Small Changes Big Impact

Social justice and innovation in primary care with Dr. Naheed Dosani

December 18, 2019 University of Toronto - Department of Family & Community Medicine Season 1 Episode 8
Small Changes Big Impact
Social justice and innovation in primary care with Dr. Naheed Dosani
Chapters
Small Changes Big Impact
Social justice and innovation in primary care with Dr. Naheed Dosani
Dec 18, 2019 Season 1 Episode 8
University of Toronto - Department of Family & Community Medicine

In studio today, we have Naheed Dosani, a family and palliative care physician at William Osler Health System. He's the founder and lead palliative care physician with the PEACH program, Inner City Health Associates, and he's a lecturer in the Department of Family Community Medicine in the Division of Palliative Care at the University of Toronto. Today's episode focuses on his work with the PEACH program, social justice and inequities in death, and innovation in primary care.

Additional links and information:
PEACH Program:
http://www.icha-toronto.ca/programs/peach 

Good Wishes Program (donation page at Haven Toronto but write 'Good Wishes Program for PEACH' in comments)
https://www.haventoronto.ca/shopandshare

Show Notes Transcript

In studio today, we have Naheed Dosani, a family and palliative care physician at William Osler Health System. He's the founder and lead palliative care physician with the PEACH program, Inner City Health Associates, and he's a lecturer in the Department of Family Community Medicine in the Division of Palliative Care at the University of Toronto. Today's episode focuses on his work with the PEACH program, social justice and inequities in death, and innovation in primary care.

Additional links and information:
PEACH Program:
http://www.icha-toronto.ca/programs/peach 

Good Wishes Program (donation page at Haven Toronto but write 'Good Wishes Program for PEACH' in comments)
https://www.haventoronto.ca/shopandshare

Dr. Rezmovitz:

Small Changes, Big Impact: a DFCM podcast. I'm your host, Dr. Jeremy Rezmovitz. In studio today, we have Naheed Dosani. He's a family and palliative care physician at William Osler Health System. He's the founder and lead palliative care physician with the PEACH program, Inner City Health Associates, and he's a lecturer in the Department of Family Community Medicine in the Division of Palliative Care at the University of Toronto. Today's episode focuses on social justice and innovation in primary care. I hope you enjoy the show.

Dr. Dosani:

Hi. Thanks for having me.

Dr. Rezmovitz:

It's my pleasure. I look forward to a rousing conversation today.

Dr. Dosani:

Very much looking forward to it.

Dr. Rezmovitz:

Yeah. So tell me, how was your day today so far?

Dr. Dosani:

Day was good. Yeah. Did a couple of outreach visits , had the opportunity to care for a couple of clients dealing with some very vulnerable situations, and here I am with you. It's looking up.

Dr. Rezmovitz:

It's looking up. Tell me about that. What do you mean an outreach visit?

Dr. Dosani:

Well, I work and have been working on for the last five years on a program out of the Inner City Health Associates called the PEACH program: Palliative Education And Care for the Homeless, a mobile street and shelter based palliative care program that meets people's needs wherever they're at, on the street under a shelter - sorry, on the street, under a bridge, in a shelter so that no person falls through the cracks. And that's kind of what I was working on this morning.

Dr. Rezmovitz:

Wow. Sounds amazing. Idealistic , but obviously you've turned this ideal proposal into something amazing. So I've been reading up on you and while this program has been - how long has it now that it's been in -?

Dr. Dosani:

Five years here in Toronto. Yeah .

Dr. Rezmovitz:

Yeah. That's amazing.

Dr. Dosani:

Thank you.

Dr. Rezmovitz:

So can you talk about that program?

Dr. Dosani:

Yeah. The initiative was a response to the fact that out there in our communities, there are folks who are structurally vulnerable. People experiencing, for example, homelessness or housing insecurity, poverty, food insecurity, trauma, social isolation, and these communities don't have access to adequate healthcare . One of the things that's quite boggling - that blows my mind every time I hear about it with the homeless population - is you're talking about one of Canada's sickest subpopulations. They are 28 times more likely to have hepatitis C, 5 times more likely to have heart disease, 4 times more likely to have cancer. And do you know what the average life expectancy is for a housed person in this country by any chance?

Dr. Rezmovitz:

Housed? You mean like someone like myself?

Dr. Dosani:

Potentially?

Dr. Rezmovitz:

I would say probably like male versus female, 78 versus 81. Around there .

