Small Changes Big Impact

Providing care to specific communities including LGBTQ2S folks and those living with HIV with Dr. James Owen

March 18, 2020 University of Toronto - Department of Family & Community Medicine Season 1 Episode 19
Small Changes Big Impact
Providing care to specific communities including LGBTQ2S folks and those living with HIV with Dr. James Owen
Chapters
Small Changes Big Impact
Providing care to specific communities including LGBTQ2S folks and those living with HIV with Dr. James Owen
Mar 18, 2020 Season 1 Episode 19
University of Toronto - Department of Family & Community Medicine

In studio today, we have James Owen. He's a family doctor at St. Michael's Hospital. He is the LGBTQ2S Health Education Lead and the Course Director for Complexity and Chronicity in the MD Program at the University of Toronto. He's also an Assistant Professor in the Department of Family and Community Medicine at the University of Toronto. Today's episode focuses on providing care to specific communities, including LGBTQ2S folks and those living with HIV. 

Show Notes Transcript

In studio today, we have James Owen. He's a family doctor at St. Michael's Hospital. He is the LGBTQ2S Health Education Lead and the Course Director for Complexity and Chronicity in the MD Program at the University of Toronto. He's also an Assistant Professor in the Department of Family and Community Medicine at the University of Toronto. Today's episode focuses on providing care to specific communities, including LGBTQ2S folks and those living with HIV. 

Dr. Rezmovitz:

Small Changes, Big Impact: a DFCM podcast. I'm your host, Dr. Jeremy Rezmovitz. In studio today, we have James Owen. He's a family doctor at St. Michael's Hospital. He is the LGBTQ2S Health Education Lead and the Course Director for Complexity and Chronicity in the MD Program at the University of Toronto. He's also an Assistant Professor in the Department of Family and Community Medicine at the University of Toronto. Today's episode focuses on providing care to specific communities, including LGBTQ2S folks and those living with HIV. I hope you enjoy the show .

Dr. Owen:

Thank you. It's great to be here.

Dr. Rezmovitz:

Thank you for coming on.

Dr. Owen:

Thanks for having me.

Dr. Rezmovitz:

Tell me about yourself.

Dr. Owen:

So I am a family doctor at St. Michael's Hospital, as you said. I've been in practice at St. Michael's for about - I think it's been eight years now. I did my training here at the University of Toronto , and I'm originally from Northern Ontario - that's actually where I grew up in a town called Wawa. It's about two and a half hours North of Sault Ste. Marie, for anyone who hasn't heard of Wawa before - and grew up there and sort of made my way through undergrad and medical school to U of T where I now actually practice in the complete opposite type of environment to a small town where I focus on inner city populations, focus on LGBTQ2S health , care of people living with HIV or folks who are at risk of HIV and then also the care of vulnerable populations generally.

Dr. Rezmovitz:

So as the LGBTQ2S lead, maybe you want to expand on what that encompasses as a way to be as inclusive as possible.

Dr. Owen:

Sure thing. Yeah. Good to do the acronyms so that we understand the term . So LGBTQ2S we're using as an acronym to essentially refer to sexual and gender minority populations. So it stands for lesbian, gay, bisexual, trans or transgender, queer and two-spirit populations. There's other ways of saying the acronym . Some people will say LGBTQ2I , LGBT - sorry, LGBT2I or LGBTI. Some people say LGBTQ+.

Dr. Rezmovitz:

Is the I the intersex?

Dr. Owen:

Intersex. Yeah. So I think - of course, you know, there's only so many letters that a person can manage to get out of their mouth and actually still sort of complete a sentence, but in general, we're using the acronym sort of as this umbrella term for sexual and gender minority groups.

Dr. Rezmovitz:

And the plus - I've actually never heard the plus before, but I assume it's not like Additionelle plus. It's more like let's be as inclusive as possible, but there's so many letters that we can get out.

Dr. Owen:

Exactly.

