It was March 2021, weeks before the due date of Professor Sarah Levitt’s first child.
Levitt (MD ’15), an assistant professor in the Temerty Faculty of Medicine’s Department of Psychiatry, was deep in the “rabbit hole” of seemingly endless diaper options.
For Levitt — who is concerned about the climate crisis threatening planetary health — deciding which diaper option would be the least environmentally harmful was confusing.
And who hasn’t been anxious about making a decision?
After 15 months of pandemic life, each and every one of us has had to grapple with their life choices. Welcome to the Age of Anxiety.
Like: How to avoid getting COVID-19? How to minimize environmental degradation? How to navigate our increasingly complex world?
For Levitt, when approaching a situation fraught with anxiety, such as determining the best diaper solution, the challenge requires a flexible attitude.
What if . . . anxiety wasn’t all bad? Could anxiety, in fact, be valuable as a driver of change, safety and health, and even evolution?
Levitt educates psychiatrists on how to address climate anxiety, and tells her own patients that environmental threats have made her feel fearful, lonely and guilty.
“Our society is wary of what we consider to be negative emotions,” says Levitt, who is also a psychiatrist at University Health Network and a member of the Canadian Climate Psychiatry Alliance.
“We’re taught: ‘You should be happy,’ and ‘Everything should be good all the time.’ That can be a really harmful narrative. It’s important to teach people that it’s OK to be anxious sometimes. Anxiety can teach you something about an experience that you’re in, as long as it’s not functionally impairing you and making your life smaller.”
It’s a timely message during the pandemic.
While previous epidemics and natural crises provide some insights into how the pandemic can negatively influence mental health, this pandemic has been an outlier in a key way, explains Professor Sanjeev Sockalingam (PGME ’08), the Vice-President of Education and a clinician-scientist at the Centre for Addiction and Mental Health, and a professor in Temerty Medicine’s Department of Psychiatry.
“We haven’t had single peaks as with most pandemics. It’s been more than a year of peaks and valleys,” he explains.
Each peak brings renewed mental-health concerns, and research indicates that negative impacts could linger for years, he says.
Medicine needs anxiety
Good medical care requires some anxiety.
“The more I’ve reflected on it, the more positive I feel about anxiety,” says Professor Jodi Lofchy (MD ’84, PGME ’90), the Interim Chief and Medical Director of Psychiatry at St. Joseph’s Health Centre, and an associate professor in the Faculty’s Department of Psychiatry.
“We use anxiety to inform our practice and make sure that we’re safe, our teams are safe, and our patients are safe,” explains Lofchy, who trains doctors in how to respond to agitated patients.
Strategies range from identifying potential risks – dangling earrings when grasped by a distressed patient can become weapons – to heeding intuitive responses.
“Follow your gut,” she advises.
Proper medical responses require vigilance, something Professor Zainab Abdurrahman (MD ’07), a clinical immunologist and allergist in Mississauga and at McMaster Children’s Hospital in Hamilton, calls the positive result of anxiety.
She regularly explains how to keep young children safe from potentially life-threatening allergic reactions, while informing parents and caregivers that the chances of death are often much lower than assumed.
“Education is key,” says Abdurrahman, who is also an adjunct assistant clinical professor in McMaster University’s Department of Pediatrics.
“I’m always trying to figure out with each person what their big fear is. It’s different for everybody.”
Relational causes of anxiety
One of the most important, but often least discussed, contributors to anxiety is interpersonal relationships.
While maintaining proper diet, sleep, exercise and taking appropriate medications, when necessary, can help alleviate some symptoms, it’s “crucial” to understand how relationships affect anxiety, says Professor Robert Maunder (MD ’84, PGME ’89), a psychiatrist at Mount Sinai Hospital and a professor in the Faculty’s Department of Psychiatry.
Relationships include some discomfort, he says, but they also provide security.
“To be engaged with other people who matter to you involves apprehension,” he explains. “It involves anticipating bad outcomes, trying to avoid them and working to improve things. A relationship without anxiety is kind of a non-relationship.”
No individual can completely control a relationship.
“It is under your influence but not under your control,” says Maunder. “Doctors can’t necessarily fix someone’s grief or loneliness. There’s lots of things in medicine we can’t solve. But, we can still certainly tend to them.”
Non-medical supports
That could include advocating for better non-medical supports.
“The pandemic has affected some people disproportionately,” says Saadia Sediqzadah (PGME ‘2020), a psychiatrist and clinician investigator at St. Michael’s Hospital.
Many of Sediqzadah’s patients experience homelessness because mental illness makes it hard for them to find and retain employment. Yet many people who don’t have these illnesses have suddenly lost jobs during the pandemic and needed government assistance. Her patients have long relied on fewer government supports during similar situations, she says.
“They often feel left behind,” Sediqzadah reflects. “It makes them feel less alone knowing that others are going through difficulties that they have been experiencing for years.”
Building community with like-minded people
In-person social networks are crucial for good health.
Encouragement from others is key for helping people complete meaningful tasks and fulfil roles successfully, says Bonnie Kirsh (OT ’77, MEd ‘83, PhD ’99), a professor in the Faculty’s Department of Occupational Science & Occupational Therapy.
“Discomfort or lack of fit between people and their worlds in real and ambiguous ways” creates anxiety, she says.
“That can lead people to think carefully about how to avoid that lack of fit or that danger ahead and create new ways of addressing the challenges so that danger or discomfort can be avoided. It can lead people to very innovative thinking and experimentation and problem-solving,” says Professor Kirsh.
Increased anxiety may also change how physicians support each other.
Early in 2021, Julie Maggi (PGME ’03, MSc ’04) was named the Director of Faculty Wellness at the Faculty.
Maggi says she’s excited to help “create a really strong leadership team that can help guide and shepherd the department.”
She knows how beneficial that is.
When the COVID-19 pandemic began, her colleagues covered her emergency room shifts so she could help her elementary school-aged son adjust to virtual school and move her clinics online. It was a “buffer,” she says, noting that the support made her want to help others later.
Doctors can still create a strong community for each other, even if they’ll “never replicate the doctors’ lounge,” Maggi says.
Doing your best
Levitt understands the benefits of making decisions within a community, even when it’s uncomfortable.
She says, for example, the process of choosing to become a parent was “a really, really hard decision,” even though she’s thrilled about the baby.
