Medical Care: Help the Health System Help You
By Claudio Munoz
More than anything else, Anthony Mohamed seems very proud of his job. Sitting at his desk on the 14th floor of Toronto’s St. Michael’s Hospital, he laughs frequently, looks for precise information on his computer, handles brochures and tries to promote the hospital core values every time he has a chance. Although he is not a doctor or a health care provider, you can see he cares about what he does.
It is an important job; right now he is the Diversity and Special Projects Coordinator for the Inner City Health Program; one of the key players involved in keeping our health care system in sync with their surrounding communities for the past 15 years.
It is not an easy task, especially in an area of high population change, like Ontario. The main gates of the hospital, on Queen East just one block east of Yonge, have seen faces of people from pretty much every country, culture and ethnic group on earth. After all, the whole world lives in this city. And sooner or later, we all have to see the doctor.
Since the 1950’s, the delivery of health services has also changed. Back in 1948, The World Health Organization (WHO) defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. In Ontario that translates not only into universal health coverage, free testing or assistance paying for meds but also into health promotion and education, participation, and respect; even research to better understand the needs of the community. Everyone living here – newcomers included – is part of the health care team. We must all do our part.
“There was a cultural shift that took place, not only for newcomer communities but for everyone,” Mohamed explains. “There is more emphasis on health promotion, this concept of giving people the information they need to make appropriate decisions about their own care.”
What the Health System can do for you
“There was a patient, a First Nations’ woman, who wanted an elder and a drummer for a sweetgrass ceremony while she was giving birth,” Mohamed remembers. “We were not able to meet all her requests, but because we partner with a First Nations organization in the downtown area, we were able to bring the elder to say the prayer, and a drummer, who played during her birth. We asked our fire marshal to turn off the fire alarm in the delivery room, and to be present during the ceremony. It was really great,” he says, still amazed by “what can be done” when the effort is made.
The experience is now studied by staff through Cultural Sensitivity training provided at St. Michael’s. The training program promotes team building (health workers are from everywhere too) while introducing health care providers to the diverse community they are serving. Staff analyse how concepts like power and privilege relate to various “isms” (racism, sexism, homophobia and so on). But most importantly, the training gives them realistic examples, so they can practice what to do in any given situation.
One of the exercises asks participants, what to do if someone asks to see an imam... which is sometimes followed by a second question from the staff, what is an imam? The learning is done in a safe environment, when health care providers are not dealing with actual patients. By the time you meet them, they would be able to tell you something like “An imam? Sure, we will contact our spiritual care chaplain and they can arrange contact for you with an imam.”
With so many religions coexisting in the province, diverse spiritual care has become a very important part of the health system. Sure, priests giving comfort at hospitals are not new, but now it is possible to easily access rabbis, imams, elders, and so on. They might not be at the hospital all the time, but they can be reached by the personnel.
The inclusion of different religionshas also translated into policies that make it easier to, for example, release the body of a dead family member sooner. This is very important for members of the Islamic community because for them when a member of the family dies, it is mandatory to bury the body within eight days. There are many more examples. Hospital authorities detected that Asian patients were not eating the food provided. Recognizing that lack of culturally appropriate food could affect patient outcomes, hospitals introduced new menus to allow patients to eat and get better. Now there are kosher, vegetarian, Asian and many more options for the patients.
Rita Kang, Manager of Patient Education at Toronto Western Hospital, explains some strategies that hospitals are now using to address diversity of the population they serve. “Toronto Western Hospital (TWH) provides interpretation services; translates important materials like brochures; and provides ethno-specific programs to address the cultural needs of various communities,” she says.
Services are tailored specifically to certain groups, depending on the ethnic makeup of the surrounding community, enabling the institution to provide ethno specific programs like the “Portuguese Mental Health and Addictions Program” and the “Asian Initiative in Mental Health”.
Members of the health team at Toronto Western hospital participate in community events and health fairs regularly, reaching out to the community, promoting services or involving people in their own health through initiatives as varied as workshops and blood donation campaigns.
At TWH there is a library, open to the public, with plenty of books, DVDs, and so on, about medical health and issues. Anyone interested in getting more information can consult them and discuss the information with any member of the health team. There are also computers for searching – in the right places – for information about conditions, new treatments or practices.
Reaching out is an important part of a healthy life for communities. The TWH conducts “Patient and Family Library Monthly Talks”, a series of presentations on different health related topics like living with diabetes or menopause. The presentations, always followed by Q & A sessions, are very popular – an average of 100 people attend each of them and, even though they are in English, interpretation through headsets allows crosscultural participation.
One of the most important of all the services and initiatives is interpretation. “In order to provide the best care, we need to be able to communicate with our clients,” Mohamed explains.
Hospitals are increasing the availability of interpreters. St Michael’s now offers face to face and over the phone interpretations, covering more than 200 languages.
“There are many reasons why you should use an interpreter instead of a family member,” Christine Papadakos explains. She is a patient education specialist, whose role is to support health care providers in providing education about health to their patients at the same institution. “Some family members might have an emotional reason to protect other family members from certain information. They might sugar-coat what the doctor is saying. Interpreters at hospitals are certified, they are used to talking to people in a sensitive way without hiding the truth.”
