Paediatrician (Quebec)
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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.
- Use Jordan’s Principle
- 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.
- In other communities she finds that children with disabilities have zero support
- 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.
- Sending people out for evaluations doesn’t work.
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.