Dr. Rezmovitz:

Okay. Just making sure that we're not - it's not derogatory in any way. I've just - I've never heard the plus before. So I'm just curious.

Dr. Owen:

No, the plus is sort of almost like a "...". To continue off - continue on letters that have not been included.

Dr. Rezmovitz:

Maybe it should be "LGBTQ2S...".

Dr. Owen:

Yeah. Could be.

Dr. Rezmovitz:

So tell me about the work that you're doing right now and how you got involved with it.

Dr. Owen:

So I'll start off with my clinical work. So I work at st Michael's and as I said, I have a focus on particularly care of people who are living with HIV. I have a roster of about 750 patients of whom about 230 of them have a diagnosis of HIV. And for the overwhelming majority of those patients, I am their primary care provider - not just for their general family medicine needs, but also for their HIV care as well. And so that involves obviously some sort of specialized work in terms of adjusting medications, knowing about drug interactions and certain competencies in terms of the care of people who live with HIV. But I also have a broader population of folks who are potentially at risk of HIV. And there are a number of populations at risk , including men who have sex with men, people who are using IV drugs , certain newcomer refugee populations , and that makes up a significant portion of my practice as well. And then in terms of LGBTQ2S health , I have a significant number of, for example, trans folks in my practice. So as someone's family doctor, I may also be doing care related to hormone prescribing or workup for surgery approvals for example. And then other sorts of care needs for trans folks and other folks within the LGBTQ2S umbrella.

Dr. Rezmovitz:

So I can only imagine that things have changed over the last 10 years. I mean, you've been doing this for eight years, you said?

Dr. Owen:

Yeah .

Dr. Rezmovitz:

But over the last 10 years, I guess with the advances in medications - in antiretrovirals for patients with HIV - and how have you adapted or changed your practice accordingly to deal with the changes?

Dr. Owen:

Yeah, I think it's interesting. I was thinking about this recently and how over time I really do think that my practice has evolved. And part of that has been sort of a personal evolution for me and an understanding of where I think my niche is - like where I think I can sort of best meet an unmet need within the community. Um, and part of that has also just been understanding as well what the changing needs are of the community. So when I, for example, did my residency training , I had some experiences in infectious disease clinics or in primary care clinics talking about - where we were focused on HIV primary care. So I was able to sort of scale up that knowledge. But then over time the landscape has kind of started to evolve. So those of us who doing HIV care started to learn, for example, in 2013, 2014, about this thing called HIV pre-exposure prophylaxis, which was this evidence-based concept of taking a daily pill to prevent HIV for folks who are at risk of HIV. So now we had a new tool in our toolbox that we could use and - for folks who a re at risk of HIV, who we were already providing care to in terms of testing and counseling and so on. And really that has sort of, I would say dramatically changed my practice and opened up this whole other avenue of care that I can now provide to patients. Recognizing that if I can identify someone who is at significant risk of HIV acquisition - be it through certain risk factors like IV drug use or sexual contact for example, or essentially sort of general prevalence within a population - for example, the rough statistic is that one out of every four men who have sex with men in downtown Toronto is HIV infected. And somewhere around 15% of folks who have an HIV diagnosis don't know that they're HIV positive. So pretty much anyone w ho's within the MSM community in Toronto, if they're sexually active with more than one partner could be at risk of HIV. So I'm now having a lot of conversations related to HIV pre-exposure prophylaxis. And so i t's really sort of pushed my practice in a bit of a new direction to really sort of provide the best care that I can to those patients.

Dr. Rezmovitz:

And so if anyone listening has never heard of pre-exposure prophylaxis, it actually is written out as a PrEP - so PrEP - you may hear it as the acronym is PrEP but we're talking about it as a pre-exposure prophylaxis today. And I guess that works a lot better than judgement .

Dr. Owen:

Yes, absolutely.

Dr. Rezmovitz:

And "shoulding" on people, which we don't do here, we don't "should" on people. But my biggest question to you then is, based on your most recent response here is what is the biggest unmet challenge? Is it a challenge? Biggest unmet need ? That you are trying to address right now?