Dr. Dosani:

Yeah.

Dr. Rezmovitz:

80 plus or minus five years in there.

Dr. Dosani:

Yeah, totally. Yeah. The average life expectancy for homeless people in this country is 34 to 47 years old. And so PEACH recognizes two things: that homeless and vulnerably housed folks - which represent a structurally vulnerable population - lack equitable access to care, and that palliative care is really important when you are homeless because you're more likely to be ill . And quality of life is really important because many of the illnesses that the folks we deal with have are actually irreversible and non-curable. And so PEACH is a response to that. But it's more than a medical program. It's a movement. It's a way for our healthcare system to say, yeah, we care. And yeah, there are silos that we function in, but we are in - we are working to break down those silos to integrate care so that people can come together and serve people's needs wherever they're at. And I don't just mean geographically, but emotionally too .

Dr. Rezmovitz:

So you're the founder and lead of the program. So tell me about that. That must've been - there may have been some barriers in trying to create this program?

Dr. Dosani:

Yeah, yeah.

Dr. Rezmovitz:

Let's talk about it .

Dr. Dosani:

Yeah. So, you know, the story starts when I was a first year resident here at the University of Toronto in the Department of Family and Community Medicine and had to do a rotation in a shelter doing primary care, and I had to care for a young guy who presented in crisis. And he showed up in crisis, I examined him and I clearly could see that he had this widespread head and neck cancer he had had - it started at the base of his tongue and it had spread throughout his head and neck. And he basically was diagnosed with cancer over a year ago at a local cancer center, but due to his mental illness - he had a longstanding diagnosis of schizophrenia and substance use - he was what we often call lost to follow up , but he actually was feeling embarrassed about how he looked, so he didn't follow up and so he began to experience pain. So he did what any one of us would do. He went to the hospital, he went to the ERs, he went to the walking clinics and he was denied access to pain medicines that would improve his quality of life. So he found himself in our care and he promised me he was going to start some pain medicines, and I got to work the next day really early to meet him and I couldn't find him anywhere. And I had found out that he had actually committed suicide. He had actually overdosed on a combination of alcohol and street drugs. It was too late - too late - too little, too late. He had committed suicide due to inadequate pain control. So that was a really traumatic event. And so you know, how we're kind of expected to just like move on and see the next patient and care for the next person. I just couldn't do it. I met with my program director and took a short leave for some self-care and used it as a time of reflection. And it was within that time that I started to realize that while people had talked about this as an issue in a lot of cities around the world, not just Toronto , there wasn't yet a formulated approach to how to address the issue. And that's kinda how this all started.

Dr. Rezmovitz:

Obviously we're going to ask now, what's the formulated approach?

Dr. Dosani:

A very logical followup question. Well, what happened was after that - so I realized this was an issue. So I applied for the Enhanced Skills Palliative Medicine Program here at the University of Toronto. And in the interview kind of said like, guys, this is what happened to me. Terry died - his name was Terry - and I want to do something about it and I hope you let me in because if you do, it'll help me to do something about it. But if you don't let me in, I'm still going to do something about it. So they let me in for whatever reason. And so during my palliative medicine training, I had the opportunity to build bridges between the housing sector - like shelters and transitional housing with the palliative care sector, so that what we could actually do was launch a program. And today the PEACH program is a full fledged 24/7 model of care that provides care for 70 to 80 clients at any given time in the city of Toronto - over 400 since its inception. Features three family physicians with enhanced skills in palliative medicine who work on the front lines on the street in the shelters with a nursing coordinator, Sasha , who really is the backbone of the program. We also have volunteers who work on our program through partnerships with organizations like Hospice Toronto and a pure support worker - someone with lived experiences as well - so that we can be able to care for people in this case management model. The program was actually named by the federal government of Canada through Health Canada in 2018 as a best practice in equity in palliative care and their new framework. So we were really pumped to hear that, you know, somebody's kind of listening and people are kind of excited about it.

Dr. Rezmovitz:

Are they funding it?

Dr. Dosani:

Yeah, it's a great - funding is always an interesting conversation. The program is funded through the Inner City Health Associates where a group of over 90 health professionals working in - over 55 street and shelter based settings, and so the PEACH program is a program of that. But one of the great things is that we're partnered with a local home care. So the Toronto Central LHIN home and community care team and specifically their palliative care team has dedicated an entire care coordinator to be part of our program. And you know, her name is Leslie and she plays a big role in bridging that gap between the street and, you know, access to beds or a physiotherapist or nursing and really lowering the bar and lowering the threshold so that this is a low barrier care, so people get what they need when they need it.

