Transitions mark moments of profound opportunity in medicine — when experience meets innovation to forge new paths forward.  

At the Temerty Faculty of Medicine, these pivotal points have defined our legacy of breakthrough discoveries, exceptional medical education and transformative patient care. 

As a paediatric kidney specialist and discovery and translational scientist, I’ve witnessed how transitions shape both scientific discovery and human experience. It has been my life’s work to unravel the mysteries of kidney injury and transplantation, and to guide children and families through challenging journeys filled with unknowns. These experiences have taught me that successful transitions require not only medical expertise, but a deep well of empathy, creativity and kindness. 

In this issue of UofTMed, you’ll meet remarkable members of our community who exemplify this approach. From compassionate care to revolutionary medical practice and scientific discovery, these leaders are shaping how we understand health and disease and are central to scientific advancement and health innovation.  

As the 18th dean of medicine at the University of Toronto, I am embracing my own leadership transition with excitement and purpose. I am committed to working closely with you — our alumni, valued supporters and dedicated partners across the Toronto Academic Health Science Network — to ensure that Temerty Medicine continues to drive end-to-end impact. 

As we renew our academic priorities, our mission is clear: The people we train, the molecules we discover, and the diagnostics, therapies, educational tools and policies we develop must positively impact the health of our communities in Canada and around the world.  

By embracing transitions as pathways to progress, we create opportunities for innovation that will shape a healthier, more equitable future for all.

Lisa Robinson, MD, FRCPC, FCAHS
Dean, Temerty Faculty of Medicine
Vice Provost, Relations with Health Care
Institutions, University of Toronto

Navigating the Move from Paediatric to Adult Health Care

By Katherine O’Brien

Oula Alaoui feels a sense of grace at the moment, although she knows it won’t last long. Her 18-year-old son, Yussuf Satar, is on the cusp of a major life change.

The Toronto teen, who understands four languages and loves opera, lives with cerebral palsy and significant medical complexities. Satar is non-verbal, has vision impairments, and is unable to sit, stand or walk independently. He relies on a G-tube for feeding.

For now, Satar is wrapped in the care of a paediatric system, but as his next birthday approaches, Alaoui knows that her son will enter an adult care system that feels like “a big unknown.”

Navigating an Uncertain Path

Each year in Canada, it’s estimated that 70,000 young people with chronic physical and/or mental health conditions transition out of paediatric care.

The shift to adulthood brings new challenges for any young person, but for teens with complex medical needs, this milestone also means adjusting to new health care teams, taking on new responsibilities and navigating the many “unknowns” that Alaoui and Satar are beginning to encounter. Research shows that this transitory period results in lower compliance with medical plans, increased visits to the emergency department, and emotional strain as supports shift or disappear.

Satar is in the early stages of this transition, participating in two bridge programs. The LIFEspan Clinic at Holland Bloorview Kids Rehabilitation Hospital assists young adults with disabilities in transitioning to adult services. Meanwhile, The Hospital for Sick Children’s Transition to Adult Care (TAC) pilot project supports youth facing medical complexities, multiple health conditions, and rare diseases.

“These two clinics are really what’s giving me some kind of comfort,” says Alaoui. Yet even with these programs, she says that the uncertainty of the adult system looms large.

Through TAC, Satar and his mother are now connected with adult care subspecialists. They are also linked to a family doctor who has some training in providing care to patients with high support needs, although such cases are not a focus of the practice. As Alaoui puts it, “Now Yussef is going to be the exception. And that doesn’t give me a lot of confidence.”

Alaoui and Satar face challenges even in Toronto, with its extensive network of hospitals and specialists, and families living in rural areas or outside of major cities face even greater barriers. Holland Bloorview recently reported on a survey of young adults with disabilities and their caregivers in which two-thirds reported lacking access to the appropriate adult specialists and clinics. This leaves young people and their caregivers to fend for themselves or, as reported by half of Holland Bloorview respondents, to continue to rely on paediatric providers.

Mental health providers who understand patients with intellectual and developmental disabilities (IDD) are also in short supply, says Yona Lunsky, the director of the Azrieli Adult Neurodevelopmental Centre at the Centre for Addiction and Mental Health. “For conditions like autism or Down syndrome, we have services and supports in paediatric care that simply don’t exist in adulthood,” says Lunsky, a psychiatry professor at the Temerty Faculty of Medicine.

Adolescent medicine specialist and TAC lead Alène Toulany (PGME ’12) notes that some paediatric specialties, such as developmental and complex care, are absent in adult care. “We need to piece together multiple specialties to make up for what they received in the paediatric setting,” says Toulany, an associate paediatrics professor at Temerty Medicine.

Cold Comfort

As Alaoui is discovering, the adult care environment is markedly different. SickKids has extra-wide hallways, large changing tables with lifts and waiting rooms designed with young patients in mind. In contrast, adult clinics typically lack these amenities. Also, Satar sometimes has to stay in the waiting room for up to 45 minutes for his appointment, which can disrupt his strict feeding schedule and trigger seizures or vomiting. And there are no toys, video games or TVs in adult waiting rooms to make the wait bearable.

When Satar was younger, Alaoui took him for blood work at labs where technicians struggled to find a vein. It took “a billion times … and was really, really hard to watch,” she says. But at SickKids, the staff would find a vein on the first or second try. Now she worries about what challenges Satar will face for even routine procedures in the adult system.

For the past decade, Alaoui relied on SickKids’ Complex Care Program when she became concerned about her son’s health. The program’s staff provide guidance by phone or email and help manage medical appointments and emergency room visits. However, this level of support is all but absent in the adult care system. “It is more cold and not as nice,” Alaoui says. “[There is] no empathy toward the extra complex needs Yussuf has.”

The patient has grown up in a very protected environment . . .

