Ensuring health care reflects Ontario’s multicultural make-up

Physicians speak to the importance of multicultural representation in Ontario’s health-care system, and the need for culturally sensitive care that considers patients’ social determinants of health. Sharing their professional experiences, family and emergency physician, Dr. Latif Murji and Dr. Catherine Yu, medical director of Health Access Thorncliffe Park and chair of the East Toronto Family Practice Network, describe the work they’re doing to break down barriers and equitably service patients of diverse populations.

Transcript

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Georgia Balogiannis: In this podcast, the Ontario Medical Association looks at current issues of interest in healthcare. Spotlight on Health gives you all the straight talk. We’re Ontario's doctors and your health matters to us. I'm Georgia Balogiannis for the Ontario Medical Association. 

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Balogiannis: One in four Ontario residents was born outside of Canada, and the province is a prime example of our country's multicultural mosaic. However, access to healthcare can be difficult for patients who have language, cultural and social barriers, and people in marginalised communities can often have worse health outcomes. In this episode, physicians discuss how to improve the quality of care for patients from diverse backgrounds. 

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Balogiannis: Dr. Latif Murji is a family and emergency medicine physician and coordinator of Global Health, Diversity and Health Equity at Scarborough Health Network. He also founded Stand Up for Health as well as the VaxFacts clinic.

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Dr. Latif Murji: It's really important that we support patients in Ontario of diverse populations because we've made a commitment to health equity, and Ontario is a very diverse place. In fact, about 30% of Ontarions are visible minorities and diversity extends much beyond even being a visible minority. So Ontario is a very diverse place, and in order to meet the needs of our diverse population of patients we need to understand our patient's needs in order to eventually meet them. And we have a ways to go for that. 

There are dangers that patients don't receive proper culturally appropriate care or support, and those include obviously adverse outcomes for those individual patients, on one hand. There's also more downstream costs for the system. For example, if we have a diabetic patient and they are not having their specific needs met because they have a different diet in their culture than the Western diet, what could happen is we could have, on one hand, a dietitian that is aware of that different culture and the dietary needs and restrictions and requirements, and actually meets those needs and leads to the patient actually managing their diabetes really well.

Or, on the other hand, if we're not aware of these things and we're just giving a one-size-fits-all approach to all of our patients, then that patient might not actually manage their diabetes well, which obviously is not just bad for them in terms of health outcomes, but it leads to things like amputation and retinopathy and nephropathy. And now our healthcare system is also burdened with huge costs to manage care, when we could have prevented this with good upstream care that was meeting the needs of our diverse population. 

There are a lot of things that physicians can do to improve the way they support diverse populations. So it starts with just spending more time with our patients who have diverse needs. If patients don't speak English as their first language, they're going to require additional support. They're gonna require, possibly, interpretation services, and that's going to take more time.

There's often equity, diversity and inclusion training offered by institutions and just approaching this training with an open mind because there actually is so much we can learn. I would say that kind of training is actually very valuable. There's a lot of pearls you can take out that you can use in your clinical practice. So on a system level, there's several changes that could be made that would really improve the way that we support our patients in the future. 

It starts with medical schools and other healthcare professional schools admitting students from diverse backgrounds for the goal to actually one day have our healthcare professionals represent Ontario's population, which is extremely diverse. Next, we could be removing barriers for internationally trained healthcare professionals to practise in Ontario so that they can integrate into our system effectively and seamlessly and provide that care for our Ontarions in need. And then lastly, institutions could invest in equity, diversity, and inclusion training for healthcare professionals. 

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Dr. Murji: Stand Up for Health is a not-for-profit organisation, and we use simulation experiences to help train health professionals and health professional students about health equity and the social determinants of health. I had my own personal lived experiences of the social determinants of health and some inequities, and when I was going through my medical training I started to realise that my peers were not connecting with these concepts the same way that I was. 

And then at some point I had this ‘aha’ moment and I realised that the difference was the lived experience that I had. So I sought to create a simulation experience that could give people some insight into what it might be like to face some of these barriers and inequities, really increase empathy, and spark discussions amongst healthcare professionals of what we as providers can do to bridge those gaps and to advocate for our patient. 

Stand Up for Health, itself, is now this learning tool. It's this simulation where you experience the life of a seven-year-old boy from Scarborough and you go over 30 years in his life where you are physically moving around in space using an iOS app. And this takes place over a couple hours. You do this with a partner and you make decisions about different events that occur in your life. And based off the decisions you make, there's different consequences and those consequences impact your trajectory through life, just as the social determinants of health would. 

Our facilitators help our participants come up with solutions for issues in their community that are related to the social determinants of health and different health inequities. And those participants, hospital employees, and staff and healthcare providers actually leave the sessions with a plan of action. 