“I still sometimes feel quite anxious about what might happen to the world that this child is coming into. You want what’s best for your kid; you need the environment to be better,” she says.
So for Levitt, participating in advocacy efforts, such as speaking to her city councillor about environmental policy, has helped her manage her anxiety.
“I’m lucky enough to have agency over my own behaviour and choices,” she says. ◂
It was 2017, and Aleks Ivovic had just finished his PhD in physiology at U of T.
His research was deeply personal.
Diagnosed with type 1 diabetes at the age of eight, Ivovic (BSc ’11, PhD ’17) studied how the innate immune system might affect cells involved in the disease.
He hoped his research would open new avenues for both prevention and treatment.
But midway through graduate school, Ivovic learned about a small wearable device known as a continuous glucose monitor, or CGM.
CGMs automatically monitor and record a person’s blood sugar level every five minutes. If an adjustment is needed, an alarm sounds. For Ivovic, it would be far less intrusive than a blood-sugar test strip, which Ivovic self-administered more than 15 times a day.
Problem was, Ivovic couldn’t afford a CGM. The yearly cost is thousands of dollars, and Ontario’s Assistive Devices Program doesn’t offset the price, except for people who receive support from the Ontario Disability Support Program.
The lack of coverage spurred Ivovic to lobby members of provincial parliament to make CGMs more accessible (still a work in progress), and consider leaving lab work for law.
“Ongoing research on diabetes is critical,” says Ivovic. “But policy changes can have an immediate and widespread impact on patients.”
A few months after completing his PhD, Ivovic applied to Osgoode Hall Law School. He’s now in his last semester.
Whatever Ivovic ends up doing, his career change is a perfectly rational response to a persistent challenge that medical researchers and practitioners face: Health outcomes are inextricably linked to policy decisions, but the majority of decision-makers have no background in science or medicine.
According to a 2019 iPoliticsopinion piece by Molly Sung (PhD ’20) and her sister Vanessa Sung, who earned a PhD in biochemistry at McGill University, only about 10 per cent of federal Parliamentarians have their highest post-secondary degree in STEMM (science, technology, engineering, mathematics and medicine).
In contrast, more than 20 per cent of Legislators are lawyers, and 17 per cent have business degrees.
By their count, there are only six MPs with graduate degrees in science, technology, engineering or mathematics, and seven MPs with graduate degrees in healthcare.
Politicians do, of course, consult with scientists.
An inescapable example are the COVID-19 roundtables — comprised of virologists, epidemiologists, geriatricians, psychiatrists, the list goes on — that offer around-the-clock guidance to leaders at all levels of government.
But what are the limits of their influence?
As Professor Mark Lautens in the University of Toronto’s Department of Chemistry puts it, “There’s a difference between giving advice and having a vote. The problem with advice is that people can ignore it.”
More scientists, he says, need to run for office. “I listen to most political discussions and it’s got nothing to do with facts. That’s a very scary proposition,” Lautens says.
Physicians in politics can certainly have a direct impact on health files. John Haggie, a surgeon, is in his second term as Newfoundland and Labrador’s Minister of Health and Community Services.
Merrilee Fullerton, a family physician, is Ontario’s Minister of Long-Term Care, and fellow physicians Eric Hoskins and Helena Jaczek (MD ’73, MHSc ’88) served as the province’s Minister of Health and Long-Term Care.
“If more scientists ran for office, we would embrace evidence-based policy in a more thoughtful way,” says Carolyn Bennett (MD ’74), who drew from her decades of experience as a family doctor while serving as the federal Minister of State for Public Health from 2003 to 2005.
Understanding available evidence is obviously helpful to decision-making. But a STEMM wave in Parliament could “change not only what we do, but how we do it,” she says.
Bennett says the value of a scientific approach to problem-solving begins with the scientific method itself, with the shared habit of “observing, asking real questions, seeking real answers.”
Those “real answers” can demand more flexibility than party politics — or voters — are typically comfortable with.
“One of the things we learned from COVID is that when the facts and evidence change, you have to change your approach,” says Bennett, now the federal Minister of Crown-Indigenous Relations.
The majority of decision makers have no background in science or medicine
“[Scientists] seem to be less stuck in consistency,” she says.
“As a scientist, you also know what you don’t know,” adds Lautens. “You’re used to dealing with complexity, you’re used to living with confusion — no sooner do you have a hypothesis then new data comes in and you have to adjust.”
A critical mass of scientists in government might be a hedge against polarization, he argues.
“What I’m concerned about in general is that both sides of the extremes are really digging in,” says Lautens. “Scientists are as full of faults as anyone else, but scientists are taught to be skeptical, whereas somebody who’s ideological doesn’t allow skepticism to enter into their perspective.”
For example, despite the frustration the public experienced with the shifting mask mandates, watching scientists debate policy solutions over the course of the pandemic seems to have boosted their overall confidence in science.
In a survey of 1,000 Canadians conducted last summer, as part of 3M’s State of Science Index, the percentage of respondents who agreed with the statement “I am skeptical of science” dropped eight points from polls conducted pre-pandemic. Globally, 77 per cent of respondents agreed that “science needs more funding.”
How funds are spent might also change if scientists are better represented in Parliament.
Molly Sung, who works in the private sector on drug delivery platforms for vaccines, sees the potential for more investment in “exploratory, discovery-based science, which leads to big advances.”
However, this type of scientific investigation doesn’t always have clear or immediate applications.
“The average politician, when they think about funding, they think about the product developed,” says Lautens.
Scientists might be more likely to invest in “big picture science” and perceive a long-term gain in funding this type of research, instead of in “the short game of politics,” he says.
That’s a pay-off for everyone, Lautens adds. “Countries that are more successful, they have long-term vision.”
Which brings us back to Ivovic.
In lobbying politicians on health care policy, he has spent dozens of hours explaining the science of diabetes to lawmakers, as well as the efficacy of continuous monitoring devices and the downstream savings by preventing complications from this complex disease.
Politicians listened politely, but nothing much changed.
It’s perhaps no surprise that Ivovic started to question whether studying physiology would have the impact he had imagined.
“If more scientists ran for office,” he says, “I would hope there would be more people interested in what devices like CGMs do, and they would have been covered years ago.”
In the end, more scientists in office could just mean broader a set of backgrounds when it comes to navigating policy decisions.