Then all of a sudden, you move to an adult system and there’s no time

Abha Gupta (MD ’00, PGME ’06 & ’07), a staff oncologist at SickKids and the Princess Margaret Cancer Centre at University Health Network, agrees that the transition process can be abrupt. “The patient has grown up in a very protected environment, where every patient has a dedicated social worker, dedicated contact nurse, a physician, maybe a fellow — a whole team of people that know the patient inside out and spend hours with the patient and their family,” says Gupta, an associate professor of paediatrics at Temerty Medicine. “Then all of a sudden, you move to an adult system and there’s no time.”

While promising work is being done across Canada to improve transition processes, the efforts remain inconsistent. Toulany, the lead author of the 2022 Canadian Paediatric Society (CPS) position statement on this issue, notes that most transition programs focus on moving patients from one specialist to another rather than addressing a young person’s holistic needs.

Ideally, transition planning should begin before a child turns 18, but many families are caught off guard when they reach that milestone. As Toulany notes, “It feels for many like they’re falling off a cliff.”

A Warm Hand-Off

Advances in medical care have improved survival rates for young patients with chronic health conditions. Today in Canada, over 90 per cent of children with complex needs will enter the adult health care system. But while this progress is welcome, it creates challenges, says Rachel Wald (MD ’98, PGME ’04 & ’07), a paediatric and adult cardiologist and research director of the Toronto Adult Congenital Heart Disease Program at UHN’s Peter Munk Cardiac Centre.

“In some ways, we’re victims of our own success,” says Wald, who is also a professor in the Departments of Paediatrics, Medicine, Medical Imaging and Obstetrics and Gynaecology at Temerty Medicine. “Having patients survive longer means we have a duty to understand their outcomes and optimize their care.”

In Canada, the transition from paediatric care to adult services typically occurs when the patient is between ages 16 and 19. In Ontario, most patients move to the adult care system when they’re 18.

For smoother transitions, experts suggest more flexible age cut-offs that consider a young adult’s developmental stage and capacity to take on new responsibilities. Allowing more extensive support beyond rigid age limits could make a substantial difference.

“Each patient’s readiness and capacity to manage their health care should be assessed individually,” Toulany says, pointing out that a patient with IDD may need just as much family support at age 20 as they did at 17.

Ideally, patients experience a “warm hand-off,” with overlapping involvement and coordination between paediatric and adult care providers. But as Lunsky explains, “We don’t build as much time as we should to allow for that overlap. Adult providers do not have the same degree of training or supports in place to provide the needed care as their paediatric counterparts.”

Toulany adds that primary care providers — often the “string that connects everything” — are rarely involved in a meaningful way.

The transition from paediatric to adult care often coincides with other major life changes, such as graduating from high school, starting a job or postsecondary education, and the shifting of peer relationships and other support systems.

“A person’s physical and mental health is impacted by the presence or absence of meaningful things like school or work,” Lunsky says.

The CPS position statement recommends additional training in transitional care for primary care doctors, with a focus on issues affecting young adults with childhood-onset disabilities.

Toulany highlights the need for doctors to understand the trajectory of brain development and executive functioning into young adulthood. She says it’s essential for doctors to conduct adolescent assessments that include a thorough social history and discussion about how their condition may impact their sexual and reproductive health.

Wald adds that it’s important to speak directly to adolescent patients about sensitive topics such as drugs, alcohol and safe sexual practices and recognize that lines of communication may not be open with parents.

Additionally, it’s crucial that young patients are taught to take ownership of their health and advocate for their care, if they are able. Toulany suggests that doctors use appointments as opportunities to teach adolescent patients self-management skills, such as taking part in decision-making and calling the pharmacy for a repeat on a prescription.

“We need to see each health care visit as a potential intervention, a way to keep a young person engaged in their health care,” Toulany says. “They’re not going to stay engaged unless they feel safe, unless they feel secure and unless they feel heard.” •

Behind the Research on Our Infectious Invaders

By Betty Zou

Human civilizations have long relied on technological innovations to make hostile environments more hospitable.

From irrigation systems that convert deserts into fertile agricultural lands to air conditioners that make hot climates more liveable, we are masters at bending the environment to suit our needs.

But what about our microbial cohabitants?

Getting by in wildly different habitats — soil one day, an animal gut the next — is no small feat when you don’t have access to tools or technologies. So instead of changing their environment, bacteria, viruses and parasites adapt themselves to survive.

For some microbes, this means changing not just what they look like on the outside, but what systems and circuitries are turned on internally. And when microbes cause disease, these changes can have profound implications, complicating treatments and making some infections harder to eradicate.

Among all of the microbial shape-shifters, fungal pathogens, such as Candida albicans, are perhaps the most prolific in their ability to transition. They can live in a yeast form as individual round cells that spread easily through the bloodstream. Or, they can exist as long threads of cells stuck together. These filaments help the pathogen penetrate tissues where they can cause deep-seated infections.

“The biology is just fascinating,” says Leah Cowen, a professor in the Temerty Faculty of Medicine’s Department of Molecular Genetics, who also serves as vice-president, research and innovation and strategic initiatives at the University of Toronto. She leads a research group focused on understanding how C. albicans alters its morphology in response to different environmental cues, such as carbon dioxide. 

One of her lab’s early foundational discoveries was uncovering the role that temperature and a protein called Hsp90 have in triggering C. albicans to switch from a circular yeast form to a filament.

More recently, her group has turned their attention to what happens within immune cells, such as macrophages, whose job is to recognize and eat up these potentially harmful micro-organisms. The fungal pathogen can escape macrophages by quickly morphing into long tendrils that rupture immune cells, causing them to die. Cowen’s team identified the protein PTMA as the signal for C. albicans to filament inside macrophages and showed that using an antibody against PTMA can prevent macrophage death and fungal escape.

Cowen’s efforts to both understand the biology of these morphological transitions and find ways to block them are not driven by scientific curiosity alone. She is equally compelled by the growing burden of invasive fungal diseases worldwide, a trend made worse by the rise of drug-resistant infections and the dearth of new antifungal drugs making it to market. 

“We are very focused on trying to translate the discoveries from our academic lab into new therapeutics. That’s a huge priority for us,” says Cowen, who is also co-director of the Fungal Kingdom: Threats & Opportunities program at the Canadian Institute for Advanced Research. 