Communication is a two way Street
Language is not the only way of communicating, though, and not the only barrier. For a system that pushes for an active role for the patient, it is crucial to make sure that misunderstandings are kept to a minimum.
If health care providers communicate with patients in the most effective way, there are better patient outcomes. “In the old model, a patient would do whatever the doctor said,” Papadakos explains. “In this model, the patient is recognized as an adult, and capable of participating in their care. More and more now, doctors are explaining what patients should do and why. When patients understand their treatment they are more likely to participate in it.”
Some health care providers are also being trained in effective communication techniques, including face to face communication and teaching. They are learning to “read” their patients personalities and learning styles, to detect what kind of person you are and what kind of teaching would make you feel comfortable and confident. If you can explain your symptoms in detail, it increases the chances of a better diagnosis and outcome.
A very direct and task oriented person, might go the doctor’s office and tell him exactly what their symptoms are. An indirect person would be more worried about other’s people feelings. “People who are more direct say what is at the top of their heads, they might speak faster, they are more animated... they tell you if they are in pain,” Papadakos describes. “Indirect people use less body language, they might not look you in the eye, and they are less likely to tell you directly what’s going on.” With these tips, a health care provider can use different techniques to make you feel comfortable. “We practice how to provide information, how to show encouragement with your body language and what kind of things can be said or done to make people comfortable. Things like not crossing your arms or tapping the desk.”
By discovering how patients learn, practitioners can teach you more effectively. “Some people learn visually, others by hearing, others by getting involved. As a health care provider you might have to give them a list of resources where they can find more information – so they can get involved; or for people who learn visually, have a video during the procedure or to make a drawing to explain the problem.”
Health care providers who go through this training might use another tool, called “teach back” – where they ask the patient to repeat the information just provided. If you can tell the doctor about the treatment or the doses prescribed, they can be sure that you understood the situation and what you are supposed to do. This helps avoid any misunderstanding that could bring you back to the hospital.
What you can do for the System
There are many other programs for immigrants, seniors, people living with AIDS and so on, available at hospitals and community centres. But for the system to work, we all we need to do our part, which in your case means being informed and stay healthy.
“Asking questions is not just OK, it is expected,” says Papadakos. “It is important that patients take an active role in understanding what the problem is and what they have to do to fix it. It is very important that you feel comfortable asking about anything that it is not clear. Be empowered to ask.” No one will think less of you because you ask questions. Even the most talented engineer or college professor may have no idea how open surgery is performed.
“Have a family doctor,” Kang says. “Go to your community health centre. They are very connected with their communities so they can help you effectively. They can help you navigate the system; they deliver many useful programs about staying healthy.”
She also invites newcomers to learn about OHIP, what is covered and what is not. Not long ago, many practitioners rejected the idea of patients seeking information on the internet. But the fact is that there are a number of websites from hospitals or health institutions providing great information on the web. Websites like “Health Canada” or “Mayo Clinic” are commonly visited by physicians and practitioners. Discuss what you find with your doctor or any member of your health team.
Your health is your responsibility too and the decisions about it are going to be yours. Health care providers would give you as many options as possible and – according to your own beliefs, necessities, or priorities – you have to choose. Even so, you need to recognize that the practitioner is the expert.
“It is most important to understand the system,” Mohamed says. “Go to the web, talk to your health care provider to understand how things work. Learn where to go for what kind of problems. There are a lot of things that can be treated by family doctors or walk-in clinics. Not everything is an emergency. The other thing is that new immigrants tend to wait until the problem is really serious – use your judgment, find the balance and go to your doctor when you need it.”
If you are interested in the health system, consider getting involved. Volunteer, join committees, even pursue a career in the sector. Support the institutions campaigns.
Promote a healthy life within your community. Do not underestimate what newcomers can contribute to the system, not just internationally trained professionals; but all newcomers. Thanks to diversity, Canada’s food guide has a lot more ingredients, options and flavours than it once had.
The “Healthy Immigrant” Effect
When they first arrive in Canada, most immigrants are healthier than the average Canadian. Doctors, medical researchers, nurses and teachers at med schools called it the “healthy immigrant effect”. Recent immigrants “are less likely to have chronic conditions or disabilities than the Canadian-born population, and are more likely, upon arrival to Canada, to rate their health as good, very good or excellent”, according to a study from Statistic Canada titled The changing health of immigrants, released in the autumn of 2005.
Professor Farah Ahmad at the University of Toronto’s nursing school explains that economic immigrants – who tend to be younger and more educated – have better health at the time of arrival.
“Research is telling us that depending on their country of origin, some immigrants’ health is affected. The healthy immigrant effect last up to 10 years.” The reasons are not all clear, but according to the publication, the process of immigration and settlement itself – the stress of finding a job, financial constraints and the lack of a social network – may undermine newcomers’ health. Of course getting old is something you have to consider in the equation but, for immigrants, it is pretty clear that missing home is not just about food.
All the services presented here were developed to better serve a new population. Using them does not guarantee to maintain the healthy immigrant effect, but it helps.