Dr. Rezmovitz:

I like low barrier care. What I'm going to do is just shout out to anybody who's listening, who's looking to donate $20 million. The PEACH program could probably benefit from a donation. I'm sure we could find a way to liaise you with the University of Toronto's - what's that office called? The Office of Advancement. Speak with Jennifer and the Office of Advancement, and we can find a way, hopefully. That's just a little plug because you know what it's about developing something that you're passionate about and obviously you're passionate about it. And so who knows, maybe this is the right time to ask for for donations to - and on this platform. You never know. Right. My father taught me if you don't ask, you'll never get.

Dr. Dosani:

Listen, I'm in. And actually we just got a couple of donations this morning for one of the interventions we run through the PEACH program. Can I tell you about it?

Dr. Rezmovitz:

Why not? This is why we're here cause cause to me this whole thing is about a small change and you brought passion and enthusiasm and you are changing the face of low barrier care to a marginalized population. And I think that is amazing.

Dr. Dosani:

Well thank you and I'm honoured to be able to be a part of it and you know, shout out to the entire PEACH team for making us possible because we wouldn't be having this conversation if it wasn't for them. One of the things that we started to recognize early on in people's illness trajectories about three, four years ago was the fact that we would go into shelters or rooming houses or meet people wherever on a park bench. We prescribed , you know, sort of like the opioid, the anti-nausea , you know, pain and manage the symptoms and we'd walk away and be like man we did nothing because that wasn't the point. The point here was total suffering, total pain, the emotional pain of what it's like to not have housing, to not have a social network, to live in poverty. And so we started a new intervention and we called it the Good Wishes program - it's a collaboration with Haven Toronto, which is a drop in center in downtown Toronto for men who are over 50. And basically what we do is we make wishes come true. So you know, there was a gentleman who was getting sicker in his shelter and he wanted to play that Led Zeppelin riff just like one more time. And we got him a guitar from a pawn shop.

Dr. Rezmovitz:

Which r iff?

Dr. Dosani:

Well, I wouldn't know because I'm not a big Led Zeppelin fan. Now you're putting me on the spot.

Dr. Rezmovitz:

Maybe it was "Whole Lotta Love".

Dr. Dosani:

I mean ask me about like Drake or something and I'm all over that . But dinners at Swiss chalet, tickets to a Blue Jays game , or "I've never been to a Leafs game", or "doc, thank you so much for getting me into this beautiful hospice that I've never been in , but none of my friends can afford to get here. Can you pay for my phone bill so that I can at least text them so I can have some communications ?" So a good wish around that.

Dr. Rezmovitz:

Okay. So obviously the next question, do you know what's the next question? I'm begging to ask this question.

Dr. Dosani:

I don't know. I'm not sure.

Dr. Rezmovitz:

Okay. How do I get involved? Because obviously I want to make wishes come true. That's what I do.

Dr. Dosani:

Well, you know, absolutely. So the donations and the fundraising goes through Haven Toronto, so if you go on their website and go on the donate page -

Dr. Rezmovitz:

What is the website?

Dr. Dosani:

It's haventoronto.ca.

Dr. Rezmovitz:

www?

Dr. Dosani:

I believe so.

Dr. Rezmovitz:

H-T-T-P backslash backslash colon.

Dr. Dosani:

That's right, yes. So we go onto the page and if you just kind of in the comments and mark it for the Good Wishes program, that's a way to support this program and we're excited to be doing some research on the impact that the Good Wishes program has had. So a real opportunity for folks to contribute from a donations perspective just speaking about potential donors that might be listening .

Dr. Rezmovitz:

No. Obviously another opportunity for Jennifer in the Advancement Office to support the Good Wishes program. So there's - because you're creating scholarship of this, this is what the University of Toronto supports, is scholarship. So how do we promote these programs? Like I don't know if everybody knows about these programs. So you've already identified the PEACH program. Now is the Good Wishes program, part of the PEACH program?

Dr. Dosani:

It is. We consider it like an intervention. Like it's something we're actually doing to treat total suffering.

Dr. Rezmovitz:

I think that's amazing.

Dr. Dosani:

Thank you.