Her team has come up with innovative ways to screen libraries containing thousands of molecules to identify candidates that can block C. albicans’ ability to switch between yeast and filament forms.  

To accelerate the development of new antifungal therapies, Cowen co-founded Bright Angel Therapeutics in 2017. The biotechnology company has two programs including one that targets Hsp90, a key enabler of C. albicans’ ability to morph into invasive tendrils at high temperatures. 

Aside from changing its shape, C. albicans can also adopt different lifestyles in response to changes in its environment. It can live a solitary life as a single cell or switch to congregate living with other fungi and bacteria in a complex microbial community known as a biofilm.

Largely due to their stickiness, biofilms are a major driver of infections associated with health care. The microbes in a biofilm are embedded in a slimy mesh of DNA, sugars, proteins and fats that bind community members to each other, enable attachment to surfaces such as sink drains and medical devices, and shield the microbes from drugs and cleaning agents. As a result, contaminated surfaces are harder to disinfect, and infections more difficult to treat.  

“The classic image of a lab-grown biofilm is a mushroom shape with a stalk that’s attached to a surface and a dome on top,” says Lynne Howell, a senior scientist at The Hospital for Sick Children and a professor at Temerty Medicine’s Department of Biochemistry who studies biofilms in the bacteria Pseudomonas aeruginosa. 

As a structural biologist, Howell wanted to know how the different components of a biofilm are made and assembled. In untangling this molecular machinery, her team discovered a protein that could break down biofilm by cutting apart the sugars that make up its sticky glue. 

Howell recalls a critical experiment in which they captured a time-lapse video showing a biofilm disintegrating after the addition of the protein and the Pseudomonas bacteria switching back to a free-swimming state. 

“It was one of those ‘Eureka!’ moments when I thought we could weaponize these enzymes against the bacteria,” she says.

This time-lapse video shows a Pseudomonas aeruginosa biofilm (white layer at the top of the liquid) disintegrating after the addition of an enzyme called hydrolase, whose activity was first characterized by Lynne Howell and her team at SickKids. No hydrolase was added to the tube on the left. (Video credit: Perrin Baker)

“Our idea was that if you can degrade the biofilm matrix, the bacteria that are embedded in there will disperse and be more susceptible to antibiotics and the immune system.”

Howell has since teamed up with collaborators in Canada and the United States to demonstrate the effectiveness of this strategy in animal models of lung and wound infections. She has also partnered with Ben Hatton, an associate professor in U of T’s Department of Materials Science and Engineering, to apply the enzyme as a coating to the inside of a catheter to prevent bacteria from attaching and forming biofilms.

Looking ahead, Howell is keen to develop the enzyme into an inhalable drug that could be delivered alongside antibiotics to enhance their effectiveness in people with cystic fibrosis, for whom chronic lung infections caused by Pseudomonas biofilms pose a common, significant threat.

While bacteria and fungi such as Pseudomonas aeruginosa and C. albicans can switch back and forth between morphologies and lifestyles, other parasites go through a more structured series of transitions.

The malaria-causing parasite Plasmodium falciparum has a complex life cycle that includes 12 life stages spanning mosquito and human hosts. These shifting targets are one reason why it took 35 years to develop the RTS,S malaria vaccine, which became the first vaccine approved against any human parasite.

Despite this milestone achievement, the RTS,S vaccine and a second malaria vaccine called R21 have several notable shortcomings. They are only effective in infants and young children, require four doses and offer a relatively short period of protection. Perhaps most importantly, while they can protect children against severe disease, they do much less to protect communities from the spread of malaria. Children, teens and adults can still carry Plasmodium in their blood, which can be passed on to mosquitoes during their next blood meal. These mosquitoes can then infect other people, continuing the cycle of transmission.

“The RTS,S and R21 vaccines have already and will continue to save lives, but there’s still more to do,” says Jean-Philippe Julien (PhD ’10), a senior scientist at SickKids and an associate professor in Temerty Medicine’s Departments of Biochemistry and Immunology.

“Our ideal malaria vaccine is a single formulation that needs to be administered only a couple of times, protects across all age groups from malaria infections, illness and death, and reduces transmission.”

To achieve this goal, a next-generation malaria vaccine must be able to target the Plasmodium parasite at multiple life stages. It’s a challenge that researchers haven’t had a good shot at solving, until now.

With the support of a $5.7 million USD grant from Open Philanthropy, Julien is leading an international team of researchers in advancing the development of a multi-stage malaria vaccine.

Each research group, including Julien’s, is contributing a vaccine component that targets a unique Plasmodium life stage. The goal is to combine all of the components into a single vaccine and identify any potential synergies or areas of interference. The team will also conduct preclinical testing of different modes of delivery to optimize the immune response.

Julien notes that in comparing the various formulation options, the researchers consider the ability of low- and middle-income countries to access the materials and manufacture the vaccines.

“Our plan is aggressive and ambitious, and that’s exactly the point,” he says.

“We now have the best tools to target different Plasmodium life stages, and with new advances in vaccine technologies, the time is now.” •

From Clinic to Classroom, Meet the Doctors Building Capacity for Gender-Affirming Care

By Erin Howe

When Chase Blodgett, a transgender man, began his transition in 2014, it was a struggle to find a physician in Whitehorse who could provide inclusive medical support. Blodgett had moved from St. Catharines, Ontario, to the Yukon five years earlier, and recalls that most people who required gender-affirming care had to leave the northern territory and move to British Columbia.

“In every exam room I entered in Whitehorse, I was the first trans person the doctor had met,” he remembers. “The best I could hope for was to find someone who would tell me, ‘I don’t know anything about that, but I’m willing to learn and try.’”

Blodgett’s experience is far from isolated.

In 2021, Canada became the first country to collect and publish data on gender diversity in its national census. It showed that about one in 300 Canadians above the age of 15 identifies as transgender or non-binary.

Yet a 2016 study of Canadian medical schools found that most of the surveyed medical students felt they had inadequate training to meet the needs of trans patients.

