Welcome to the Residents Corner Newsletter!

Winter 2011
 

Happy New Year!

On behalf of the section executive, we wish all of you a happy and healthy new year!

As always, the Residents Section is working on several initiatives, including updating old or tired electives databases on the CPS website, and working with Program Chairs to improve and refine the paediatric subspecialty matching process.

We're also looking forward to a resident advocacy day across Canada this spring and, of course, to the CPS Annual Conference in Quebec City this June. We hope to see you at sessions we've planned, including our Residents Advocacy Dinner - with a talk by Dr. Leila Srour entitled "Taking on big formula" - and a session on becoming an academic paediatrician.

We're always happy to receive suggestions for initiatives and events, so keep them coming.
Enjoy this issue of Residents Corner, and all the best for the coming year.

Your CPS Residents Section executive,
Gillian Dolansky (president)
Dina Kulik (vice president)
Sarah Waterston (past president)
 

News and Views

Dreams and disabilities

I was saddened a couple of months ago, when I heard that the "Centre for Dreams" in Markham, Ontario had been asked to leave their location. New condominiums are to rise up in its place. The Centre for Dreams is an organization founded by Elaine Vollett, initially inspired by the needs of her son John who has cerebral palsy. Here, "Dreams" is an acronym for Developing Relationships with Exceptional Adults in Modern Society. Elaine started the program in her basement with her daughter Michelle, as they did not have access to a suitable program for John.

Although this is a youth- and adult-based program, it got me thinking about our own world of paediatrics. We continue to make gains in optimizing medical management of our patients with developmental disabilities; but from a social perspective, do we have more to offer?

In the Neonatal Intensive Care Unit it becomes apparent that somewhere amid the tangle of wires and tubes, we can now keep 23-week-old neonates alive. We are all aware of the proverbial double-edged sword: Rates of disability due to cerebral palsy and other congenital conditions rise with advances in technology and medical care. As our thoughts revolve around diagnosis, investigations, and ensuring that all the child's medical needs are met, we may forget that this makes up only a fraction of the child's life.

Issues of acceptance, life-style changes, financial issues and the remodelling of family dynamics may be overlooked as they unfold. Just as medical issues hold precedence in our minds, social issues are often at the forefront of parents' minds. Just acknowledging these other issues exist may drastically improve the therapeutic alliance we have with our patients.

It has been long acknowledged that social circumstance has a large impact on health and happiness, especially in paediatrics. Bullying, segregation, lack of emotional and physical support, suboptimal access and financial stress all impact the health of a child. In these cases, caregivers, parents and siblings are deeply affected, ultimately impacting patients themselves.

In this particular group of children and adolescents, facilitating and optimizing skills such as communication, vocational skills and the activities of daily living can make a major difference to the quality of life of both child and caregiver. 

What can we do as paediatricians?

Interestingly, parents may have unrealistic expectations of what their children can or cannot do. Elaine tells me that many of the parents she has been in contact with underestimate the abilities of their children. She also pointed out that genuine and complete parental acceptance of their child's disability seems to positively influence the optimization of that child's potential. Parents are the most important advocates for their child's health. As paediatricians we have a role to play in facilitating parental acceptance and providing links to services such as counselling, family group support networks, financial services, and provision of information that may help to empower parents.

With so many aspects for families to contend with, I feel that it is our duty as paediatricians to advocate for these children as much as we can. Being more deliberate in our attention to the social endeavours of the child, and to their long term goals, can help to bridge the gap between social and medical domains. 

The Future

On a larger scale, integrating people with disabilities into society facilitates acceptance, and equality. In an ever- changing society, are we dynamic enough? Elaine tells me they still struggle to get their members into employment. Advocating for our adolescent patients with disabilities, for example, to gain work experience or community service at our own hospital or community-based institutions, would allow these young people to utilize their potential and increase social acceptance in the process. Furthermore, seeing these individuals contributing to society may inspire parents and caregivers of other children with developmental disabilities.

