Whisper to Shout
Raising the Volume on Patient Advocacy and Engagement
BY ERIN HOWE
When Gary Bloch was a young doctor, he assumed that if an illness could be treated, his patients would get better. But years of working with low-income Torontonians have taught him that poverty is a serious barrier to good health.
“I wasn’t really seeing health improve even though I was following all the guidelines, giving patients all the right tests and prescriptions,” recalls Bloch, an Assistant Professor in the Department of Family and Community Medicine and Staff Physician at St. Michael’s Hospital. “As I started to dive deeper into my patients’ social situations, I came to understand what they were saying. Poverty was the biggest factor in their lives.”
Bloch has seen how sick buildings and bad air contribute to asthma, and how cheap, unhealthy food leads to obesity and heart disease — which are avoidable if you have the means to afford other options and treatable if you have the money to pay for the drugs.
Studies have shown the role income plays in many major diseases and chronic conditions like diabetes, heart disease and acute illnesses. As well, people living in poverty tend to become sick more frequently than people with more money. They also experience more accidents and trauma, and have lower life expectancies than the general population.
That’s why the family physician has become an advocate for much more than just his patients’ personal health.
These days, Bloch counsels low-income patients not just to take their medications, but also to file their tax returns to receive benefits and credits. He’s also well-versed in the intricacies of income support, welfare and disability support systems.
These are some of the ways Bloch puts his patients at the centre of care and helps empower them to improve their circumstances. But he also believes that part of his job is to share what he knows about poverty and health with medical students, government — anyone who can make change.
“The reality is that changes aren’t going to come from the one-on-one interactions,” says Bloch. “And that’s true of anything, that’s true of smoking, of things like getting people to wear seatbelts. It’s a real public health issue and we can deal with these things on an individual level, but we also have to deal with them on the higher level.”
When he teaches, Bloch builds upon the idea that physicians should ask about their patients’ individual stories, life situations, social supports, housing and income. And he advocates for changes that could benefit low-income populations across Ontario, helping to found Inner City Health Associates, a group of doctors working with the homeless as well as an advocacy group called Health Providers against Poverty.
Engaging Patients Everywhere
Just as there can be no “one size fits all” approach to medicine, there is a range of ways some physicians are educating and empowering people to improve their own health.
Mike Evans is encouraging people to make positive behaviour changes with health messages that reach people where they are and in engaging formats that allow people to share — what he calls healthy viruses. This includes his well-known whiteboard video series, particularly one called 23 and 1/2 hours: What is the single best thing we can do for our health? The video illustrates the benefits of just 30 minutes of daily, physical activity and has racked up more than four million views on YouTube since it was posted nearly three years ago. His Med School for the Public on YouTube has had over 10 million views with topics ranging from hip and knee replacement to stress management to the early childhood brain.
“The reality is that we can give people all the knowledge we want, but until we engage them, it’s really hard to start the process of change,” says Evans, an Associate Professor in the Department of Family and Community Medicine as well as U of T’s first Chair of Patient Engagement in Childhood Nutrition.
The message may be timeless, but the medium is expanding from the one-directional doctor-to-patient communication to peer-to-peer health care. “Most care happens at people’s homes, not in clinics or hospitals, and I happen to think the public is our biggest missing health workforce — a workforce we need to mobilize.”
“Most of us are part of social networks, in both the old and new senses of the word,” says Evans, who creates his videos with the help of filmmakers, designers and other experts and clinicians. “Your friend is much more likely to open a story or video that comes from you, rather than something that comes from a corporation. Stories trump data, and our task is to storify evidence in such an engaging way that people push the share button.”
“We Have a Voice We Can Do Something With”
Students have proven successful at that effort. Many at the Faculty of Medicine are keenly aware of the idea that improving health extends beyond the exam table.
“Medicine doesn’t begin and end in a hospital office,” says Phillip Gregoire, a second year undergraduate medical student.
Earlier this year, Gregoire and two of his classmates started a petition asking the Toronto Police Service to stop automatically reporting suicide attempt records to the Canadian Police Information Centre.
He was inspired by the Ontario Privacy Commissioner’s request for police services across the province to put an end to the practise.
“We’d been learning a lot of about social determinants of health, and this seemed like a clear policy issue that was going to dissuade patients from receiving the care they need because of a fear that this kind of mark on their record could prevent them from doing things like cross the border or getting a job.”
Recognizing that many people see health professionals as having a privileged place within society, Gregoire says he and his fellow MD students need to use their position for good.
“We have a voice we can do something with. And we should use it for a good cause,” says Gregoire. “It’s important to step back and look at the bigger picture and ask, how are the decisions that are being made affecting this patient, and is there something I can do about that?”
“A lot of us went into medical school because we wanted to provide a service to the community and especially help people who are marginalized, or have difficulty accessing health care,” says student Emily Stewart. “So when there are opportunities to stand up for people whose voices might not otherwise be heard, it’s a rewarding reminder of why we are here.”
Stewart was one of about 30 medical students who picketed outside on one of the coldest days last winter, urging then-Health Minster Deb Matthews to fill the gap in health care coverage that resulted from federal cuts to care for refugees.
She helps teach at refugee shelters with the University of Toronto International Health Program, sharing information about how to shop for inexpensive food or how to survive winter. She has also volunteered for iREACH, an initiative launched in 2012 by medical students who wanted to help marginalized and vulnerable groups. Volunteers in that program provide translation, medical history taking and educational workshops for immigrants and refugees.
These examples of advocacy are driven largely by compassion. But Brian Hodges, a Professor in the Department of Psychiatry, argues that while both caring and advocacy are important, each is a separate competency.
“Caring is traditionally understood by most of us as being about the patient and family relationship,” he explains. Advocacy exists at a larger level.
“There is a perception that caring is easily lost today for a number of reasons, partly because of the rise of the technical sides of health care. The predominance of new and exciting tools, like electronic patient records, and the drive for efficiency are examples of the things that can challenge us to sustain a compassionate, caring environment.”
Hodges leads the Phoenix Project, sponsored by Associated Medical Services (AMS), a charitable organization. The five-year project’s aim is to help health professionals balance compassion and technical expertise.
The group helps professionals create more supportive teaching and clinical environments and awards grants to advance increased understanding of compassionate, patient-centred care.
As the Vice-President of Education at University Health Network, Hodges also oversees clinical education for about 6,500 students each year, and says the organization works to create an environment that models these essential elements of working in the health professions.
“To my mind,” says Hodges, “there’s no such thing, as a competent health professional who is not caring and compassionate.”