Then in 2018, a literature review found that despite improvements to health care for transgender people over the preceding decade, there remained a gap in the training of health care professionals.

Ultimately, Blodgett, an education support coordinator and transgender human rights advocate now working in Whitehorse, found a supportive family physician and a psychiatrist. But in the process, the 38-year-old says he had to educate his care providers.

“It makes sense to feel uncomfortable as a professional in an area you’re not familiar with. But improvement starts with learning,” says Blodgett.

Across the medical education continuum at the Temerty Faculty of Medicine, change is underway.

Faculty members such as Yonah Krakowsky (MD ’11, PGME ’13, ’15 & ’16), a urologist and assistant professor in the Division of Urology at Temerty Medicine, are working to expand capacity for gender affirming care.

Krakowsky is also the medical director of the transition-related surgery program at Women’s College Hospital (WCH), the first of its kind to be based in a Canadian hospital.

He says that before the clinic opened in 2019, anyone seeking the procedures had to go to Quebec, the United States or overseas.

Today, the WCH program offers a variety of procedures, including genital reconstruction and chest surgery.

Many of the highly specialized surgeries that his team performs require significant aftercare that can be challenging to coordinate virtually.

Part of Krakowsky’s mission is to educate other health care providers and learners about recovery from gender-affirming surgery, whether or not they plan to specialize in the field.

Krakowsky regularly speaks to first-year medical students about his practice. Afterward, he notices a spike in the number of emails from enthusiastic learners wanting to know more.

“In time, this means we’ll have young doctors in the community who are aware, who know what questions to ask and who have connections to the surgeons who do this work,” says Krakowsky. “Our hope is that even if people have to travel for surgery, there will be people in their communities who will be able to say, ‘I saw this during my training and have adequate knowledge to triage and treat you.’”

In addition to providing learning opportunities for medical students, the clinic welcomes trainees in other professions, including nursing and physical therapy.

Biomedical illustrators have also joined Krakowsky’s team in the operating room, which could create a new surgical atlas and share the knowledge further.

“One day, I think basic gender-affirming care, like speaking with our patients about gender or addressing their concerns following surgery and hormone therapy, will just be part of general medical knowledge,” he says.

That day is coming soon. In 2025, Temerty Medicine’s MD Program will introduce a new trans and gender-diverse curriculum as an integrated component of undergraduate medical training.  Jordan Goodridge, an assistant professor in Temerty Medicine’s Department of Family and Community Medicine, is the health theme lead for the MD Program’s 2-Spirit, Lesbian, Gay, Bisexual, Transgender, Queer, Intersex and Asexual Plus (2SLGBTQIA+) curriculum. Education scholarship, experts in the field, medical students, and insights from trans and gender-diverse individuals will inform the new material.

The update will replace pre-recorded lectures and PDF documents with online learning modules that will be available to medical learners as well as external health care providers and trainees.

The comprehensive series will span topics including language, mental health, sexual and reproductive health, hormone therapy and transition-related surgery.

About 20 years ago, Raymond Fung (MD ’01, PGME ’06), then an endocrinology resident, wondered why there wasn’t more training to prepare him to provide hormone therapy to transitioning patients.

“Hormones belong to my specialty. Gender-affirming hormone care should be a core competency in endocrinology,” says Fung, a lecturer in Temerty Medicine’s Division of Endocrinology and Metabolism, and the head of the endocrinology division at Michael Garron Hospital. “We’ve made progress, but we’re not there yet.”

To help move the needle, Fung holds monthly online sessions for endocrinologists who want to learn about gender-affirming care. Inspired by Rainbow Health Ontario’s 2SLGBTQ Health Connect program for primary care providers, Fung wanted to create something for colleagues in his specialty.

“It’s been good to meet others who have similar interests in providing this kind of care and who have questions, as we all do. And, we learn from one another,” says Fung.

He has also been involved in creating standardized training objectives for transgender care education in endocrinology.

In addition, Temerty Medicine’s Department of Family and Community Medicine offers residents a six-month enhanced skills program in 2SLGBTQIA+ health care. Trainees learn how to provide transgender and non-binary care, masculinizing and feminizing hormone therapy, gender-affirming surgeries, fertility preservation and mental health.

Research underscores the importance of these new learning opportunities.

Trans PULSE Canada, a survey of trans and non-binary people, found that in 2018, just over 52 per cent of respondents had a primary care provider with whom they were comfortable discussing trans health issues. More than 44 per cent reported having an unmet health care need.

Kathleen Armstrong (MD ’11, PGME ’13 & ’21), an assistant professor in Temerty Medicine’s Division of Plastic, Reconstructive & Aesthetic Surgery, contributed to the report. She is also collaborating with an international team that aims to develop a patient-reported outcome measure for gender-affirming treatments.

The studies help shed light on the kinds of care that individuals who are transgender or non-binary want and the barriers they face.

As Armstrong and her colleagues work to expand the pool of professionals who can help, she says it’s critical to recognize that each individual’s journey is unique.

“Twenty years ago, it was assumed that if you were a trans man, you wanted testosterone, a mastectomy and a phalloplasty,” says Armstrong. “Now people can say, ‘You know, testosterone is actually not important for me and my journey,’ or that they just want chest, or top, surgery. It’s about listening to the patients and their specific needs.”

In addition, Armstrong is a plastic surgeon specializing in gender-affirming mastectomies and breast augmentations on WCH’s transition-related surgery team.

Armstrong also teaches residents and fellows about top surgery.

“One fellow who worked with me last year is now in Halifax, another returned to Montreal. They’ll each offer these surgeries in their respective cities,” Armstrong notes. “It’s exciting to see knowledge transfer like that across provinces.”

Medical educators such as Krakowsky, Goodridge, Fung and Armstrong are gratified to see their colleagues’ growing interest in deepening their understanding and honing their skills.

Blodgett expresses a similar gratitude, acknowledging the efforts of educators and others in advancing training to support the health of trans patients. “This work saves lives,” he says. “You are heroes to us every day, even if you never know the impact you have had.” •

Can AI Become Our Trusted Clinical Co-pilot?

