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.
• 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.
• 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 at 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.