“It’s not that we need 50 chemists,” says Lautens. “What we want is diversity of opinions and experiences.” ◂
What if there is no diagnosis?
For many patients with rare diseases, the path to a diagnosis is long and winding. Meet three people whose experiences led them to advocate for others looking for answers and community.
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Isabel Jordan
Isabel Jordan works to amplify patient voices through her work with the Rare Disease Foundation, which she helped establish. A parent of a young man with an ultra-rare condition, Jordan’s advocacy was prompted by her experiences navigating the health care system. Jordan and her son both live with Ehlers-Danlos syndrome, which affects connective tissues throughout the body.
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Ian Stedman
Ian Stedman is law professor whose research focuses on public sector governance and accountability and regulations for emerging technologies — particularly in health care. He has lived with Muckle-Wells syndrome since infancy — but only received a diagnosis in his thirties after his newborn daughter showed the same symptoms. The autoinflammatory condition causes rashes, joint pain, fevers and pink eye.
[embedyt] https://youtu.be/bfLOBPxRWQ8[/embedyt]
Lynella Welcome
Lynella Welcome is the founding coordinator of the Sickle Cell Awareness Group of Ontario. When she was three-years old, Welcome was diagnosed with Sickle Cell Disease (SCD). The condition causes red blood cells, which are usually rounded, to become crescent-shaped and less able to move well through the vessels. In SCD, red blood cells also die prematurely, resulting in a constant shortage. Symptoms can include pain, infections, anemia and stroke.
In the emergency room, it’s rare that Shaun Mehta knows his patients.
“I’m meeting a patient for the first time every shift. And, they often have a big backstory with them,” says Mehta (MD ’15, GPLLM ’19, PGME ’20).
Any data on past visits, if that data even exists, is scattered across the medical system, separate and siloed.
It’s up to Mehta to learn who his patient is and what prior care they’ve received.
But, what if that history was more easily accessible? What if all that data lived in one place?
Questions like these got Mehta, a staff emergency physician at St. Michael’s Hospital and North York General Hospital who completed his emergency medicine residency in the Temerty Faculty of Medicine’s Department of Medicine, thinking about blockchain.
Blockchain — a much-hyped tech development created in 2008 by a founder who is still unknown — is a decentralized, distributed, permanent record of transactions involving … well, anything really.
While the most famous implementation of blockchain technology is the digital currency Bitcoin, blockchains can be used to store, track and distribute all kinds of digital assets, from artwork to apps.
Efforts to bring blockchain to Canada’s medical system are still in the early stages.
The consulting firm EY Canada worked with Canadian Blood Services to develop a proof-of-concept blockchain that, according to a case study, “could guarantee the visibility, security, and reliability of records from donation to transfusion.”
Every blood draw would be entered into a blockchain and then tracked as it moves through the supply network, letting anyone see its location and status in real time.
University Health Network offers another proof of concept. It uses blockchain not to store medical records but as a record of consent, promising to let patients more easily control who can and can’t have access to their health data.
Plus, there are still likely more blockchain developments to come.
For Mehta, who published a journal article in November 2020 exploring potential uses for blockchain in health, the promise is ease of access for all.
The thinking is that taking medical records out of their silos and storing them on a blockchain could bring accessibility and transparency to the health care system — not only for medical professionals, but for patients too.
“Blockchain technology holds promise for augmenting health information exchange and fundamentally enabling greater data transparency, safer patient care, improved healthcare efficiency and more robust medical research,” says the article in BMJ Health & Care Informatics.
With blockchain, Mehta says it would be easier for anyone with an internet connection to see their medical histories, control who could view and use their data, and ultimately make more informed decisions about their health. There would be fewer unnecessary tests, less repeat work.
Patients in this idealized world could receive more effective, personalized care.
But making this vision a reality won’t be a simple matter of upgrading some software and having everyone install an app.
It’s important to consider the kinds of solutions that patients — especially marginalized patients, who aren’t well served by our health care system — actually need or want, solutions that may not even involve blockchain at all.
“Almost all health disparity is based on what [white settlers] set up for Black and Indigenous people and has simply just become practice,” says LLana James, a PhD candidate at Temerty Medicine’s Rehabilitation Sciences Institute, and the AI, Medicine and Data Justice Postdoctoral Fellow at Queen’s University.
“The problem isn’t the data records. The problem is the people who produced the system that produces the records,” James says.
Sheryl Spithoff — an assistant professor with the Faculty’s Department of Family and Community Medicine and a clinician investigator at Women’s College Hospital who researches addiction medicine as well as the impact of commercial interests on the health care system — would like to see patients be part of the conversation too.
“They bring a different perspective,” says Spithoff (PGME ’13, MSc ’19). “I think it always helps to ground it in ‘Why are we doing this?’”
Professor Spithoff has written about the growing commercialization of electronic health records.
She believes it’s important that any new system — blockchain or otherwise — be built in the public interest, with respect for Indigenous data sovereignty and how people want their data shared and used, particularly if the data will be used for secondary purposes, such as research.
“I think we need better regulation and better oversight,” Spithoff says.
We also have to consider that making records more easily accessible and widely available may actually cause more harm for some patients, says Professor Ahmed Bayoumi (MD ’89, PGME ’93, MSc ’97), who teaches at both the Faculty’s Department of Medicine and the Dalla Lana School of Public Health’s Institute of Health Policy, Management and Evaluation.
“There’s still a lot of stigma and a lot of discrimination in the health care system, and in the way that health care is delivered to people who have experienced marginalization. And in many ways, that stigma and discrimination is reflected in the language that we use,” says Bayoumi.
He points to marginalized patients who have had biases and inaccuracies entered into their medical records, which then get perpetuated in their every future encounter with the medical system.
For marginalized patients, technologies such as blockchain represent a double-edged sword. There’s the opportunity, perhaps, to correct the record if the patient has the agency to do so. But there’s also a greater risk that biases are perpetuated on an even wider scale.
Mehta says that blockchain isn’t the only solution to modernizing health records; there are still important technical, legal and regulatory issues that need to be worked out. But he thinks there’s also a lot to like.
On a technical level, blockchain could mean better security and privacy for records, and less chance of records being tampered with.
Having everyone’s health records stored in one place could allow researchers to more easily study sample sizes that span provinces or countries.