By John Lorinc

Artificial intelligence promises to reshape health care as we know it, saving precious time — and lives.

Medical researchers and clinicians are at the forefront of one of the most dynamic — and sometimes contentious — fields in technology. But as we harness the power of AI in everything from diagnostics and imaging to chatbots for patient interactions, what’s ahead for this bold new partnership between humans and machines?

In 2020, a Unity Health Toronto team launched an AI-driven software platform designed to be the digital eyes and ears of the physicians and nurses in two busy hospitals. CHARTWatch tracked about 150 data points, including vital signs, test results and demographics flowing into the electronic health records of patients admitted from the ER to a general internal medicine ward. But the algorithm embedded in CHARTWatch not only watched that data, it continually analyzed it, looking for patterns that indicated an escalating emergency situation and, when necessary, alerted medical staff.

Earlier this fall, CMAJ published the results of a study that compared the results of CHARTWatch’s first two years on call with the three previous years. The findings confirm the efficacy of a technology specifically intended to cut the risk of in-patient deaths. The study found that when CHARTWatch was functioning, there were “significantly lower” non-palliative deaths and a 26 per cent reduction in unexpected mortality.

Muhammad Mamdani, the study’s senior author and the Unity Heath’s vice-president of data science and advanced analytics, says CHARTWatch seemed particularly well suited to spotting previously undetected infections, such as sepsis that requires antibiotics, and worsening cardiac conditions.

One of the key findings, he explains, is that the algorithm inside the platform tends to be more accurate than physicians at capturing the untimely deaths of very sick patients admitted to hospital wards.

“What we’ve learned is that clinicians are typically not very good at prognosis,” says Mamdani, who is also the director of the Temerty Centre for Artificial Intelligence Research and Education in Medicine (T-CAIREM) at the Temerty Faculty of Medicine.

“We collected over 3,000 clinician predictions and were able to show that when a physician says a patient’s going to die or go to the ICU, they’re right less than a third of the time. That told us that the AI algorithm doesn’t have to be perfect, but it has to beat a very low bar.”

The Promises, the Risks 

The envisioned benefits run the gamut, from improved clinical assessments of neurological pain to effectively managing day-to-day tasks, such as documenting patient encounters with primary care doctors who use AI scribe technology for note-taking.

We constantly have to educate our clinicians, new residents, new nursing staff and new physicians — this is a collaboration between AI and humans

Yet, as with all things AI, there are red flags including the known racial biases of machine learning, mistakes in the vast data sets used to train the algorithms and nonsensical outputs, which the AI industry calls “hallucinations.” The technology also poses important questions about safety, efficacy and the regulation of AI-driven software systems embedded in medical devices.

Human factors engineer Enid Montague, an associate professor in the University of Toronto’s Department of Mechanical and Industrial Engineering, says that the goal should be to find a balance between these technologies and the people they serve, including both clinicians and patients, and particularly those from marginalized groups in society.

“There is an excitement to say, ‘Let’s just automate everything in health care,’” Montague says. “But I’m really interested in patients being able to use … generative AI tools to help them manage the work that they have to do themselves in decision-making.”

Expanding Possibilities for Patient Care

One of the most promising applications of AI technology in health care involves imaging and using the software to support both diagnostics and patient interaction. Mojgan Hodaie (MSc’94, PGME’04), the surgical co-director of the Joey and Toby Tanenbaum Gamma Knife Radiosurgery Centre at University Health Network’s Toronto Western Hospital, has developed an AI application to support her neurosurgery practice.

Hodaie, who is also a surgery professor at Temerty Medicine, was familiar with early imaging-related AI applications, to interpret X-ray results. But she saw an opportunity to apply AI to the diagnosis of trigeminal neuralgia, a condition marked by intense attacks of facial pain that typically affects older people. It results from a blood vessel compressing a nerve in the brain stem.

She knew that MRI didn’t always show nerve compression in patients presenting with symptoms. “We wanted to know: What else can we look at in the brains of these patients to give us a better understanding of this pain condition?”

Her team built an algorithm trained on thousands of brain scans conducted at Toronto Western and even larger sets of publicly available brain MRIs. The team sought to identify a specific “pain signature” — small structural changes in the brain, such as an abnormal thickness in specific grey matter areas, that occurred in patients with known trigeminal neuralgia. The algorithm scanned the MRIs for a proxy, seeking the specific neurological fingerprints the condition leaves, to provide additional certainty when diagnosing patients whose imaging does not show evidence of the tell-tale nerve compression.

Hodaie’s team hasn’t rolled out this application in a clinical setting; however, with the algorithm, she will be able to tell her patients with far more precision the likelihood of a surgical intervention being successful. She also envisions applications for other elusive pain conditions in which a specific physical symptom, such as a tumour or broken bone, isn’t discernable using conventional imaging.

“I fundamentally think, in 2024, we really need to do better for our patients,” Hodaie says. “I should have a better opportunity of telling them how likely it is that I will be able to help them, and what their experience in care will involve.”

Not all health care related AI applications drill as deeply into medical processes. Mamdani points to examples such as AI-supported scheduling platforms that allow ER administrators to ensure that nurses, physicians and other health care staff are deployed according to hospital policies; for example, to cover routine rotations between units or to pair junior and senior staff.

“It typically takes a senior nurse about 90 minutes a day to assign nurses to different zones in the emergency department. A clerk on our medical staff spends about two hours a day on this task,” Mamdani says. But this human approach, he notes, violates HR policies 20 per cent of the time.

Conversely, he says, the AI scheduler “looks at the nurses’ history, it looks at the rules and then assigns the nurses.” The time spent on this task plummeted to a matter of minutes, with far fewer violations of hospital HR policies.

Evolving Governance 

Jay Shaw, an assistant professor of physical therapy at Temerty Medicine and the research director of AI, Ethics & Health at U of T’s Joint Centre for Bioethics, points out that the governance of such technologies is crucial, and an evolving domain.

