they sometimes stop using EMRs because hunting for menus and buttons disrupts the clinical encounter and hinders doctor-patient interaction.”

At present, software packages from different manufacturers seldom work together. Mamdani explained that “often patient records have to be printed out and delivered by mail.” This slows down the treatment process and further clogs the system. This lack of electronic communication also exists within institutions, where medical professionals print records for hand delivery. The poor integration of software and communication often opens the door for third-party organizations to perform patchwork to mend discontinuous records together, as is the case with Alberta Netcare and ConnectingOntario. But it is important to note that privatizing health care record management can carry serious consequences for patients and the health care system as a whole.

Though records are currently scattered among hard copies and various software, it is possible to unite the system. As Christodoulakis’ research notes, adopting or changing EMR systems requires “training, maintenance, IT support, system upgrade and data storage, governance and migration costs,” often too expensive a barrier for small and medium-sized institutions. Based on an estimate from 2010, the financial cost equates to $10 billion. But integration of an efficient database of medical records is just the tip of the iceberg.

Addressing the divide

According to Hamada, “health care providers have been in many ways slow to adapt to the technological boom.” He explained, “This is in part due to our education, which is lacking in any content regarding technological innovation and also the lack of foresight in the institutions that we work for.” Hamada’s workplace has not adopted EMRs, seldom uses software beyond email, and the state-of-the-art equipment he uses runs on an operating system that has not been supported since 2014.

For Hamada, adapting to changing tech is easy. But at his workplace, a recent change in the process of ordering porter services, or facility managers, continues to confuse many despite having support hotlines available throughout their upgrade. Mamdani and Christodoulakis both confirmed that some health care professionals are resistant to the technology making its debut in the health care system.

This is in part because people dislike change and re-learning concepts, but also due to a lack of transparency in data use. Hamada reports that at his workplace, data is collected but its use is a mystery. “In order for nurses to see data as a positive thing, there needs to be greater transparency and involvement around changes made based on evidence,” he said.

Mamdani, a renowned leader in health care, has emphasized facilitating communication between disciplines throughout his career. He integrates tech, economics, and data science into his team, and advocates for strong leaders to continue to bridge the technological gap. He believes that this systemic divide will continue to exist until teams learn to find a common language and talk to each other.

Mamdani’s team includes a few data scientists who work closely with health care professionals to build a data-friendly culture. Their research has been able to predict, with 80 per cent accuracy, the length of patient stays. Data science facilitates communication with the whole team and allows a more unified progression for the patient’s care. His team has also been able to predict trends in staffing, which saves approximately $200 million for St. Michael’s Hospital and could save up to $800 million for others.

Technological change, along with all of its benefits, comes with a very real cost. In Hamada’s workplace, the technology remains in the shadows because qualified health care professionals excel at what they are best at — taking care of people. The numbers show that Canadian health care is effective, even without consistent EMRs or databases that communicate. The cost of tech disturbs that status quo. But a centralized database would likely reduce redundancies in health care and improve efficiency. Advanced analytics has the strong potential to push our health care system to better look after us, especially as our population ages.

Improving outcomes and better integrating the health care system into the digital world is an important pursuit — but it must be checked with an emphasis on people and care over all else. In an ideal application, technology would and should improve our ability to take care of one another.

The Varsity has reached out to Campus Health Services, which declined the interview request, as well as the Gerstein Crisis Centre.

Free pharmacare — if you’re younger than 25

Is the new OHIP+ program really a step in the right direction?

Free pharmacare — if you’re younger than 25

If you were to ask random passersby for examples of distinctly Canadian things, you would be sure to collect an eclectic mish-mash of responses. These would likely be topped by maple syrup and hockey, perhaps with an honourable mention of colourful money and the CN Tower. Among these answers would likely be our universal healthcare system.

Given that nearly all developed nations, with the noticeable exception of the US, have adopted some form of free, accessible, universal healthcare, it may be considered odd that Canadians take such pride in a system that is not unique to them.

Statistics Canada reported in its 2013 General Social Survey that our health care system was our second greatest source of national pride, tied with Canada’s armed forces, with 64 per cent of Canadians polled reporting being proud of it.