And Mehta believes blockchain could help give patients their rights back, too.
“I really think you can increase patient autonomy — which is something that we’re always trying to do — by having an easier access to your records,” Mehta says.
Meanwhile, James emphasizes that technology cannot correct deeply entrenched systemic inequities.
“It’s a false promise. Let’s pay attention to how we’re being offered things that don’t address the anti-Black and anti-Indigenous racism that is killing people in the health care system and across sectors,” she says.
“Why are we focused on things like blockchain when people are still being left to die in emergency rooms due to racism? When they are still openly mocked by health care staff? When we are still treating patients based on pernicious, racist myths, such as the belief that Black people have lower baseline lung capacity?”
Technology is not an automatic go-to or fix for Black and Indigenous people, James says.
“It doesn’t address systemic issues and having our data — data that often embeds false ideas about us — more centralized and accessible, can makes us more vulnerable, not less,” she says.
“Unless technology is part of ending the conditions that are producing the disparity then we’re actually being distracted. Unless it’s part of decolonization, there are no rights to be gained and easier access is almost meaningless. People are thirsty for a different way forward and the courage to do it.” ◂
What if we could boost precision medicine using AI?
My dream, which I hope digital technology can accomplish, is to provide truly personalized health care.
The nature of how we do medical research is to conduct large studies with thousands of people. Half the group gets one drug, half the group gets another drug.
The problem is that you end up with a result of what worked best, on average.
It would be amazing if we could use artificial intelligence (AI) to sift through all of the available studies’ data to find out what treatment may be best for a specific person.
Among five or six different treatment options, it would be amazing if a digital tool could tell you what priority number 1, 2 and 3 is for treatment in an individual case.
Husam Abdel-Qadir (BSc ’03, MD ’07, PGME ’13, PGME ’17, PhD ’18) is an assistant professor in the Temerty Faculty of Medicine’s Department of Medicine. He is also a cardiologist with Women’s College Hospital and University Health Network.
What if we all had universal patient ID?
Technically, patients own their data, but hospitals and family doctors keep that information in their office.
Often, patients don’t have physical access to their records because they are hard copies housed with their health care providers.
In an ideal world, we’d all have a unique identification number or ID.
As a physician, I could pull up all of your medical information using your singular ID. And as a patient, I could access all of my medical information with my lone ID.
Today, we have the ability to access our financial and bank records online, and we can go to any computer anywhere and log into our bank accounts. So, why is the health care industry lagging behind?
Nishila Mehta is a third-year student in Temerty Medicine’s MD Program.
What if there was a single place to navigate many services?
I work with people with disabilities who are often trying to navigate online services.
They’re looking for help with things like home modifications or income assistance.
Or they’re looking for assistance with technology, for supports like wheelchairs, walkers or hearing aids.
But, accessing help can mean interactions spread out among many different parts of government. Or, it can mean having to follow up with multiple agencies or organizations.
Navigating supports can take hours and hours each day.
To add to the difficulty, these services are often siloed and don’t communicate with each other. Bureaucratic barriers are a big problem.
My digital dream is that there will be a single online platform where people can go to manage their own information, and share it with health and social services.
Ideally, the platform would be user-centric, rather than administration-centric. Hopefully, this platform would improve the lives of the people who use it and enhance service delivery.
Rosalie Wang (PhD ’11) is an assistant professor in the Faculty’s Department of Occupational Science & Occupational Therapy, and an affiliate scientist at the Toronto Rehabilitation Institute.
What if we saw disabilities differently?
Currently, many people living with disabilities face discrimination when they seek health care.
During the COVID-19 pandemic, these inequities have worsened.
People with disabilities have been treated as if they don’t exist. Their needs are ignored.
Staying two metres apart from people isn’t possible if a person with a disability needs assistance.
And a person can’t wear a mask if they need breathing supports.
In the future, I would like to see a recognition that patients with disabilities are people with mind-body differences. The language we use needs to move away from impairment and disability.
I would also like to see more health care providers with mind-body differences.
Recognizing these differences would mean a more inclusive health care system.
Karen K. Yoshida (BPHE ’79, BSc PT ’82, MSc ’86, PhD ’91) is a professor with the Temerty Faculty of Medicine’s Department of Physical Therapy and the Rehabilitation Sciences Institute.
What if patient records transcended borders?
Moving forward, especially with globalization, we’ll have a lot of people moving to Canada. We’ll also have a lot of people flying around the world because the rise of remote work means people can live wherever they want.
The biggest dream in this scenario is a worldwide electronic medical record.
If this was possible, a patient visiting from another country would be able get the exam they need because the entirety of their health information would be immediately accessible.
Then, we’d potentially be able to overcome a language barrier with a patient because the patient’s entire past medical history would be in the electronic medical record. This bastion of information will suddenly enable way better patient care.
Yousuf Ahmed is a third-year student in the Faculty’s MD Program.
What if your watch reported your steps to your doctor?
In the future, wearable data is going to become a bigger thing. Your smartwatch or other wearable devices will be able to collect your weight, your height, your heart rate, your oxygen monitoring, and your temperature.
All of the data on your smartwatch, or other wearable devices, will be integrated into your health data.
Plus, I also expect that chat bots will become more common for people when they interact with health care services.
So, for example, a patient might need a prescription renewal. They could log into a hospital website or a clinic website and then type their request into the search line.
Then, a chat bot would ask them a few questions in an automated way.
The search results could give the person different ways they could get a prescription – through an in-person appointment with a doctor, or a video or phone visit.
Or, maybe their request is answered immediately, in an automated way and the prescription gets sent to them straight away.
In the future, chat bots could help optimize medical care.
Sacha Bhatia is an associate professor in the Faculty’s Department of Medicine and a population health and value-based systems executive with Ontario Health.
A chance conversation with a patient launched Professor Giuseppe Papia on his journey to becoming one of Canada’s leading vascular surgeons specializing in limb preservation.
It was early 2009, and Papia was doing rounds at Sunnybrook Health Sciences Centre.
In the vascular surgery ward, Papia encountered a 90-year-old man with peripheral artery disease (PAD) and an intense pain emanating from an injured toe.
In a healthy person, foot ulcers and contusions are a minor nuisance and typically heal in a few days or weeks.
But people with PAD heal poorly or not at all.
Amputation is often the only recourse.