Despite the multiple barriers that still exist to this process of integration, I feel that as paediatricians we must be part of the change, actively encouraging a more positive outlook for our children with special needs. Services vary widely depending on region, but our awareness as to what is needed and what is available will ultimately allow us to help families as well as enhance our understanding of the "bigger picture". Along with advocating for the best medical care possible, giving some attention during the consultation to what the long-term goals are, and ways to achieve them, is well within our realm. If children with developmental disabilities are helped with social progression from an early stage, we can also improve medical transition into the adult world. For example, early institution of services to optimize communication skills will ultimately allow young patients to advocate for their own health as much as possible.

Programs like the Centre for Dreams provide people with a developmental disability to lead independent lives, to grow their life skills, and to realize their potential as valuable contributors to society. When I heard this story, I was humbled by the vision this ordinary family had turned into an extraordinary reality, not only for their own son, but for so many other members. They had turned a difficult circumstance, one we will probably see in our own practice, into something progressive and dynamic. This is an example of a family finding their own solution to a very real problem. Having links to, and supporting, organizations which help to implement life skills will help us to support our patients and their families.

As paediatricians, we are aware of the enormous impact social circumstances have on the health and well-being of any child. Being advocates, empowering parents and promoting acceptance and equality in society may be among the greatest gifts we have to offer.

Neha would like to acknowledge Elaine Vollett and Michelle Del Carmen at the Centre for Dreams, for sharing their experiences.

Neha Sharma (PGY2)

Paediatric resident outreach project with asylum seekers:
Some children in Canada are being denied adequate access to health care

Each year, thousands of people move to Canada as immigrants, sponsored refugees or asylum seekers. Many of these new arrivals are children. Asylum seekers, who are also known as refugee claimants, are individuals who seek refugee status after their arrival in Canada. Because of the precariousness of their status, they represent a uniquely vulnerable population. In March 2009, several of the paediatric residents at the Montreal Children's Hospital started an outreach project with asylum seekers at the nearby YMCA residence, where the majority are housed during their first month in Montreal (PRAIDA, 2008). This project was made possible by a grant from the Foundation for the Promotion of Social Paediatrics, and has consisted primarily of health information sessions and the distribution of health-related materials. Through this project, we have gained further insight into some of the barriers faced by asylum seekers during their first few years living in Canada.

In addition to past hardships and the numerous difficulties that accompany adjusting to life in Canada, many of these asylum seekers, including their children, also experience multiple barriers to health care (Rousseau, 2008; Ter Kuile, 2007). Several studies have shown that asylum seekers and their children have worse mental and physical health outcomes than the general population (Beiser, 2001; Hyman, 2007; Nadeau, 2006).

Asylum seekers display remarkable resilience and continue to make valuable contributions to our society. They, like all other individuals, have a right to adequate access to health care.  Unfortunately, however, they are not granted the same rights to health care as the general Canadian public.  Their unique coverage, through the Interim Federal Health Programme (IFHP), is designed to provide care primarily for essential services and medical emergencies (CIC, 2006). This is problematic for several reasons, but especially so in the case of children. Asylum seekers wait on average 16.5 months for their hearing to determine their refugee claim (CCR, 2008), and they have IFHP coverage throughout this period. This interval represents a considerable length of time in the life of a child. As paediatric residents, we know very well that children require routine care such as vaccines, dental and medical check-ups in order to ensure adequate growth and development. While in theory the IFHP provides coverage for many of these services, in practice we find that access to services is limited, particularly with respect to routine dental care and some medications. Through our discussions, we have also learned that asylum seekers are often denied health care even if the services they require are eligible for coverage. Some clinics in Montreal simply refuse to provide care for them, citing unfamiliarity with the IFHP. In response, we are creating a survival guide on how to navigate the IFHP. We also hope to advocate among health care practitioners and the public about the rights of asylum seekers through presentations and publications.

Despite Canada's international reputation as a champion of refugee rights, another reality we've encountered is that recent policy changes have dramatically reduced the number of asylum seekers making refugee claims in Canada. In July 2009, two policies were adopted that severely impacted the flow of asylum seekers into Canada. These included the imposition of visa requirements on Mexicans and the amendment of the Third Safe Country Agreement, which prohibits individuals to make an asylum claim in Canada if they arrive by land from the U.S. These policies drastically reduced the influx of Mexicans and Haitians, who made up the majority of asylum seekers coming to Montreal. The YMCA residence, instead of housing over 300 asylum seekers a month, now houses less than 50. Our project has adapted: We offer similar health information sessions, but now to former residents of the YMCA when they are invited to return for monthly workshops.

