Paediatrician (Quebec)
Background
Works with Cree and Inuit people in Northern Quebec
Long experience working with remote care
Used to spend 15 weeks a year up north
Spent 1 day a week at the children’s clinic
Also does some medical day hospital
Hadn’t used telemedicine platform. Didn’t find it useful for pediatrics for patients up north
What has changed after the pandemic?
Still goes up north because there isn’t covid there
Doesn’t go to the hospital because of covid
Some aspects work better, for example follow ups with children with attention deficit, anemia, abdominal pain, constipation, and etc works really well remotely
Less consults than previously. Family physicians giving fewer referrals
New consults by Zoom (started half way through pandemic)
Mostly uses telephone
Books an hour per case, usually on time because of the reduced client load
Also takes less time because they focus on the issue. The child is usually not present, so they don’t have to miss school
Miss doing the initial physical exam, this is suboptimal, have to rely on family physician's report
In the past have had cases where the consult missed information that was found during the physical exam
However physical exams are often not needed for follow ups
Some benefits, for example those with developmental issues, can observe the child in their natural environment via Zoom. This provides better information than trying to observe them in the clinic
Interaction with children is not as good, but with the parent it isn’t difficult
Working with children in the north
Social pediatrics
See them as a team (multidisciplinary), including someone local for cultural reasons
This is a model for how things should work continuing into the future
However, this doesn’t work well remotely.
No internet
Social pediatrics doesn’t work well with multiple people on the phone
Different dynamic
The children see the local doctor immediately and get put on a list for referral but the pediatrician doesn’t go there for maybe several months later
There is a gap between the issue and when they are seen
The pediatrician thanks the patient for coming, instead of the patient thanking them. (Reversal of typical practice in the city)
Being able to call the parent is a benefit
Can reach them sooner (less of a gap)
Can talk to them at their home (more comfortable environment)
Can setup follow ups by phone calls, most like that
80% don’t show up for their, in person, appointments (specifically for Inuit community). However, they are more receptive to answering phone calls.
There isn’t a language barrier in terms of English, they speak English very well.
The cultural barrier is huge and maybe bigger than anywhere else in the world.
The phone remains the best tool for remote medicine
They work with parents of young children, has not experienced any barriers to using technology. Often they are even more adept at it.
Some communities have local physicians, some have visiting physicians who come once a month.
If need be they will fly a patient out to receive care
Are the needs of children with disabilities met?
No they aren’t being met
Take 1.5 hr to see a child in a non-clinical environment, a playroom.
Federal program
Named after an indigenous child born in Manitoba, who couldn’t go home for 2 years, but was able to with lots of equipment
There was a debate between who should fund this, the province or federal government. In the end Jordan died before the debate was settled
What’s missing in Jordan’s principle (opinion) is physiological/mental health support for parents. Parents are a fundamental part of a child’s life. Investing in the parent is also an investment in the child.
The model they are using in Great Whale is working really well.
In other communities she finds that children with disabilities have zero support
They do have abilities to diagnose children, but they see them once every couple years so support is not good.
They need to have local educators
Sending people out for evaluations doesn’t work.
Foreign environment
May have to travel with others because their parents are on a blacklist for behavioural issues down south.
Need regular meetings (now with remote practice, can have more opportunity to meet)
The local educators want to do the job, and just need help doing it.
Is there substance abuse with children
Starting as early as age 8
Issues with cigarettes, alcohol, cannabis
Children are often out on the street
Don’t feel safe at home
Overcrowding at home (sometimes 15/house, whole family in a room)
This causes them to reproduce the behaviour they see at home
Suggests to have a bus that can go around the town for the children to get food, have a safe place to play, and interact with professionals (they have something like this in Montreal)
ACES (adverse childhood events)
Asked 10 questions (neglect, abuse, parental separation, family violence, parent incarcerated, parent with mental health issue)
The higher the score the more likely of health issues
People with scores of 8 or higher tend to have 20 years less life expectancy.
In the north they have a 15 year lower life expectancy. It’s also likely that many children and their parents have been exposed to alcohol during pregnancy (in utero)
“The deepest Well” book, the author, Nadine Burke Harris M.D., also has a Ted talk.
Cultural safety
They speak English so it’s easy to assume they have the same foundational concept
e.g. the colour blue.. in different languages it’s the same concept but different word. Until settlers came, for them blue and green were the same colour.
7 in most languages is a short word, but in the Inuit language it’s 8 syllables and translates roughly to “a little less than 2 times 4”
important things are short words
They have a different concept of time, not as important/precise as we might refer to time.
In medicine our tools are words, but our words are not understood as we expect them to be
Concepts between indigenous communities don’t always match occidental perspectives, which can cause confusion, even when speaking the same language.
Who is at greatest risk for exclusion with virtual care?
It’s the same people, the ones who don’t come. They are also the ones most at risk
It’s always the same people who fall through the cracks.
Is there a trend for why they don’t come?
Some forget
Some are busy, it isn’t a priority for them
It’s hard to know if virtual care might reach more of these people
In general home visits aren’t welcome, but not entirely sure why. Might be related to feeling judged.
They have cellphones but they may not have cellular service. They use mostly for text communications it seems.