While chatting with the patient about the prospective amputation, Papia learned that the man was a former rocket engineer who had developed missiles for NASA.
“He told me, ‘I had to take the scientists’ impossible ideas and actually make them work,’” says Papia. “That got me thinking. With a creative approach, it might be possible to save this man’s toe. So I asked myself: What new approaches could I use to help this patient?”
The timing of the conversation was crucial.
In 2008, Papia completed training at the Cleveland Clinic, where doctors were performing angioplasties to help open arteries in legs and feet.
Coronary angioplasties are used to clear blockages in the heart. A thin wire attached to a small balloon is fed through a blood vessel in the arm or groin, and the balloon is inflated to open an artery narrowed by plaque buildup.
After the conversation with the patient, inspiration struck Papia.
With lower-extremity angioplasty, the wire needs to be a lot longer to reach the affected area.
He wheeled his patient to the hospital’s catheterization lab, where doctors perform coronary angioplasties. Papia wanted to see if the hospital had the correct tools for a lower-extremity angioplasty.
Unfortunately, the wires in the lab were too short. But Papia crimped a few of them together to fashion the 3-metre-long wire he needed.
Next, he performed a lower-extremity angioplasty on the man’s leg, improving blood flow to the man’s foot.
The following day, the patient reported that he had slept well without any pain. It was a promising sign.
Days later, the pain still hadn’t returned. An amputation of the man’s leg was ultimately avoided.
“It was a transformative moment for me, realizing I could perform lower-extremity angioplasties, and it could save people’s legs, feet and toes,” says Papia.
Now, fast-forward 12 years.
Papia has the right tools and a team of vascular surgeons trained in lower-extremity angioplasties. They’re regularly saving the legs, feet and toes of PAD sufferers.
But Papia’s work is far from over.
Today in Ontario, 40 per cent of patients with severe PAD face major amputation even with treatment including angioplasty. Between 2005 and 2016, there were more than 12,000 major leg amputations.
Patients with diabetes are the most vulnerable and at highest risk for major limb loss. To avoid amputation, early detection is critical.
Papia’s current priority is establishing a national program to facilitate early ulcer detection, and co-ordinated medical, wound and vascular care for PAD patients. Many of Papia’s patients have philanthropically supported his work.
“If we could get primary caregivers involved and regularly screen at-risk patients for foot ulcers so they don’t end up in the emergency room, we could see a dramatic decrease in amputations,” says Papia, who was appointed the J. Ross & Patricia Quigley Chair in Limb Preservation at U of T in 2018.
“It’s taken us years to get here, and we’re finally seeing some real progress. Now, there’s further to go.”
Giuseppe Papia (BSc ’95, MSc ’03, PGME ’05, PGME ’07, PGME ’08) is a member of the Division of Cardiac and Vascular Surgery, and the Division of Critical Care Medicine at Sunnybrook Health Sciences Centre. He is also an assistant professor in the Temerty Faculty of Medicine’s Department of Surgery.
In the face of public skepticism, political partisanship and the weighty gloom of a global pandemic, the pharmaceutical industry served up something that would have seemed like a miracle in the pre-COVID-19 world.
Armed with huge sums of government funding and germinating technology, global drug-makers formulated safe and effective COVID vaccines at record-shattering speeds. This historic achievement begs the question: Can we streamline drug or vaccine development by drawing on the learnings of 2020?
The answer is yes, according to a recent editorial in The Lancet: “Clinical trials are an essential tool in medical research, but COVID-19 has exposed ways that their design, conduct, and reporting could be improved,” the author concludes.
“The rapid design and launch of clinical trials designed to research COVID-19 has shown that certain aspects and practices of clinical trials could be improved, streamlined, or modernised in ways that would benefit patients, practitioners, and all research.”
The sheer magnitude of this accomplishment grows when compared with statistics from the past 15 years.
Meanwhile, success rates plunged while research and development (R&D) costs skyrocketed.
Estimates vary, but drug companies typically win approval for only a small fraction of the molecules they put into the long pipeline of trials.
Success rates fell from about 11 per cent to five per cent between 2005 and 2013, although they’ve nosed up since then. R&D and marketing costs can run to more than US$2-billion per compound.
Even venture capitalists would consider these batting averages dismal. Yet rigorous scientific inquiry, especially when it involves medication, is unlike almost any other form of product development.
There are no shortcuts, says Professor Muhammad Mamdani, who specializes in the use of data analytics in clinical treatment, and teaches at both the Temerty Faculty of Medicine and the Leslie Dan Faculty of Pharmacy.
But Professor Lakshmi Kotra, an expert in drug development and disease diagnostics at the Leslie Dan Faculty, says that regulators and early-stage researchers should adopt a problem-solving approach.
Emerging computational tools and more dynamic approaches to the regulatory review of clinical trial data can assist with understanding disease pathology and deliver results more efficiently.
In agreement is biochemist Anne-Claude Gingras, a professor at Temerty Medicine’s department of molecular genetics and a senior investigator at the Lunenfeld-Tanenbaum Research Institute at Sinai Health.
She points not only to the demonstrated viability of the mRNA vaccines, developed using gene sequencing, but to emerging ideas about the importance of interdisciplinary collaboration in drug discovery and the removal of unnecessary roadblocks in clinical trials.
The mRNA process was “super-charged,” says Professor Gingras. “A year ago, I didn’t think this way.”
But now, with the first large-scale successes using mRNA techniques, Gingras says, “I think you’ll see a lot more of these.”
Organizational culture
In response to years of rising budgets and fluctuating success rates, some of the largest pharmaceutical companies have sought to recast their management of the meandering drug discovery process.
Some have focused on organizational fixes, moving, for example, to implement “agile development techniques” that require more co-ordination across far-flung drug development teams. As well, the focus is on crisper decision-making about when to pull the plug on floundering projects that are soaking up resources.
Professor Anita McGahan, a strategic management expert at the Rotman School of Management and a professor at the Munk School of Global Affairs and Public Policy, says that the largest drug companies are outsourcing more of their R&D to startups, incubators and university research labs to reduce risk.
Novel ways of collaborating, which have been much in evidence during the pandemic, represent another approach that has gained momentum in the past few years.
Other approaches include the Accelerating Therapeutics for Opportunities in Medicine (ATOM) consortium, which includes GlaxoSmithKline, the U.S. Department of Energy and National Cancer Institute, as well as universities in California. ATOM’s mandate is to promote pre-commercialized research tools.