Tech firms develop health care related AI applications that may or may not be subject to approval by Health Canada or the United States Food and Drug Administration. Others, such as CHARTWatch and Hodaie’s MRI-based algorithm, emerge from academic research labs that are subject to university research ethics protocols. Shaw notes that most of the health care related AI-based applications he has seen are not classified as medical devices and so are exempt from the kind of regulatory scrutiny that applies to manufacturers of heart valves or blood thinning drugs.

Shaw also points out that experience from non-health care AI technologies shows how applications have been developed without input from the individuals who will be affected by their use. Community engagement and a rigorous approach to addressing ethical issues will make these technologies better and more effective, he says, pushing back against the notion that ethics is an impediment.

If you don’t get the ethics right,
it’s going to come back to bite you

A multidisciplinary approach is similarly crucial. Shaw cites a project, funded by the Canadian Institute for Advanced Research, to develop AI tools for diabetes prevention. “That project is about a very specific, narrowly defined algorithm that predicts the onset and complications related to type 2 diabetes,” Shaw says, adding that the team includes machine learning experts, epidemiologists, ethicists as well as members of the community. “It’s important to talk to people who are affected by this.”

Transparency and Safety 

These concerns will grow more important as generative AI technology becomes ever-more powerful and the potential applications multiply. The most recent versions of large language models (LLM) like ChatGPT, for example, score well on medical school exams and can provide detailed answers to patient prompts. And some researchers are looking into the possibility of allowing patients to interact with specialized LLMs as a first interaction with care.

As University of California San Diego virologist Davey Smith told JAMA, “You could imagine that people who don’t have access to primary care providers all the time, or highly specialized physicians such as myself, might be able to still access information in appropriate ways to receive some health care and health care guidance.”

But in a recent issue of Nature, a U of T team led by Bo Wang (MSc’12), chief AI scientist with UHN and an assistant professor with Temerty Medicine’s Department of Laboratory Medicine and Pathobiology, argues that the researchers and clinicians building these emerging applications should use open source LLMs. Using non-proprietary algorithms, for example, those developed by tech giants such as OpenAI, would ensure transparency and safety.

“In the rush to deploy off-the-shelf proprietary LLMs,” the researchers caution, “health care institutions and other organizations risk ceding the control of medicine to opaque corporate interests. Medical care could rapidly become dependent on LLMs that are difficult to evaluate, and that can be modified or even taken offline without notice should the service be deemed no longer profitable — all of which could undermine the care, privacy and safety of patients.”

A Powerful Partnership 

Geoffrey Hinton, 2024 Nobel Laureate in physics lauded as the “Godfather of AI,” has sounded the alarm on the perils of the technology outsmarting its human creators. But the professor emeritus in U of T’s Department of Computer Science also extols its promise, specifically for health care applications.

“AI can make a tremendous difference” in diagnosing difficult cases, Hinton told journalists at a U of T news conference in honour of the Nobel announcement, citing data about the improvement in accuracy when humans and machines work together.

From Mamdani’s vantage point at the intersection of AI-driven research and clinical care, he is keenly aware of the risks, such as physicians or nurses becoming overly reliant on systems that generate diagnoses or catch tell-tale indicators that a patient is in decline.

He refers back to a lesson from the deployment of CHARTWatch. “We constantly have to educate our clinicians, our new residents, new nursing staff and new physicians that this is a collaboration between AI and humans,” he says. “It’s not one or the other — it’s the two working together.” •

Making My Own Path

My long and unconventional path to medical school started in a homeless shelter where I was living when I began my undergraduate studies at the University of Toronto. When the journey is long, you think that everything will change once you arrive at your destination and that even the air you breathe will be different. But of course, when I finally arrived at med school, many things, including the air, were still the same. 

One thing that has changed is my idea of what success looks like. Medical school is the first time when everything I’m doing in and out of the classroom — even things I’m not being assessed on — is relevant to my goal of becoming a good doctor. For me, this includes embodying professional values in my actions and interactions with my peers and educators, and members of the broader health care community who I meet along this journey. 

In undergrad, it felt like there was a box and success meant fitting myself into that box. But in medical school, the message has been, “Here are the things you need to do to be a good doctor. Now, what is your version of that, and how can we support it?” I feel supported in finding whatever shaped container works best for me to achieve that goal.  

My concept of time has also changed. Between my medical studies and job as the editor-in-chief of an arts magazine, free time is something that I must now actively schedule and carve out space for. I am as deliberate in planning my free time as I am in planning my professional and academic time. 

I think my transition to med school was a little easier because I completed my undergraduate and master’s degrees at U of T, which meant I was familiar with the school’s atmosphere, pace and philosophy of assessment. I was able to hit the ground walking and hopefully by the winter break, I can start to run. 

Michael Zarathus-Cook (MHSc ’23) is a first-year student in the MD Program at Temerty Medicine. •

Medicine Has a Way of Keeping You Humble

Adjusting to residency has been a rush — there are a lot of new acronyms to learn and late nights fuelled by lots of coffee. The pace is intense, but it’s the kind of challenge I thrive on.

So far, the biggest challenge has been mastering the balance between being a learner and a decision-maker. In medical school, you’re in the passenger seat, absorbing knowledge. But as a resident, you’re expected to take the wheel and navigate real-time decisions.

Seeing how quickly patients trust me with their care is humbling, and it motivates me to be better every day. Each patient encounter adds a little more to my toolkit of clinical skills.

I’ve also become a patient advocate, which is both challenging and rewarding. Being the one who explains a diagnosis, guides patients through treatment options and addresses their fears is a significant responsibility. It has been a lesson in compassion and communication. I’ve learned how to ensure patients feel heard, even when time is tight. The moments when it’s clear that patients truly understand their conditions and feel empowered in their care is truly fulfilling.

Medicine has a way of keeping you humble. The biggest surprise has been realizing how much I don’t know — and that’s a good thing. Learning to trust my instincts while remaining open to learning from my mistakes has been helpful. I’m guided by the advice of a great mentor who told me, “It’s OK to be wrong, as long as you’re willing to learn why.”

