Making Exercise Appealing for Young Couch Potatoes

Yes, there’s a television in Steinbeck’s Scottsdale, Ariz., home. But the family’s television room also boasts an exercise bicycle, mini trampoline, and several large exercise balls.

Her two children are just as interested in the tube as any other red-blooded American kids, but Steinbeck sees to it that if they’re tuned in, they’re exercising at the same time.

Everyone in the family uses the equipment as we watch television, the author of the best-selling Fat Free cookbook series explains. That way, the kids are hardly ever sitting and they’re in constant motion. It’s one way to make viewing more than a passive activity. Read more…

Will climate change make medical conferences unethical?

A new essay by , a McGill professor of psychiatry, argues that, because of the threat of climate change, doctors must rethink whether they really need to travel to distant venues to attend medical conferences.

Dr Young writes,

"I have noticed that attendance at meetings in cities such as Kyoto and Florence is much higher than at meetings in ... I do not want to get into trouble so I had better let you fill in your own candidates for dull cities. This raises the possibility that research is not always the only motive for attending meetings."
He acknowledges that getting his colleagues to change their behaviour will not be easy. Dr Young illustrates that point by way of an example from his department at McGill.
"In a recent committee meeting I attended, one of the committee members pointed out that the academic under discussion had an excellent publication record but had unfortunately given hardly any presentations at international meetings. When I pointed out that this was not an issue given the carbon footprint involved in attending meetings the committee members all laughed, which I thought ironic given that the area of specialization of the candidate dealt with aspects of moral responsibility. I had to get quite assertive to convince them that I was serious."
The essay appears in the current issue of the Journal of Psychiatry and Neuroscience. Read the full thing (PDF).

Meet your new CMA president-elect, Jeffrey Turnbull

At last week's annual Canadian Medical Association conference in Saskatoon, delegates elected Dr Jeffrey Turnbull to be president-elect, meaning he'll become president next August in Niagara Falls.

Dr Turnbull, an internist by training and a 2007 inductee into the prestigious Order of Canada, has been involved with many, many aspects of medical practice, medical education and medical policy. He's led innovative programs to treat homeless patients in Ottawa. He's helped develop a "wet shelter" program for alcoholics that provides them with a fixed number of drinks doled out over the course of the day, to try to get their habits under control. He's also worked overseas on many occasions, with patients in need in countries such as Bangladesh, Kenya, Nigeria and elsewhere. And he recently became the chief of staff of the large, busy Ottawa Hospital. On the educations and policy sides of things, he's served as chair of the University of Ottawa's Faculty of Medicine, president of the Medical Council of Canada, president of the College of Physicians and Surgeons of Ontario, and on various committees and panels for other medical organizations.

But enough of résumé recitation: Dr Turnbull and I sat down to talk about an hour or two after he was officially confirmed as the CMA's next president. What follows is an unedited transcript of the interview, which touched on politics, harm reduction, physician wellness, and lots more.

SAM SOLOMON: I guess the place to start is to ask what your thoughts are on the fact that there was a sort of narrative constructed around your election, that you were the left-wing candidate in the Ontario election -- and I don’t know if that was by virtue of John Tracey being in the election as well and that there was a sort of need to give it a sort of story or something -- but I wanted to know what your thoughts are on that and also, I guess, what that means for the CMA, especially in relation to what we’ve seen in the last couple of days [of reform talks here in Saskatoon] and the last couple of years [under the presidencies of Brian Day and Robert Ouellet].

JEFFREY TURNBULL: So, Sam, I wouldn’t classify myself as left-wing, and I would say that I hold in some circumstances views that are very, very compatible with those of my two competitors, John and Deborah [Hellyer]. They’re excellent physicians, excellent leaders, and I supported many of their views. They’re dedicated advocates for their community. So we agreed on almost -- on many -- we probably agreed on more things than we disagreed on. I hold some views that may be different. We didn’t really get a chance to sit and debate our individual views, but we have had a chance to talk about some of those things and there’s much more commonality than there is difference. So perhaps the way that was portrayed was an effort to distinguish individuals. I wouldn’t call myself necessarily a left-wing candidate.

I guess from the context of the CMA presidency, one of the big questions, which was one of the motions we had here today, is what role should not just private delivery but private funding play in the public healthcare system?