McGahan says the industry has sought to work more closely with health insurers to gain a deeper understanding of patient responses to drugs that have made it past the regulators.
“The pharmaceutical companies are becoming much more oriented towards prevention,” she says.
Ethics boards and regulatory approvals
Clinical trials on human subjects typically involve researchers at multiple hospitals and universities in different regions or provinces, each with its own research ethics guidelines.
Gingras says transferring material about patient results from one institution to another soaks up a lot of time and energy, and slows the process of aggregating and evaluating results.
“The paperwork is crazy,” she says, describing this process as one of the largest procedural hurdles and a bureaucratic obstacle that’s not subject to federal or provincial policy-making.
With COVID-19, vaccine trials and the testing of new treatment protocols straddled every institutional boundary, Gingras says there has been a growing recognition of the inefficiencies in the current system.
Some Toronto-area hospitals, she notes, have recently developed a shared material transfer agreement to help with research involving human tissue samples.
The agreement also assists with sharing data.
“People now realize this has impeded our ability to quickly move with solutions,” she says.
On the regulatory end, the vaccine approvals illustrated to the general public that agencies — such as the U.S. Food and Drug Administration and Health Canada — can accelerate their analyses.
Artificial intelligence and machine learning
In recent years, researchers have been looking much more closely at the uses of AI for everything from early-stage inquiry, such as identifying potential molecules or compounds that have therapeutic benefits, to applications.
Mamdani, Vice President of Data Science and Advanced Analytics at Unity Health Toronto, says his team has deployed a machine learning algorithm that continuously monitors about 100 data points every hour from internal medicine patients.
The algorithm identifies patterns and permutations that predict the need for intensive care for a patient. Other algorithms assist with optimal drug use and dosing, like adjustments of warfarin, an anticoagulant.
“It allows greater precision in terms of predicting the performance of a drug,” says Mamdani, who is director of the Temerty Centre for AI Research and Education in Medicine at the University of Toronto. “I think we’ll see much more use of AI in the next five to 10 years.”
The authors pointed out that at present, only 10 antiviral drugs have been clinically approved for use, even though over 200 viruses are known to infect humans.
“The SARS-CoV-2 pandemic,” they write, “has brought the need for antiviral drug development into sharp focus, not only to respond to the current global health crisis but also to prepare for future outbreaks caused by other viruses for which antiviral drugs are unavailable.”
The collaborations and innovations that emerged during the pandemic may speed this process, they state.
While Kotra says the lessons gleaned from the COVID-19 vaccine approvals don’t necessarily apply to challenging diseases, such as neurodegenerative conditions, process improvements may indeed be possible, which is good news for patients.
“Anything we do must be done with those patients in mind,” he says.
Mamdani points, by way of example, to the regulatory streamlining that Health Canada employed during the pandemic to accelerate its evaluation of COVID-19 vaccines.
“Do we require more resources? Yes. Could it be done for other drugs? Yes,” he says. ◂
The late David Dime (BSc ’73, PhD ’78) was enthralled with the possibility of what science could do for the world.
“For him, scientists were superheroes,” says Dime’s widow, Elisa Nuyten.
“He truly believed scientists could work together to solve humanity’s biggest problems. And, I think it’s something he’ll be proven right on. Just look at the past year and what’s happened with the development of COVID-19 vaccines.”
Dime studied organic chemistry at U of T, earning a PhD in 1978.
“My interest in chemistry came initially from my father,” he said in a 2006 University of Toronto magazine article.
Dime’s father ran one of the oldest pharmacies in Toronto before retiring in 1986. Dime told the magazine he was fascinated with the pharmacy’s “old bottles of chemicals, roots, barks and elixirs.”
In 1982, Dime founded Toronto Research Chemicals (TRC) after a chance conversation with another chemist, who asked him to make a compound that wasn’t available on the market.
TRC — which started with three staff in a small lab on U of T’s St. George campus — eventually grew to employ more than 400 people at 15 production sites across Toronto.
The business became a leading manufacturer of the specialized chemicals used in scientific research, exporting to more than 90 countries.
“Everything he did with TRC reinforced his belief in the importance of combining the academic and business worlds to help translate science into real-world applications,” says Nuyten. “It’s one thing to do science in a silo, but another to bring it into the world and make it useful.”
In 2017, Dime met Professor Leah Cowen (PhD ’02), then Chair of the Temerty Faculty of Medicine’s Department of Molecular Genetics. Dime decided the department was the perfect place to make a difference.
“David’s discussions with Leah resonated within him,” recalls Nuyten. “He had already been thinking of molecular genetics as an important field. Its applications are pretty direct and, therefore, impactful.”
In 2018, Dime and Nuyten made a gift to establish catalyst awards in the department. Their awards support researchers whose work has potential for future commercial applications, but might be too high-risk to qualify for more traditional funding.
Professor Mikko Taipale, an assistant professor in Temerty Medicine’s Department of Molecular Genetics, was the first scientist to receive a David Dime Family Catalyst Award. The award helped fund his research into new ways to break down unwanted proteins, such as those found in cancer cells.
In 2021, Professor Kieran Campbell, also an assistant professor in the department, became the second scientist to benefit from the family’s support. Campbell is investigating new drugs to target tumours by using approaches that combine statistics, data science and genomic editing.
“Research like Mikko’s and Kieran’s will generate fundamental insights and has tremendous potential to shape the way we treat disease in the future. But seed funding is key,” says Cowen, now U of T’s Associate Vice-President, Research. “Scientists need early support to launch their work and build sustainable momentum.”
Since Dime and Nuyten’s original contribution, their impact on the Department of Molecular Genetics and the Faculty has grown.
Following Dime’s death in July 2020, many of his family members and friends made memorial gifts to the fund.
In 2021, Nuyten and her children, Julian, Sophia and Camille, made a new commitment to expand the family’s namesake fund to include additional scholarships for promising molecular genetics graduate students.
“David understood that scientific discovery can only happen when scientists — the people driving the ideas — have the funding they need to do their work,” says Cowen. “He witnessed declining government supports for research and innovation firsthand, and cared deeply about ensuring high-potential projects could get off the ground. The research funded by these awards and scholarships will be a powerful legacy.” ◂
Story by Edgar Akuffo-Addo, as told to Hilary Caton
Growing up in Ghana, every day for 18 years of my life I was surrounded by people who looked like me.