Dr. Rezmovitz:

I've been talking about total suffering in my clinic because I'm a community family physician and we talk about three types of pain and I always talk about physical pain, emotional pain and existential pain. And that's the total suffering, right? That injustice that's just like, it is not fair. And it seems like existential pain goes to exacerbate the other two types of pain because if you can't get out, if you have no way of getting out, then you're just locked in to focusing on the types of pain that you have and people with emotional pain suffer so much as much as those w ith with physical pain. I mean Terry, it sounds like had some physical pain, but more importantly he probably had a lot of emotional pain and an existential pain that he's like, I'm just done.

Dr. Dosani:

Absolutely. You know, it's interesting because the PEACH program, that model has been replicated in cities across Canada now. So Victoria, Edmonton, Calgary, our colleagues, we have like a family across Canada. It's kind of neat. When we come together at conferences or when folks are in town, we always talk about this concept of double vulnerability. The idea that in palliative care specifically, we're so comfortable talking about the pain associated with, you know, death, dying, sadness, existential distress. But when it comes to that other kind of vulnerability, that second vulnerability, not having a roof over your head, not having money in the bank account, not having food in a fridge or if our caregivers support you overnight and you overlay that, that double vulnerability is what we're talking about. People are falling through the cracks again and again and again. And this is why - I'm going to put it out there. I'm a big fan of birth. Like I love birth. I love, I think it's great.

Dr. Rezmovitz:

You like watching it?

Dr. Dosani:

No, no. Not necessarily watching it. In terms of an academic equity - as an equity concept.

Dr. Rezmovitz:

Oh sorry.

Dr. Dosani:

But I feel like birth has had its day, like we've talked a lot about birth. It's time to talk about death because death is a social social justice issue. Just like birth is a social justice issue. And there's a lot of literature, a lot of people have looked at equity issues in birth, but in death, if there were inequities that exist during a person's life, you bet they amplify as people start to die. If you're homeless during life, you would likely die more homeless. If you're poor during life, you probably die poor . If you're socially isolated during life, you probably die more socially isolated. And I'm not trying to be like all doom and gloom , but that is the stark reality of the inequities that we see and how deaths should be viewed as a social justice issue. A double vulnerability is a concept that really brings that home.

Dr. Rezmovitz:

So first of all, everybody dies.

Dr. Dosani:

Yeah.

Dr. Rezmovitz:

And so aligning with that , if we talk about just the basics of death and the first thing that comes to my mind is we talk about ownership over your own death choice, right? Choice as equitability in dying. Our dogs and cats have more grace in their death than humans sometimes do.

Dr. Dosani:

Right?

Dr. Rezmovitz:

And so we see a move towards medical assistance in dying that I think is amazing because we should be offered a choice as humans with dignity to be able to die as we lived - or even better because it's exactly what you're saying. Death is a part of life and we should be talking about it.

Dr. Dosani:

Absolutely. And yet we've stigmatized death and dying so much in our public discourse that I think it's truly initiatives like for example, PEACH , if you will, that might allow us to look at that experience for people, that human experience - and yeah, data is huge and research is important, but it's the narratives. It brings it to life and it brings home stories. And we were just blown away at how Canadians coast to coast are so compassionate when ever we have a story about one of our clients out there, whether it was, you know, it's the story of Terry or the story of Archie, who is a guy in his mid fifties who was an engineer who had a home, and due to an unfortunate sequence of events became homeless. And then his son was diagnosed with a terminal diagnosis at the same time. And you know, he was in a CBC radio documentary called "What's a life worth?", which really begs the question - when someone's dealing with so much trauma - what is a human life worth? But it's really great to see that kind of support.

Dr. Rezmovitz:

Well, that's what we're trying to do here. We're trying to tell the stories of the physicians in our department because we go through a lot of stuff. I try to think of this podcast as Humans of New York meets the doctors of DFCM.

Dr. Dosani:

Love it.

Dr. Rezmovitz:

And where we can actually promote , um, the narrative that we want in our, in our careers. And so you're doing that. You are promoting this narrative. You're the founder and lead of PEACH program. It's an impact not just in our community but in communities all across Canada. And so my question to you is about narrative right now. Your Twitter feed says that you're a physician change agent. So tell me about the - I know you want to talk about death, I don't want to talk about the death of your physician c hange a gent, but we are g oing t o talk about the origin story a nd the birth of how you became a physician change agent and how you've grown as a person because of it.