Well, that motion was pretty clear about private delivery.

Yes, but I think part of what we are talking about when we talk about transformation in the context of these meetings is funding and not delivery. Especially when we talk about the European model -- those are things that pertain to funding and not to delivery for the most part.

To some extent that’s true, Sam, and I agree. From my perspective, I think that the private versus public funding and delivery component of the discussions have been to some extent a diversion away from what I think are some of the really essential aspects of issues that we should be trying to deal with. We’ve gotten caught up in a divisive debate where it’s very emotionally charged -- there are lots of implications for that. I think we need to defuse a lot of that and we need to focus on quality care; we need to focus on how we can serve our communities as best we can. Those issues relate primarily to access and coordination of care. And I believe that, yes, there is one component of that that might be how we deliver that within the context of a publicly funded healthcare system, but that’s just one component. There are lots and lots of other things that will have a much greater impact that we need to be spending more time on.

A short follow-up to that: Drs Day and Ouellet, and Dr Doig also this weekend, have mentioned that some of the restrictions on a variety of private sector activities that were imposed by the Canada Health Act have turned out to be quite restrictive -- and I don’t think that they mean the principles themselves but the way that they’ve been interpreted, is the message I’ve gotten from Dr Doig especially. I wonder whether you agree with that, that the Canada Health Act in some ways, that physicians’ innovation might be limited by that, whether that’s something the CMA should be looking at.

Well, there’s lots of opportunities for us to discuss and debate certain circumstances of privatization of delivery systems, but I think in that context we have to bring in evidence. As you know this is a very emotional debate, Sam, but we have to bring in the best evidence that we can. And I think that, up until now, one of the things that has been lacking is a formal investigative approach to bringing in evidence-based decision-making on policies that relate to private versus public delivery of services. When we get that formal information, if there are circumstances where we can be much more effective in the way we deliver care using a private delivery model, well, I think we should look at them. I think it would not be inappropriate to do that, as long as it doesn’t have adverse effects elsewhere. But we need evidence.

How and where did you get involved in homeless care? What sparked that interest?

It goes back quite a long time, Sam. I’ve been caring for the homeless now for 12, 14 years. I have always had an interest in serving vulnerable populations and in my community they probably represent the most vulnerable and the most disadvantaged. I started off with some of my patients who were coming to the emergency department. They were homeless, and I would send them off with antibiotics and they would return days later, sicker. And I would wonder why they hadn’t taken their antibiotics, and I felt that the best thing for me to do was to go down to the shelters and find out why. That led to me starting a program, with many of my other community partners, that now provides service for the most disadvantaged in the city, and it’s been a template or a prototype for development of similar programs across the world.

One of the things -- and correct me if I’m wrong here -- that the program, the Inner City Health Program, does is administer the clinic where alcohol is dispensed to addicts?

There are several components to it, Sam. There is the component where we provide palliative care services for the dying homeless, dying of the consequences of their addiction or HIV or some other illness. We have a step up, step down program, where people come from the hospital or are prevented from going to the hospital. So, Sam, if you have pneumonia, you would probably take your antibiotics and go to bed and get some chicken soup. A homeless person can’t do that. They, unfortunately, will perhaps try to get into the Rideau Centre [shopping mall] before they’re asked to leave, they won’t have the money to buy antibiotics, and they won’t have access to a family doctor or anyone to support them. So we bring them in, provide them antibiotics and good care and we prevent them from going to the hospital. And it saves substantive dollars because they don’t want to be in the emergency department and nor do we want them there. They get ineffective care in that context. We have a community outreach program, and now we have a program for women, so we have several other programs. But the program that you’re referring to is the Managed Alcohol Program, where we take inveterate alcoholics who have failed every treatment program, and we give them managed amounts of alcohol, trying to reduce the amounts as much as we can on an ongoing basis, but stabilize their addiction and provide them with meaningful health services.

Do you anticipate that next year, when you actually accede to the presidency and there’s certain to be more public attention on your background and your thoughts, do you anticipate that that program and your involved in it could be something of a problem in a public relations sense? And I don’t mean that people will disapprove of treating the homeless, but because it is essentially a harm reduction program and those programs, as you know, have not been particularly popular in Canada.