Michael Balas (MD ’24) is a first-year resident with the Department of Ophthalmology and Vision Sciences at Temerty Medicine. •

Discovering the Joys of Leadership

Becoming a principal investigator (PI) is a career path in which years of intensive training in bench science may not quite prepare you for the actual day-to-day demands of the job.

As a graduate student and then a postdoctoral fellow, I learned how to apply the scientific method to design experiments and tackle questions for which we don’t have answers. Now, as an early-career PI, I also spend a lot of time answering emails and juggling a million administrative tasks. The job requires me to constantly pivot between the “Big Picture” and details such as experiment design, training and finance. It’s overwhelming but also exhilarating.

When I moved back to Toronto from California to establish my own lab at The Hospital for Sick Children (SickKids) in early 2023, I was pleasantly surprised to discover I felt better prepared for the role than I thought I would be. I credit the training I received as a graduate student at the University of Toronto and SickKids, and the autonomy I had during my postdoctoral fellowship at Stanford University for preparing me for this transition.

My research program is partly focused on regeneration in axolotls, a species of aquatic salamander. These animals have the unusual ability to regrow and repair almost any body part, including arms, legs, the spinal cord and even the brain and the heart. We want to understand this process to see if it can be applied to improve the healing and repair of human organs and tissues, particularly after trauma, injury or degenerative diseases.

I’m very excited to bring the axolotl model to Toronto, a world-renowned hub for regenerative medicine. And I am incredibly grateful to the team at SickKids who have been instrumental in helping set up the infrastructure for an axolotl colony.

This fall marks a huge milestone for our lab — my first cohort of graduate students just completed their first year, and our first axolotls arrived a few weeks ago. I can’t wait to see what my team and I will accomplish in the coming years. The biggest joy of being a PI is working with students and seeing their skills and confidence grow. It’s a huge responsibility and privilege, and I can’t wait to do more of it.

Olena Zhulyn (PhD ’14) is a scientist at SickKids and an assistant professor of molecular genetics at Temerty Medicine. •

The Art of Retirement

Medicine is extremely demanding. It’s easy to let other passions go, and risk losing part of yourself.

Before starting my mixed internship in Montreal in 1978, I had a strong commitment to drawing and a realization that I didn’t want to lose that with the pressures of practising medicine. So I delayed my internship and studied art for six months.

Learning to examine living anatomy and the unique character of each model made me a better observer and physician. Studying the frailty and beauty of the human figure is essential to understanding who we are.

Later, when I was working as a physician, I took my degree in medical illustration at the University of Toronto. I could work 12- to 14-hour days as a doctor, with the unpaid demands of administrative work and hours on the phone. But one day a week, I could have that meditative time and make illustrations. It was a lifesaver.

I published as a medical illustrator for years and, for two decades, also taught anatomy for artists and life drawing at the Ontario College of Art & Design (now OCAD University).

In 2017, after 39 years in medicine — 36 in independent practice — I retired. The transition wasn’t difficult, but I felt a sense of letting people down. There are people who you grow connected to, like the woman whose husband I cared for as he died. I was the only one in the practice who knew her before she was a widow, and the struggle she went through. Another patient, an older gentleman, said, “I thought you were going to see me out.”

As physicians, these are the people with whom we share the most intense conversations of our lives. It’s hard to walk away from that.

But when I left medicine, I wasn’t just stepping out of something, I was stepping into something else — a parallel career that had sustained me during my medical practice.

Now I teach workshops at the Haliburton School of Art and Design. Life drawing is a social thing, and I love the connection. Observing a live model is similar to practising medicine. It’s an enormous privilege to enter another person’s world and examine them without judgment.

Stephen Tulk (MD ’77, BScAAM ’88) is a retired family physician and anatomy professor, a practising artist and teacher. •

2024 Dean’s Alumni Award Recipients

Visit temertymedicine.utoronto.ca/alumni to learn more about the Dean’s Alumni Award recipients and other alumni programs.

By Emma Jones and Heather McCall

As an MD student, Katherine Sawicka (PGME ’20) was already considering specializing in neuroanatomy and neurology, with a particular focus on children and youth.  

But her decision to further specialize in multiple sclerosis (MS) care was solidified when, while studying at the University of Saskatchewan, one of her classmates experienced an MS attack.  

“I would go visit her in hospital and bring our histology homework,” remembers Sawicka, now a neurology trainee in the Temerty Faculty of Medicine’s Department of Medicine and a clinician-scientist completing her PhD at the University of Toronto’s Institute of Health Policy, Management and Evaluation. 

“She would share with me her experience, and I really saw how scary the unknown is — not knowing when the next attack will be.” 

As Sawicka learned more about the disease, she recognized that patients and families face additional challenges transitioning from paediatric to adult care. 

“When a patient reaches the age of 18, they’re transferred to a different care provider. It’s a transfer — not a transition, which is gradual,” she says. “This abrupt change can be difficult for someone at that age.” 

Sawicka explains that not only does this “now-adult” need to learn how to manage their symptoms independently and take more responsibility for their care, they’re experiencing many other changes; for example, starting a job or post-secondary education, forming new relationships and exploring their gender identity. 

“It’s already a very challenging time,” she says. “Unfortunately, there are no global or regional best practice guidelines for how to support MS care during transition.” 

Wanting to improve those health outcomes is why Sawicka is focusing on this cohort of patients as a researcher with the SickKids Research Institute’s Child Health Evaluative Sciences program. Bolstered by philanthropic support from donors, she is seeking to better understand the self-management of MS during this transitionary period to inform the development of targeted support structures and long-term care strategies to meet their unique needs. 

Canada has one of the highest rates of childhood-onset MS, and its prevalence is on the rise. In Ontario, for example, the incidence has grown from 2.93 per 100,000 people in 2003, to 4.07 per 100,000 in 2019. 

Advances in MS diagnostics and detection mean that more teens than ever will transition from family-oriented paediatric care to self-management. However, childhood-onset MS is still associated with a high burden of disability in adulthood. Research and support are needed to assist this growing cohort of young patients. 