As paediatric residents, we are committed to the health and well-being of children and their families in Canada. Part of this commitment involves speaking out against the injustices that prevail within our society and fostering an attitude of change. Asylum seekers and their children are not receiving equitable access to health care in Canada. It is time for something to be done and we need the support of all paediatricians for this change to begin to occur.

If you have questions, similar experiences to share, or if you are interested in collaborating on an advocacy campaign, feel free to contact us:
gillian.morantz@gmail.com
brett.schrewe @gmail.com
tamara.gafoor@mail.mcgill.ca

Gillian Morantz (academic general paediatric fellow)
Brett Schrewe (clinical educator fellow)
Tamara Gafoor (PGY3)

Residents as advocates

As a third-year paediatrics resident, I have unfortunately encountered many situations in which patient care was potentially compromised by complex social circumstances.

I have met parents who have made the difficult decision to leave their country of residence in order to access medical services for their children.  Not only are these parents faced with an ill child, but they are often forced to deal with numerous other stressors such as lack of housing and income.  To compound these problems, they also face paying for health services much like other individuals in this country who, for various reasons, are uninsured medically.  To get a sense of the financial burden, consider that at our institution, just registering for a clinic visit reportedly costs over $200 and admission to the hospital costs an average of $500-1000 per day.

Barriers to health care also exist for those who have medical coverage.  For instance, families who are homeless or living in shelters are often unable to afford transportation to seek medical assistance or to pay for medications.  Other individuals, such as immigrants, struggle with navigating a new health care system and with communicating or understanding their child's health issues.  On several occasions, I have witnessed physicians giving information to parents who appear to be politely nodding with understanding but when asked later, will acknowledge they understood very little of what was being said.

What can we do?

Residents are often among the first health care professionals to come into contact with these patients. We are thus in a unique position to be early advocates.  What can we do to help?  Here are a few things that came to mind...

  1. Remembering to take at least a brief social history is essential: If we don't know, then we can't help.

  2. Reminding our staff to be sensitive to social situations impacting health care and supportive of initiatives that may help to ease a family's burden (e.g., giving free medication samples).  

  3. Obtaining the assistance of a social worker early on is important. They are much more experienced in, and knowledgeable about, accessing services or funds.  

  4. As painfully slow as it may seem, using an interpreter or language line ensures that caregivers more fully understand their child's medical issues.

  5. Simple gestures, such as listening to parents talk about their struggles or gifting a book or toy (readily found in many clinics or wards) to a child who may not be able to afford such items, can mean a lot to families.

Finally, I would like to send out a friendly reminder to all paediatric residents to please advocate for your patients!

Jackie Chiang (PGY3)

 

On a lighter note...

... this collection of documentation statements by health care professionals (including a doctor or two), were gleaned from patient charts during a recent review of medical records:

  • I saw your patient today, who is still under our car for physical therapy.

  • The patient had waffles for breakfast and anorexia for lunch.

  • The patient lives at home with his mother, father, and pet turtle, who is presently enrolled in day care three times a week.

  • The baby was delivered, the cord clamped and cut and handed to the paediatrician, who breathed and cried immediately.

  • The patient was in his usual state of good health until his airplane ran out of gas and crashed.

  • While in the emergency room, she was examined, X-rated and sent home.

  • Exam of genitalia reveals that he is circus sized.

  • Exam of genitalia was completely negative except for the right foot.

  • Rectal exam revealed a normal size thyroid.

  • She is numb from her toes down.

  • The skin was moist and dry.

  • The lab test indicated abnormal lover function.

  • Patient was alert and unresponsive.

  • When she fainted, her eyes rolled around the room.

  • Patient has chest pain if she lies on her left side for over a year.

  • On the second day the knee was better, and on the third day it disappeared.

  • The patient is tearful and crying constantly. She also appears to be depressed.