It is a harm reduction program. It is controversial. It is a program, however, that has been enormously, enormously successful.

But that hasn’t stopped people from criticizing some of the other [harm reduction programs] that have also been successful.

No, and I appreciate that. And I am very pleased to defend that program. I am very proud of it, the successes of that program. And I think the CMA should be proud of physicians providing a service to a community that is so disadvantaged.

What do you think of some of the other harm reduction programs, and what role do you think physicians can play in promoting things like that, that do have evidence supporting them obviously, like your program does?

Once again, I support the need for critical review of any initiatives that are controversial like these. But where there is good evidence, in order to manage the adverse consequences of addiction, I think it’s the responsibility of all of us to embrace the best evidence, the best programs and the best care.

Has the CMA done enough to get involved in the processes that lead to the programs getting support from the government, because that’s ultimately where the money is coming from for these things, and somebody needs to speak up at some point -- not that doctors haven’t done that.

Doctors have spoken up and tried to promote these programs in many circumstances. I think the CMA has a responsibility to look at vulnerable populations across Canada. Not just the homeless: aboriginal and First Nations communities, the elderly, those people living in rural contexts -- they all struggle with access to care, and meaningful care, and I think the CMA has to speak up not just for the majority of our population but those vulnerable and disadvantaged. That’s our job as physicians.

And would you support the expansion of those harm reduction programs elsewhere in Canada, for instance, you know, safe-injection sites or the provision of heroin for addicts?

Um. That’s a very complex question, Sam, and I’m not trying to be evasive but the answer for that is very site-specific and that’s why it’s complex. So what might be appropriate for Vancouver might not be appropriate for Ottawa. So for example, Ottawa does not have a very significant heroin problem, so a safe-injection site where heroin is administered would not be a -- our problem is crack cocaine. And the administration of crack cocaine in a supervised environment may or may not be of benefit, but it’s a totally different context than that in Vancouver. So, very context-specific. So I couldn’t generalize to say the Vancouver model should be all over.

I guess part of what I’m trying to get at is whether harm reduction is something that -- because it’s something you’ve been interested in, you’ve been involved -- whether it’s something that you want to have more involvement and draw the CMA into a little bit more than it has been. Whether it’s something that is on the plate of things you’re interested in doing.

No, it’s not one of my principal agenda items. I think the big agenda items are access to care and systems change to help vulnerable populations. Those would be much bigger. Now, within that context, yes, there may be a small component of harm reduction, but that’s not the major issue, that’s not the fight we should be choosing to go to the wall on.

When you do become president, will you be taking a leave of absence from the Ottawa Hospital?

No. I have a colleague who will help with my chief of staff responsibilities. I’ll reduce some of my clinical practice at the hospital. But I still hope to care for the homeless, and I still hope to look after some aspects of my practice in the developing world.

Does that mean you’re planning on going overseas next year?

I go overseas on a regular basis.

Do you go every year?

Pretty well. Whether that be to sub-Saharan Africa -- I finished a project recently in Nigeria. I had been in Kenya quite a bit. I am considering going to Angola now. I missed out on an opportunity -- I’d wanted to go back to Bangladesh, where I’ve done an awful lot of work. I was meant to be there in July, so I hope to go later.

The last thing I wanted to ask you about is physician wellness, which I know you spoke a lot about during the Ontario Medical Association campaign. What’s the goal? What are the specifics of what we need? I know there have been a lot of people in Ontario who have worked on that, but from the CMA it feels like often we hear “It’s a good goal” and then...

Yeah, so the CMA has to work with its provincial and territorial medical associations, it has to work with faculties of medicine and regional communities of physicians to enhance physician wellness. It’s an environment where there’s much greater stress. Physicians are asked to do much more with much less and it’s one where everybody recognizes they’re working well beyond what they can in their capacity because they’re just so dedicated to their patients, but one has to wonder whether it’s sustainable at this pace. So we have to work with those people, all of those partners, to provide meaningful systems of, one, early identification of issues; promotion of wellness, so enhancing wellness and not waiting for problems to occur, so promoting healthy lifestyles and addressing workload issues early on; addressing the issues early when they appear; and then having meaningful, confidential programs that can be accessed by physicians that can deal with the issues and get them to the point where they have a more sustainable practice.