Dr. Dosani:

Well, I was born and raised to a family - both my parents are refugees. They came to Canada in the 1970s from Uganda due to crisis and war. And so you know, growing up in that household - things were a little different. It was hard at times. There were times where it was, it was difficult making ends meet for sure. But you know, I was always instilled with that understanding of what community well-being and social well-being really means. I.e., the social determinants of health. And with that upbringing in mind, I always knew that whatever field I would fall into, that would be used as a springboard for social change. And it kind of started off as like broadcasting. Then it kind of went into like engineering, but I was not so good at like math and physics. And then I kind of found myself in health and healthcare, and started reading about all these amazing physicians who are making change from Richard Hinesville to Samantha Nutt to James Verbinski in global health and international health. And then kind of fell into learning more about the fact that structurally vulnerable populations and marginalized populations exist right in our backyards. And there are so many health equity issues here at home. So I'd say that, you know, my upbringing is really connected to this date, to who I am - and shout out to my parents who are my biggest fans. Hi mom and dad.

Dr. Rezmovitz:

Hi mom and dad .

Dr. Dosani:

No doubt they'll be listening because they're a huge part of that. But if it wasn't about social change through medicine, then I don't know if I'd be doing medicine right. This is what it's about.

Dr. Rezmovitz:

This is medicine.

Dr. Dosani:

This is our social contract with the community that we serve. This is what we were supposed to do.

Dr. Rezmovitz:

I've had this conversation with a lot of people and we talk about - I always talk about systems. And so what you're doing is being a social engineer. You're recognizing the importance of your cultural values and projecting the worth on these important issues and changing the community and the social structure of the community that you're engaged in. There's so many different ways to do this. And at the end of the day, we need to remember, this is medicine. This is medicine. As much as food is medicine, as much as physical activity is medicine. This is medicine. I mean we've been so focused on pills for so long, but at the end of the day, sometimes having a conversation with someone and supporting them is medicine.

Dr. Dosani:

That's right. That's right.

Dr. Rezmovitz:

Because think about medicine 400 years ago when we didn't have antibiotics, what did someone do? They did a house call and they supported someone through their illness. That's what medicine was. That's what medicine is. It's a part of it. And there's antibiotics, which are amazing.

Dr. Dosani:

There'll always be a need for antibiotics. But you know, sometimes there's a pressure to - well there's not enough funding for that or there's not enough resources and absolutely like I'll be the - we run the PEACH program. Very aware. There's not a lot of funding. There's not lack of housing. I mean this problem would arguably just go away if we just had housing first for everybody. But until that time, there are ill people on the streets who need care, and arguably palliative care as well. And sometimes it's not about getting the funding or the resources, but it's actually - like the resources are arguably out there. It's about making connections and relationships and partnerships to galvanize energy. So imagine an engineer, so imagineering a new way to sway resources to where you need to go. And I think one of the big things was connecting the Toronto Central LHIN home and community care palliative care team with Inner City Health Associates. So we could do the PEACH program, right? That kind of partnership never existed and now it does. So we can do this work.

Dr. Rezmovitz:

You know, another opportunity might be to have a podcast where you talk about donating to a go fund me page.

Dr. Dosani:

Another plug to the Advancement Office.

Dr. Rezmovitz:

Oh yeah. Anyway, never lose an opportunity to build a legacy. I think you're doing an amazing thing.

:

Thank you.

Dr. Rezmovitz:

So have we spoken about the barriers yet to you doing this?

Dr. Dosani:

Well, I think the previous comment about resources is often listed as a barrier. I think when you look at some of the - for the folks we serve, the barriers that they are experiencing in accessing care in general - I mean I'm going to really be maybe stating the obvious, but like we went and created a healthcare system called home palliative care. And just sit with that for a second.

Dr. Rezmovitz:

I do, I get it. So part of me takes my old brain which says, due to the population that you serve, do they have health cards? Right? Is it about getting - figuring out how to get health cards so that people that are engaged in this can get paid. Thinking about getting people who are marginalized identification even. So it's like taking the bar and moving it so that you're not just providing care, but you're providing integration into a community.

Dr. Dosani:

That's right. For sure.

Dr. Rezmovitz:

And so you know, you mentioned peer support workers, you mentioned social workers. So is that a part of it also because what percentage of the people that you're supporting have OHIP card?