I always saw myself represented.
This was nothing new or groundbreaking.
It was simply fact.
It wasn’t until I moved to North America in 2012 to pursue a career in medicine that I realized that this is not the case for many Black people, especially those in medicine.
After completing my undergraduate degree in human biology and a graduate degree in health care management at Cornell University in Ithaca, New York, I began my MD studies at the University of Toronto’s Temerty Faculty of Medicine.
As a first-year medical student, I was required to take a few basic prerequisite courses, and one of them was a first-aid class.
It was there that I noticed something that was troublingly common.
Every video and image shown to us during the class only featured people with white skin. This included the online training videos we had to watch beforehand and the in-class examples.
It was clear that white skin was the standard. And, it made me pause.
I know that for medical professionals practising in a multicultural city such as Toronto, the patients who come seeking medical attention will vary in skin tone.
It also made me ask: How representative is research at showing people with different skin tones?
Then in June 2020, after the global pandemic was underway, I started hearing about a mysterious rash called “COVID toes.”
It was getting a lot of publicity, and I wondered what it would look like for someone with my skin tone. Thus, my own research began.
If you’re interested in dermatology, you’re familiar with the Fitzpatrick Scale, which is a numerical classification for human skin colour.
The scale goes from 1 to 6, with the lowest number (1) indicating the lightest skin tone and the highest number (6) being the darkest skin tone.
It was originally created to estimate how different types of skin react to sun exposure.
As I flipped through the pages of various medical journals indexed in PubMed — with studies from Italy, Spain, France and Germany — I was desperately searching for any of the COVID rash symptoms presented in melanin skin, which would be 4 to 6 on the Fitzpatrick Scale.
Every video and image shown to us during the class only featured people with white skin
I wanted to know: What about people of colour? Where do we fit in?
But in the images I was seeing, I encountered only images of light skin tones, of types 1 to 3. In the end, I couldn’t find much.
Less than one per cent of the more than 1,000 images I surveyed showed a person of colour, types 4 to 6 on the Fitzpatrick Scale.
The researchers had completed a systematic literature review of 46 articles describing cases of cutaneous (skin) manifestations associated with COVID-19 published between December 31, 2019, and May 3, 2020.
This review included 130 images and found zero images of darker skin.
Although this finding is disturbing, it’s not surprising.
After poring over 1,000 COVID images on PubMed, I reached out by email to researchers from other countries about what I was seeing, or what I wasn’t seeing. An overarching theme emerged: they told me the under-representation of darker skin tones was a problem and they wanted to change it, but what could they do? Their populations were predominantly white, and they just didn’t have enough Black patients.
Meanwhile in Canada, the City of Toronto released race-based data showing that 83 per cent of reported COVID-19 cases consisted of Black people and other people of colour, despite only representing half of the city’s population.
That’s when it clicked — this gap in representation in the COVID images was highlighting a much broader issue for people of colour in dermatology.
For almost all types of skin conditions, Black people are being under-represented, even in simple skin conditions such as eczema and dermatitis.
But that’s not to say there are zero images of darker skin in my dermatology textbooks.
That over-representation is used to perpetuate a stigma.
And make no mistake, there’s a statement being made there about Black people, intentionally or not.
It was glaringly obvious that the source of the inequities that people of colour face in the health care system bleeds from its core — education.
If future dermatologists are not exposed to the way skin conditions manifest on darker skin, they’re not fully equipped to diagnose, let alone treat, a person of colour, and this directly impacts the quality of patient care. Change starts with building educational materials that represent people who look like me.
I am currently working on a paper that tells clinicians what to look for when it comes to diagnosing COVID-19 skin manifestations on skin of colour.
The target audience will mostly be primary care physicians, as they are patient-facing and the first point of contact, and they can make a referral.
Systemic racism in medicine isn’t new and it presents itself across most fields. It just so happens that dermatology is one that can easily be seen.
And this systemic racism disproportionately puts people of colour at risk by delaying care or misdiagnosing.
It’s been established that most patients with darker skin tend to present with later stages of diseases. Why? Because the physician doesn’t know what they’re looking at or looking for and run unnecessary tests that only delay a diagnosis, in some cases until it’s too late.
But that can change.
It starts with trying to balance the scales of representation.
It’s my hope to one day open my own dermatology clinic in both Ghana and Canada knowing that I made a difference in the next generation of physicians’ education and the health of people of colour. ◂
Edgar Akuffo-Addo is a first-year student in Temerty Faculty of Medicine’s MD Program.
Dermatologist Marissa Joseph has been practising for 10 years.
Every day, she sees patients of colour who come to her downtown Toronto clinic for help.
“In my practice, I serve a diverse community of patients, and I see a lot of patients with skin of colour who may have had misdiagnoses or delayed diagnoses in the past,” says Joseph (PGME ’06, PGME ’10), an assistant professor of dermatology at the Temerty Faculty of Medicine.
“I see the relief on their faces when I walk into the room,” she says. “Often, they feel like their skin is not understood.”
It hadn’t occurred to Professor Joseph or other educators to overhaul the dermatology curriculum that first-year MD students receive.
That is until 2018, when three students approached the faculty with concerns about how skin of colour was being covered in Derm Week, a week-long course each January.
“As a woman of colour who has tried to include diverse images in what I present, after our first meeting with the students I thought, ‘We should have done this already,’” says Joseph, the Medical Director of RKS Dermatology Centre at Women’s College Hospital.
“I wasn’t thinking in terms of innovation or seeing the curriculum as a whole. Reflection really can make a difference.”
In the study, researchers found that in the Derm Week curriculum, less than seven per cent of images were of skin of colour.
The study also looked at the results of a survey of first-year and third-year students in Temerty Medicine’s MD Program.
The survey asked students to diagnose five skin conditions in white skin and skin of colour, and then measured each student’s diagnostic accuracy. It also asked them to rate their confidence in their diagnoses.
Ultimately, the researchers found that students were more confident diagnosing skin conditions in white skin than in darker skin.