Yet, despite the lavish praise, Canada’s national health care system lacks what many systems in other developed countries have: a subsidized prescription drug program.

Approximately one in 10 Canadians are forced to forego prescribed medication due to financial difficulties. Such difficulties are one of the many issues that the Government of Ontario chose to tackle in its 2017 budget with the introduction of the new OHIP+ program.

Having come into effect on January 1 of this year, OHIP+ provides more than 4,400 medications — that were only partially covered by the existing Ontario Drug Benefit plan — free of charge to anyone under the age of 25 in Ontario with a health card number.

“Young people aged 19-24 are less likely to have access to prescription drug coverage or the financial means to pay out-of-pocket due to higher unemployment and lower incomes,” wrote David Jensen from the Ministry of Health and Long Term Care’s Communications and Marketing Division. “The unemployment rate for youth (aged 15-24) in Ontario is almost three times higher than the unemployment rate for adults over the age of 25.”

Dr. Danielle Martin of U of T’s Institute of Health Policy, Management, and Evaluation and the university’s School of Public Policy and Governance sees OHIP+ as a step forward for the province.

“The introduction of OHIP+ is an amazing accomplishment for young people and their families in Ontario. Doctors often see families in our offices who cannot afford to pay for their prescription medicines, and sometimes those medicines are lifesaving or critical to a child or youth’s quality of life,” explained Martin.

Martin is one of the authors of the Pharmacare 2020 report, which calls for universal national coverage of some medications, and she has defended single-payer health care systems before the US Senate.

She made it clear, though, that this program is just the first step. “Covering prescription medicines for people up to age 25 is a critical step on the road to universal pharmacare in Canada, and it will make a big difference for a lot of people. Now we just need to close the gap between ages 25 and 65.”

Painting OHIP+ as the best step toward a universal pharmacare program is not the most accurate depiction. A recent Parliamentary Budget Officer report shows that introducing a fully universal program right off the bat would in fact be cheaper than OHIP+ in the long-term.

This has prompted some criticism of OHIP+. U of T’s Dr. Jessica Ross is among its critics, stating that “OHIP+ is a small step forward, but not a smart one” in an opinion piece published by the Toronto Star. Instead, Ross supports the adoption of free pharmacare for Ontarians of all ages.

There are also concerns about how the province will pay for OHIP+ — with a $465 million price tag, the expansion will not come cheap.

Despite being included in what the Liberal Party describes as a balanced budget, the $465 million figure is dubious, as a breakdown is not included in the budget document itself. This caused Ontario New Democratic Party leader Andrea Horwath to postulate that the expansion was a last-minute addition to the budget.

Regardless, the reception among some U of T students has been warm. “OHIP+ is a net positive for students everywhere,” said UTSU Vice-President Internal Daman Singh. “We expect it to complement the UTSU plan, and we don’t foresee any negative impact.”

The more cynical among us may wonder about the timing of the expansion. It is not out of line to think that the introduction of OHIP+, in conjunction with the minimum wage hike and recently improved OSAP benefits, is a play by the Liberals to woo young voters before the upcoming provincial election this summer.

How effective is this move? Only time — and the ballot boxes — will tell.

An international student’s perspective on the Canadian healthcare system

International healthcare debates can put benefits, drawbacks of Canada’s approach in perspective

An international student’s perspective on the Canadian healthcare system

It is common for strangers in a foreign land to feel disinclined to critique its customs and practices. Sharing my experience with the Canadian healthcare system here makes me an exception to the rule.

Discussions about healthcare in Canada often focus predominantly on the strengths of the current system, particularly when compared to complementary systems around the world. As the debate around healthcare rages on in the United States, many references are made to the successful Canadian alternative. Nevertheless, significant evidence suggests that the system is not as flawless as it is made to appear.

In August 2016, I rushed to the emergency room at Mount Sinai Hospital. As a result of a freak accident, I had gotten a papercut in my eye. I found a receptionist behind a desk and a couple of doctors in the hallway, all of whom seemed utterly unaffected by my red eye and tearful pleas for urgent help. The fact that I waited for two and a half hours to receive medical attention was an unexpected surprise — I had heard many people speak highly of the Canadian healthcare system in the past.