Dr. Dosani:

Yeah, it's a really great point. And so there are folks who are non-status who are uninsured, but there are a significant proportion of folks who really should have health insurance but don't have their cards. So that's why ID clinics are a very popular intervention at most shelters or housing providers. And thankfully our community partners are actually doing ID clinics quite regularly, which is amazing.

Dr. Rezmovitz:

You're going to have to expand on the acronym. What is an ID clinic ?

Dr. Dosani:

So it's the idea that because folks who are on the street live very difficult lives where they're very busy, keep - and don't have the resources to hold very important documents, they often don't have their documentation. And so an ID clinic is where you meet an individual who understands that and they work with you to get your health card, get your driver's license, get your documentation so you can get healthcare, social assistance and whatnot. This is arguably the first thing that we work on with people if those - there are deficiencies. Absolutely. But then once they have - there's a common assumption that just because we have universal h ealthcare that everyone has access to care or palliative care. That's just not true. And in the case of folks who are homeless, as I was saying before, we called it home palliative care. T here's no greater example of social exclusion in our h ealthcare system, arguably - in my opinion - than this issue, because t here's a significant proportion of folks who do not have a home and we went and called it home palliative care. So what do you think happens to folks who are homeless? We've created a health system that's structurally incongruent with the ability to provide palliative care to the homeless. And that's why, you know, I 'm like, why is this so unorthodox and so exotic like we are going into people's homes. These are their homes, these are their communities. It's just not what we're used to. So our system often requires a phone number. We require full forms to be filled out. We need an address to send equipment. And if we any one of those pieces are not there, w e're like hands up, care cannot be provided. And that's not fair and that's not right. I guess that's wh at r eally what PEACH is response to.

Dr. Rezmovitz:

Now I think it's amazing. You've taken the structure of the system and flipped it, which is what we need. We need people who are passionate and enthusiastic and willing to put the time in to realize that there are inequities and we need to support those people. If we went along with the status quo, then there's a continuation of marginalization of people. We can't have that.

Dr. Dosani:

No, no. I mean we're really good at equality . I say this all the time. We're really good at giving people the same things to be happy and healthy. That's - Canadian healthcare is pretty good at that.

Dr. Rezmovitz:

Equality, not equitability.

Dr. Dosani:

But equity is where we need to move, right? Where people get what they need to be happy and healthy and our system is not good at that. And particularly for folks with complex needs, like folks who are homeless and vulnerably housed, folks with serious mental illness, folks with substance use disorders or a combination of those three. And then you throw in palliative care on top of that, it can get really challenging.

Dr. Rezmovitz:

So I've had this conversation with my kids who've said things to me like, it's not fair. And I said, you're right, but you're different. Are you the same? Are you the same as your sister? He's like, no, I'm not the same. I was like, so why would you expect us to parent you the same? Why would you expect that you're going to get the same? I said, I'd love you all the same, but I like you all different depending on the day, right?

Dr. Dosani:

Yeah. Yeah. Fair.

Dr. Rezmovitz:

Right. It's not equality. It depends. And so why would we expect that we're going to provide h ealthcare the exact same to every single person? Obviously the context is going to be different for some people. And so if the context is different - and I think this is where our system falls short. There's a really good theory - educational theory that underpins an approach. It's called a realist approach by P awson and Tilley, and it talks about C plus M equals O and i t's context plus mechanism equals outcomes. And so if we apply the same mechanism to every single person, should we expect the same outcome? We can't because the context is going to be different.

Dr. Dosani:

Absolutely.

Dr. Rezmovitz:

And so the question is really we should be focusing on what outcomes we want and then figure out what the context is. And that's where the research comes in where we have to figure out the context. But you can't generalize to every person because sometimes the mechanism isn't good enough. You need to go above and beyond in order to get the outcome that you want.

Dr. Dosani:

Absolutely. And a really, really good example of that here in Ontario is a very common data metric that is , you know , palliative care programs pride themselves on - it's kind of like you have to track this metric - is the percent of people who die at home. So if that's high, then you run a really good program. And if that's low, then you know you need to do some work, for example. It's one of the big dot metrics from the Ontario palliative care network.

Dr. Rezmovitz:

Sounds binary.