VaxFacts clinic is a opportunity for patients in Ontario to speak with the physician one-on-one in a judgement-free, confidential space over the phone, have any questions they have about the vaccine answered. And the other really important thing that we're trying to do is bring a health equity lens to the entire design of VaxFact. We've also partnered with the Black Physician Association of Ontario so that we actually have a VaxFacts for Black communities stream, where if a patient is black and they choose to feel more comfortable speaking with a black physician, we have that option available for them. 

I mentioned the health equity approach, but it's also the clinical approach that we're taking is called motivational interviewing. This involves actually listening to the patient, validating their concerns, partnering with them. Rather than having a power dynamic, you're actually sharing that power in the space with the patient and working with the patient to make a decision together. So it requires a commitment to health equity and understanding that we need to take more time because it's important to actually serve our patients well.

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Balogiannis: Dr. Catherine Yu is Medical Director of Health Access Thorncliffe Park and Chair of the East Toronto Family Practise Network.

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Dr. Catherine Yu: I think that it's absolutely necessary for us to provide culturally appropriate care as physicians coming into contact with diverse populations, having the privilege to meet many patients from different backgrounds. We are afforded the knowledge over time and the wisdom to understand what challenges arise from specific backgrounds and the successes that we might have, having an understanding of what resonates most to specific individuals according to what community they belong to.

If we're unable to deliver culturally appropriate care or culturally competent, culturally sensitive care to our patients as individuals, some of the dangers that I can see are misdiagnosis, misuse of our resources in the communities in terms of ordering tests, for example, that are not necessary. I think that it's important for us to listen carefully to our patients, to what they say, but also from the context that they come from. It does take a lot of learning on our end and openness to dig deep into what ails our patients. 

Often physical complaints in the older way of doing medicine might mean an exploration of further physical symptoms and not necessarily a focus on mental health, a focus on the social determinants of health, which I think is really part and parcel of what we're talking about when we say culturally competent care.

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Dr. Yu: This lovely patient of mine has not received primary care for over 20 years since arriving in Canada and meeting her for the first time and realising that a huge part of why she has not had her health issues addressed, which were quite serious by the time I met her, actually, she had uncontrolled diabetes and was really quite sick right then. She had not been able to establish a trusting relationship with anyone and not just speaking about doctors, but just even the doors to open up to get to a doctor. 

She was quite hesitant as she came from a traumatic past and the meet-and-greet appointments that we have often with our new clients involved taking a good medical history, understanding their medications, allergies. We spent a whole hour on her social history. Listening to her and being able to gain her trust was a key step to her care. I'm happy to share that two, three years later without much medication, with her food security being addressed, and with her mental health being addressed in a culturally sensitive way, her physical health is just fine.

One individual's illness is never in isolation. Their families get impacted, their jobs get impacted, their places of employment impacted, their community members within their neighbourhood get impacted, and neighbourhoods will also, of course, impact the rest of the next door neighbourhood and the community that's being served in a larger geography, for example, where a community hospital serves. I think that, as a family physician, what I've learned from the start is that it really takes a lot of humility. It takes a lot of courage to learn and admit to also needing to learn more. It's a constant learning journey for all of us, and cultural competency is one of those domains that I think we need to explore further, together with our community practises. 

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Dr. Yu: There are many investments that are very well meaning in terms of health services for equity deserving communities. There is a collective of family doctors, primary care champions, administrators who work together within the structure that's now empowered and enable us to establish a number of initiatives. One of them is called the Primary Care and Community Response Teams — the East Toronto Family Practise Network co-led with our partners that serves vulnerable populations, primarily the homebound, primarily adults or seniors.

Through the pandemic, uh, looked at our geography, mapped out how each of our quadrants are doing in terms of primary care supports and community services supports. We started to focus on geographies that were disproportionately impacted by the pandemic. I mean, the pandemic was just the accelerator here, but obviously it speaks to all the health needs of those communities have had anyways, and mapping it out was a good exercise for us to understand that we needed further investments.

For example, so a specific area of Gerard Street where old Chinatown was had quite a number of doctors retire. And I know this isn't a story just isolated to that street, but what we did at the East TFPN, together with our health partners, was to look at an initiative to increase capacity more urgently for primary care attachment in that area. We sought support from our health partners to find small amount of funding to coach physicians who were still around or newer in practises to increase capacity in the practises to be able to take some of these patients that were going to be orphaned. So that's a sustainable solution.

Part of it was to study what was needed right straight from the local neighbourhood, which is part of culturally competent care, I think. Hearing from the community agency partners directly is a great learning experience for me. For my, I think the primary care, I see great improvement in terms of us as a profession, getting the supports that we need to be able to learn — and learn to provide — better and more culturally sensitive and culturally competent care. There's a lot of work still to be done, but I do think that much already has been done.

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Balogiannis: This podcast is brought to you by the Ontario Medical Association and is edited and produced by Jodi Crawford Productions. To learn more about the Ontario Medical Association, please visit oma.org. 

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