Dr. Andreas Laupacis, Executive Director of the Li Ka Shing Knowledge Institute at St. Michael’s Hospital, wrote an article in the Toronto Star that accurately sums up my experience. Laupacis argues that the staff within the medical system have become so accustomed to the endless waiting line within and outside the ER that they have become desensitized to its heartbreaking impact on patients.  

Unaffected staff seem to be the just the tip of the iceberg that plagues the Canadian healthcare system. It is also extremely difficult to book an appointment the day a medical problem occurs, or even on the day after. Furthermore, timely access to specialists for patients seems like a luxury. The problem is further compounded because long-term medical care facilities, such as hospitals and nursing homes, are overburdened, while home care options for patients are limited. This creates a vicious cycle — patients who require a lower degree of care cannot leave the healthcare system, while others in need cannot enter it.

As illustrated by my experience, and those of many others, the Canadian system faces some serious problems that need to be addressed. At the same time, if we are to engage in a balanced, productive debate about healthcare reform, it is also important to acknowledge what Canada is doing right.

Notably, I cannot help but admire the principle of universal, equal access to medical care. When compared to the developing world, Canada’s system becomes even more pronounced. In my home country, India, for example, an underfunded and inadequately staffed public healthcare system makes access to proper medical care extremely difficult for most people.

There are also some things that the United States can learn from Canada. In the context of the present debate on healthcare accessibility, the best example is the principle of universal coverage. The Patient Protection and Affordable Care Act, more commonly known as “Obamacare,” reflects this principle to a degree, given that the act expanded the scope of Medicaid to adults who could not afford adequate healthcare and made universal health insurance mandatory. However, The Republican Party, who currently hold a majority in both the House of Representatives and Senate, want to overturn this legislation on the grounds that it hinders job creation and burdens too many business enterprises.

This also raises several questions about how public healthcare should be managed, the most of important of which was whether it should be publicly or privately insured. In the US, as in India, private insurance companies dominate the healthcare sector.  To remedy this, Obamacare made it illegal for private insurance providers to deny coverage to those insured based on pre-existing terms and conditions included in policy documents.

Though many people in Canada also have private health insurance, most Canadians are not dependent on their employers for the healthcare benefits and security they need, unlike their American counterparts. It is incredible to me that the medical costs of Canadian citizens and permanent residents are covered by taxes paid to the government. This means that the average Canadian pays less than the average, insured American for the healthcare they receive. Even international students attending Canadian post-secondary institutions in Ontario are covered by the University Health Insurance Plan.

Moreover, the federal government subsidizes the cost of several non-prescription medical drugs. The flip side of this is that prescription drugs in the country are exorbitantly priced,  making them inaccessible for many people. The CBC estimates that Canadians wasted approximately $15 billion — of $81 billion spent — on prescription drugs in the last five years.

The divergences in healthcare regulation strategies adopted by Canada, the US, and India shed light on the fundamental question of how to make access to healthcare simultaneously efficient and low-cost. There is little difference between Canada and the US in this regard: a study conducted by the Commonwealth Fund placed the Canadian healthcare system ninth out of the 11 developed countries surveyed, while the American system ranked 11th.

This indicates that both systems yield inefficient results, despite being driven by different economic principles. Furthermore, the case of uninsured prescription drugs shows that economic barriers can sometimes make healthcare just as inaccessible in Canada as it is in the US.

Considering Canada in international context is beneficial, for there is much that Canada can learn from ongoing healthcare debates. For one, the American example shows us that policy changes in healthcare cannot be made suddenly, which is something the Canadian government must realize when it modifies the existing system.

Ultimately, the Canadian healthcare system is a mixed bag of benefits and drawbacks — all of which must be acknowledged if we are truly committed to improving our system. When we have conversations about healthcare in Canada, we should adopt a balanced perspective or risk disregarding the areas that are most in need of reform.

Rohit Khanna, writing for The Walrus, observes that “Healthcare becomes the embodiment of a nation,” and therefore it too, must be looked after. The alternative is painful, hazardous disillusionment.  

 

Sonali Gill is an incoming fourth-year student at St. Michael’s College studying Criminology and International Relations.