Sawicka’s goal is to understand this cohort’s perspectives, priorities and challenges associated with MS self-management by interviewing young patients in the Greater Toronto Area as they move from The Hospital for Sick Children to St. Michael’s Hospital, Unity Health Network. She will also use data from the larger Canadian Prospective Cohort Study to Understand Progression in MS to better understand the experiences of young MS patients. 

“MS really affects young people in a very personal way, not just their health but socially and professionally. Through those intereviews, I saw how resilient young people with MS are.” 

Sawicka’s findings and recommendations will inform a model of best practices for adolescents and young adults with MS. Ultimately, the best practices will help ensure that every young MS patient is supported by accessible, responsive interventions and clinical care programs. 

“I’m spending a lot of time talking to people about self-management and how they manage their MS beyond medications, which will allow us to advocate for and contribute to those other very important parts of MS care.” 

Recently, Sawicka has been directly involving study participants by inviting them to help her develop lines of inquiry and survey questions. This type of engagement not only ensures the relevance of her research, it builds trust with the participants and provides them with a vehicle for sharing the thoughts and feelings they might struggle to communicate during clinical appointments. “It’s a satisfying way to explore issues that are important to people with MS that we don’t necessarily have the resources to explore in clinic,” she says. 

For Sawicka, the interdisciplinary collaboration made possible by pursuing this research through U of T and Temerty Medicine has been critical. She trains alongside students with backgrounds in paediatrics, nursing and occupational health, and collaborates with leading clinicians and scientists across the Toronto Academic Health Science Network as well as with researchers from peer institutions elsewhere in Ontario. 

Sawicka is a grateful recipient of the Elizabeth S. Barford City-Wide Research and Education Collaboration Fund in Multiple Sclerosis, which allows her to focus on ensuring that her research will have an impact and benefit clinicians everywhere. 

“I just feel so privileged and blessed to receive support,” Sawicka says. “It allows me to really prioritize, keep the work relevant and make it excellent.” • 

Starting the Conversation About End-of-Life Care

By Emma Jones

When it comes to decision-making at the end of life, David and Bunni Bresver want people to know their options and start talking about the care they want.

For the Bresvers, an individual facing a serious illness coming together with their family members, friends and caregivers to make informed end-or-life plans, based on personal values, is an expression of love for all involved.

“Everyone is entitled to be aware of the options available to them, for both the rest of their life as well as at the end of their life,” says Bunni. “These conversations give the power back to the patients.”

Bunni and David’s commitment to educating people on end-of-life care options and empowering them to make their own choices has come from their experience in supporting six family members through a progressive, terminal illness.

“Watching someone you love die that way is extraordinarily difficult,” says David. “We were often with family members who were supporting others who were terminally ill and would have conversations about how they didn’t want this for themselves. But later, when they received their own diagnosis, we would watch it happen all over again.”

“My mother died of cancer and dementia,” adds Bunni. “The most heartbreaking part was that before she died, she told us, ‘Don’t remember me this way.’ That will always stay with me.”

As stewards of The Feiga Bresver Academic Fund, named in honour of David’s grandmother, the Bresvers aim to equip physicians with the skills and language they need for compassionate end-of-life conversations with their patients.

In 2021, David and Bunni created the Bresver Family Chair in End-of-Life Care and Medical Assistance in Dying in the Temerty Faculty of Medicine’s Department of Family and Community Medicine. Their aim is to advance and build capacity among primary care physicians to provide comprehensive end-of-life care.

In their professional lives, both Bunni, a retired psychologist, and David, a lawyer, have had many conversations with clients and colleagues coming to terms with a terminal diagnosis.

“I certainly see clients with questions around estate planning but generally, people are not really interested in having a deeper conversation,” says David. “Most people in that position don’t realize they have the power to make important choices for themselves, but they have only limited or incorrect information.”

“There’s so much more to talk about,” Bunni adds. “What do they want the end of their life to look like? Where do they want to be? At home? In a hospice? What personal possessions or music would bring them comfort? Who do they want to have there with them?”

The current holder of the Bresver Family Chair, Jeff Myers (PGME ’97), is a palliative care physician at Sinai Health’s Hennick Bridgepoint Hospital and a medical assistance in dying (MAiD) assessor and provider. Myers, who is also a professor with Temerty Medicine’s Department of Family and Community Medicine, is developing training opportunities to equip family doctors with the tools to support evidence-informed planning and end-of-life care, including MAiD.

As a palliative care doctor, Myers often sees how a serious illness can leave a patient and their family unprepared for the progression of the disease, with the patient and family caught off guard by the patient’s quickly declining health. With good conversations, this is entirely preventable, he says. Having supported hundreds of patients through end-of-life care — some choosing MAiD, but most not — Myers has witnessed the consequences of overlooking these critical discussions.

But now, patients and their physicians are embracing conversations about what was once a taboo subject; namely, what it means to have a terminal illness.

“People are becoming more comfortable with exploring and understanding what to expect at life’s end,” Myers says.

“These are conversations that can help not only the patient, but also their family members, be at peace with this next transition.” •

In this 1977 photo, renowned heart surgeon and inventor Wilfred “Bill” Bigelow (MD ’38), shares a laugh with colleague and head nurse Jessie Doyle as he is surprised with his surgery clogs, bronzed in celebration of his retirement.

As head of Toronto General Hospital’s cardiac surgery division for over 20 years and Professor of Surgery with the University of Toronto’s medical faculty, Bigelow revolutionized cardiac care. 

In the late 1940s, Bigelow pioneered the use of hypothermia in open-heart surgery. In 1950, Bigelow co-developed the first electronic cardiac pacemaker alongside fellow U of T surgeon John Carter Callaghan (MD ’46) and Ottawa electrical engineer John Hopps. Their innovation paved the way for modern implantable pacemakers, a device Bigelow himself would later receive.

In recognition of his contributions to medical science, Bigelow was made an Officer of the Order of Canada in 1981. He died in 2005, leaving a legacy of innovation and improved patient outcomes in cardiac care. •