Dr. Dosani:

It is rather binary in the sense that , yeah, if you live in a very nice home and you have lots of children and an income and you have private home care and public home care, you're more likely to die at home. But for many of the folks we serve - let's say a trajectory that could be two or three years - we might have for 99% of the trajectory kept them out of hospital, but on the day of their death, they show up in an emergency department for the last six hours of their life. And it's like a big X against us, right? So sometimes even the outcomes we use - the generalized populations - it's not fair. It's almost has - it's classist in a way because to say percent of deaths at home - there's so many assumptions about the social determinants of health that even would ever make that possible. So we fall victim to sort of generalizations around data collection because we collect the same kind of data that everyone else does because we're supposed to, and we fall short sometimes and I find that those nuances are lost.

Dr. Rezmovitz:

So it sounds like you have some existential pain also around metrics.

Dr. Dosani:

Absolutely.

Dr. Rezmovitz:

So what we need to do is connect you with an educational scientist to help you develop some better metrics that reflect what you guys are doing and maybe on the process. Maybe connect you with the quality improvement program here. So we can improve - not improve, but highlight what you're doing from a better-ship. Do you know about better-ship?

Dr. Dosani:

To some degree.

Dr. Rezmovitz:

It's about being better. It's like friendship except it's about better ship . And so it seems like that's what you're doing. And so if you guys can report on, you know, how you're making this world a better place through the process. Right? You just need a better metric, right? Because then you can, you can market what you're doing.

Dr. Dosani:

That's right.

Dr. Rezmovitz:

Instead of succumbing to the metrics that don't fit your context.

Dr. Dosani:

Absolutely.

Dr. Rezmovitz:

Right. It's about the mechanism. Because you're obviously getting amazing outcomes, but you can't tell that story because you're being delegated to a mechanism that's been forced upon you. You know , I hear you mention that it's classist. Um, there's another word that you used and I apologize, I can't remember right now. Um, but there's this pain that you're suffering - this program is suffering because the metric is being forced upon you. And so we need to find a way to change that.

Dr. Dosani:

Yeah. Small change, big impact.

Dr. Rezmovitz:

Small change, big impact. Because you're doing it.

Dr. Dosani:

Yeah. Absolutely.

Dr. Rezmovitz:

Okay. We're coming near to the end of our time, and so is there anything you'd like to impart on the listeners today? Something like if they only knew.

Dr. Dosani:

I think one of the things that I'll say is that if any of this work - if it does anything , my hope - and I know our team talks about this a lot of the time -the PEACH team's hope is that we work - we aim to destigmatize a population that is often stigmatized in our communities. I hear a lot about folks who are on the margins, who are homeless and vulnerably housed, and we hear things like, Oh, they did it to them or they're lazy or they use drugs or - I have never met a client w ho e ver wanted to be in the position - or he or she ever wanted to be in a position like that. I've never met a person who chose to be in that situation. There a re significant proportion of folks who are vulnerably housed on the streets because of serious mental illness, because of substance use disorders, a combination of - but even one third of Canada's homeless population does not have a mental health diagnosis or substance use disorder, but i t's in the situation they're in due to weakening social and economic infrastructure at national, provincial, regional and local levels associated with social assistance you know, medicare, pharmacare, h ousing, so on and so forth. So weakening social infrastructure - weakening social safety net is a huge cause of homelessness, and we talk a lot about pathways to the s treets. So if that's one thing I can leave with people, I hope people will work to better understand the society around them and how society is actually paving these pathways to the street, unfortunately for members of our community.

Dr. Rezmovitz:

Thank you for the one last plug. How do people get involved?

Dr. Dosani:

Yeah, so absolutely. We did talk about the Good Wishes program through Haven Toronto and checking out their website and through donations . For more information, you can check out www.icha-toronto.ca and click on the PEACH program. I'm @NaheedD on Twitter and Instagram. And you can follow many of our PEACH team colleagues , through that because we're always kinda like putting up new content and re-tweeting each other and putting up posts, and so you can follow the journey and the movement there. More to come in 2020 and I hope we'll be having further conversations around upcoming work. But thank you so much for having me today.

Dr. Rezmovitz:

Thank you. I look forward to another conversation.

Dr. Dosani:

Me too.

Dr. Rezmovitz:

Take care.

Dr. Dosani:

Thanks.

Dr. Rezmovitz:

This podcast was made possible through the support of the Department of Family and Community Medicine at the University of Toronto. Special thanks to Allison Mullin, Brian Da Silva, and the whole podcast committee. Thanks for tuning in. See you next time.