“Despite the fact we’re in an extremely diverse city and thinking we might be doing a great job with equity and diversity, we’re not. The implication of the research is that even if students are doing OK in their diagnoses, they don’t have confidence in their diagnoses. And that is going to lead to worse care for racialized patients,” says Dahlke, the Undergraduate Director of Dermatology education at the Faculty, who practises at St. Joseph’s Health Centre in Toronto and Hotel Dieu Hospital in Kingston.
“It fosters mistrust in the medical system. And, it aggravates disparities in care.”
In an effort to address these concerns, Dahlke is leading changes to the undergraduate dermatology curriculum, with more students and faculty involved.
Changes to Derm Week include increasing the proportion of images of skin of colour in large group lectures to 50 per cent, creating new learning objectives on recognizing dermatologic conditions in different skin types, and weaving themes of equity and diversity into the curriculum.
But more work needs to be done. And faculty say they have student feedback to thank for their efforts so far.
“I think the main message is that we need to reflect on how we teach and the need for representation,” says Joseph.
“When you look, you’ll find changes that need to be made. This should be built into the curriculum because people intuitively know there is a problem. This is something everyone needs to know.” ◂
What if the Medical Profession Stopped its Sizeism?
Story by Hilary Offman
I’m a physician.
I’m also someone who society, at one time, would have considered obese.
Morbidly obese. Their words.
I can tell you that sizeism in the medical community is real.
Frankly, the medical terminology alone — “morbidly obese” — is mean and blaming.
Take my interaction with a specialist in a downtown Toronto cancer hospital in 2005, after I found out I might have the gene that causes breast and ovarian cancer.
“If you’re BRCA2 positive, you will need surgery,” she said. “But I won’t operate on you. Because of your size.”
Did I only imagine that she lingered on the word “size” just a bit too long?
She didn’t even look sheepish as I stared at her in stunned silence.
Despite my medical background, I couldn’t tell how much the specialist’s words conveyed genuine risk and how much they reflected implicit disgust.
That’s the thing about being fat.
You don’t know how much of a physician’s diagnostic opinion is based on scientific fact or internalized stigma.
Physicians aren’t typically aware of the degree of their negative reactions to treating fat bodies. They don’t know how their pejorative beliefs undermine the development of a positive rapport.
Fat patients often receive the message that they are to blame for whatever ails them — causing them to conclude that they don’t deserve compassionate care.
Ask any fat patient, and you will hear about a doctor who dismissed their complaint or automatically blamed their size when it turned out to be something else.
What would have helped me most as a fat patient was not tough love, but extra kindness to combat my secretly held belief that I deserved to die.
Family history dictates that my siblings and I need screening colonoscopies.
The first time I was preparing for a colonoscopy in 2010, my extreme anticipatory anxiety landed me in the ER the night before with a severe panic attack that mimicked a pulmonary embolism.
I knew that to go through with it, I needed a general anesthetic.
As I lay on the gurney, the anesthesiologist looked me up and down.
“I’m not putting you under,” he balked. “Too big.”
“You have to,” I pleaded.
The alarm in my voice had the doctor shaking his head with dismay and pity, but he relented.
When I woke up from the procedure, my relief was profound.
I felt great — no wait, “Owwwwwww.”
I touched my face tenderly. The bruises didn’t appear until the next day.
I realized the anesthesiologist had grabbed my cheeks and pushed my jaw forward to keep my airway open.
I told myself that because fat people have fat necks, he probably had to use more pressure than he might have otherwise — the kind of pressure that leaves marks.
It was a needed jaw thrust manoeuvre, I tried to reassure myself.
But, having been shamed so many times before, I couldn’t help but wonder if a bit of extra force was also my justified punishment for wanting a choice of anesthesia.
In 2020, I returned for a repeat screen.
I was more than 100 pounds lighter thanks to intensive psychotherapy levelled at the intractable shame that always made everything worse.
Despite years of fruitless efforts to lose weight, I had refused to give up.
I recognized the same specialist right away.
“Hey,” I bantered lightly, hoping my trembling voice didn’t give me away. “I think you were my anesthesiologist the last time I was here. I was a lot bigger then.”
He smiled vaguely, saying nothing more. When I woke up, my cheeks felt pristine.
Have you ever conveyed contempt you didn’t even know you had as you spoke medical “truth” to an obese patient?
If you were morbidly obese, would you want to consult a physician if you already knew how you would be treated?
Physicians don’t have to ignore size altogether to treat fat patients with compassion. But they do need to consider how they may inadvertently be humiliating them due to their unacknowledged size discrimination.
As someone who knows what it is like to be fat and how the medical profession operates, I promise that a shaming approach, even one founded in valid concern, will backfire.
It will only promote further avoidance of what feels like inevitable and thinly veiled judgment.
Only if we allow ourselves to see and talk about fatphobia will we ever transform a world that prevents so many of our patients from getting the care they need. ◂
Hilary Offman (BSc ’88, MD ’92, PGME ’97) is a psychiatrist and psychoanalyst in Toronto, and a lecturer at the Temerty Faculty of Medicine.
We asked artists and writers who worked on this issue…
What is the greatest unexplored possibility for medicine or health research?
Uterine fibroids disproportionately impact women of colour, particularly Black women. Some women may experience few or no symptoms; others can suffer debilitating pain. It would be wonderful to see more extensive research in this area.
Lauren La Rose is a writer, editor and communications specialist, who explored digital dreams for the future.
I’m especially interested in the convergence of ocean science and medicine, and the possibility the latest and greatest antibiotics may come from bacteria only found in the sea.
Matthew Braga is a journalist who writes about technology, science, and business. He looked at the impact of patients carrying their own health data.
There needs to be more research involving people with developmental and physical disabilities, especially when researchers are looking at how anxiety affects people or how the pandemic has changed their lives.
Meagan Gillmore is a journalist and writer who spoke to experts about anxiety.
The greatest unexplored possibility is finding medicine from different planets. One NASA-funded project has astronauts growing lettuce in space to produce specific drugs. Who knows what we’ll find next?
Julianne Aguilar is an artist and illustrator who created the visual work for Don’t Stop Relievin’, which looks at the future of drug discovery
I think the greatest unexplored possibility for medicine and medical research is within botany. The natural world remains largely unexplored, and potentially contains the keys to new medical discoveries.
Brian Jiang is an illustrator and artist. They created the visual work for Digital Dreams, a piece that explores technological fantasies.
Now it’s your turn — what possibilities do you think need to be explored?