  • The patient has been depressed since she began seeing me in 1993.

  • Discharge status: Alive but without my permission.

  • The patient has no previous history of suicides.

  • Patient has left white blood cells at another hospital.

  • Patient's medical history has been remarkably insignificant with only a 40 pound weight gain in the past three days.

  • Both breasts are equal and reactive to light and accommodation.

  • Skin: somewhat pale but present.

  • Patient was seen in consultation by Dr. Blank, who felt we should sit on the abdomen and I agree.

  • Large brown stool ambulating in the hall.

Sanjukta Basak (PGY2) 
 

Join us in Quebec City this June!

Don't miss our activities for the upcoming CPS Annual Conference, June 15-18, 2011:

  • Advocacy Dinner - Wednesday, June 15, 18:30-20:30 - Keynote: Leila Srour, MD (Laos)

  • Business Meeting - Thursday, June 16, 17:00-19:00

  • Resident Social - Thursday, June 16, 19:00

For a chance to see your own work in print and earn free admission to the CPS Annual Conference, consider submitting an interesting and educational clinical "pearl" in the Trainee Clinical Case Competition - The deadline is March 15.

Early bird deadline - Don't forget to register before April 30!

Visit the conference website for details on all of the above.
 

Grant opportunities (Application deadline: April 30)
   

From your CPS resident liaisons

So, you want to be a hospitalist...

The CPS Hospital Paediatrics Section was established in 2005 with the goal of capturing the diverse group of paediatricians from across Canada with a common interest in the care of hospitalized children. With over a hundred members, the section is forging connections through educational activities, by contributing to CPS position statements, advocacy, and potential research collaborations. We aim to improve practice while maintaining a general paediatric perspective, as distinct from paediatric subspecialties.

Another objective of the Hospital Paediatrics Section is to support residents in career development by offering a bursary to offset the cost of presenting academic research in the field at a major national or international meeting. The Hospital Paediatrics Section organizes CME activities at the CPS Annual Conference.  For the June 2011 gathering in Quebec City, an interesting interactive session for infectious disease and hospital paediatricians is planned. We will discuss controversial practices in the management of common infections in hospitalized children.  Another session is a journal club forum, featuring the latest published research in a "quick hits" format.

Finally, many of the section's executive are enthusiastic mentors and would love to discuss possible career paths in  community practice or academe, fellowship and scholarly opportunities. If you would like to become a member of this section or are interested in being linked up with a mentor in hospital paediatrics, please contact sanjay.mahant@sickkids.ca.

Niraj Mistry ( PGY4, Resident liaison, Hospital Paediatrics Section)

Here is a brief update on what the Paediatric Emergency Medicine Section of the CPS is working on:

  1. Resident electives: To ease elective planning for residents, we are updating all the information on PEM electives opportunities at Canadian sites.

  2. Mentorship program: A new initiative pairing PEM fellows with staff attendings from sites across the country.

  3. eForum: Check out the CPS eForum for discussions on various topics relating to paediatric emergency medicine.

  4. The Anna Jarvis Paediatric Emergency Medicine Teaching Award was established to recognize outstanding educators whose experience spans several levels: from the local to the international, from undergraduate courses to CME. Consider nominating one of your own PEM attendings! Visit www.cps.ca/English/Awards&Grants/Jarvis.htm for details.

Whether you see yourself as a future "emergentologist" or not, we would love to hear from you! If you have ideas for CPS conference sessions, or for initiatives where we can take a lead... or anything else, please contact me at  shirmee.doshi@sickkids.ca.

Shirmee Doshi (PGY2, Resident liaison, Paedatric Emergency Medicine Section)

 

Stay connected!

The Canadian Paediatric Society is on now on Facebook. Join now and receive timely links to CPS news, new statements and publications and upcoming CME opportunities. Follow Caring for Kids on Facebook and on Twitter for links to child and youth health information that's ready-to-share with parents.

 

The Residents Corner editorial team

Sanjukta Basak, Dina Kulik, Jodie Ouahed.

 

Si vous préférez recevoir ce bulletin en français, écrivez à education@cps.ca.