Dr. Owen:

So it's been interesting. There's things that come out, right? So many of us have added PrEP into our practice - and I do want to say by the way, because cause I found this as an analogy that's helpful for family doctors in particular, just to understand what PrEP is and the role that primary care might play. Take the analogy of a person who is at risk of pregnancy. So we all know how to talk about pregnancy prevention with our patients. Use condoms to protect against STIs.

Dr. Rezmovitz:

And pregnancy.

Dr. Owen:

And pregnancy. Yep. But condoms are the only thing that will protect against STIs and pregnancy together. If a condom breaks, you've got the option of plan B, and if you want to, we have the option of contraception, like the oral contraceptive pill for example, which is a daily pill that prevents pregnancy. Now take that same paradigm and take out pregnancy and insert the concept of HIV. So condoms - yes, for HIV and STI protection. We have post-exposure prophylaxis or PEP, which is sort of like the plan B if a condom breaks , and now we have PrEP, which is sort of the daily preventive pill. So when I presented that before to family doctors, they'd been like, "Oh yeah, I kind of get it" and how I can see how this might fit into the care of folks who I'm working with who may be at risk of HIV. But this is a long way of getting back around to your original question, which is kind of what's the biggest unmet need now, I would say. And what I'm really seeing - I'm seeing kind of two things I think within our practices. So one is the care folks who are living with chronic hepatitis C because there's in recent years, there's been this whole sort of paradigm change in terms of Hep C where the treatments are remarkably easy to prescribe. And in our practices we had large numbers of folks with Hep C that we struggled to get in to see a hepatologist to get treated. Now as a primary care provider, you can do the workup for the patient and prescribe one of these medications. They're hideously expensive and there's various hurdles that you have to jump through. I don't want to oversimplify it, but it's totally within the scope of a family doctor. And so at St. Michael's, we've actually got a project to try to eradicate Hep C within our family health team at St Mike's. We're really working hard to do that. The other thing I would say the biggest need that I'm seeing is around mental health and addictions. So with folks who I'm working with, there are certain populations that may be at higher risk of -particularly crystal meth use. And we're seeing a lot of sequella of that. And so I, myself and colleagues who I work with, we've all been trying to figure out how we can adapt our practices from understanding evidence based treatment options all the way to understanding how we can just be accessible to someone who may have a very chaotic lifestyle as a consequence of their substance use. So we're really trying to figure out how to meet that need in the community and I can tell you that it's a huge unmet need out there at the present time.

Dr. Rezmovitz:

I agree with you. I see it in my practice every day . There's a lot of mental health issues, a lot of addiction. People are numbing their pain with substances. There's a lot of pain out there. But for the family doctors who are listening right now , and patients to bring up with your primary care providers - sometimes as a provider, managing patients where you see them infrequently, like the occasional patient, might be overwhelming. Especially in a community where you feel like you don't have enough time ever to spend an hour on a patient that you rarely - like you don't know. You aren't trained to see these patients very often. And so , I mean with your permission - I know you'd given a presentation in the past about it and hopefully we can produce something so we can create - almost like I'm issuing you a challenge. Can I help you as lead for CPD, and you and I develop some programs of professional development for people out there on hepatitis C and HIV, even PrEP? In the meantime until we produce this stuff, is there any way -

Dr. Owen:

Yes.

Dr. Rezmovitz:

You can feel it? Can family doctors refer to you?

Dr. Owen:

So I recognize that we're on audio because I'm sort of I'm like nodding my head the entire time while you're saying this. I think that that would be absolutely incredible because I'm a big advocate for primary care led HIV care , hepatitis C care, and particularly things like PrEP for HIV. Like there are specialty clinics that will do that in the city, and they're great. They're absolutely great resources and I think that for someone who's not familiar with it, absolutely use those resources if you need to. But it - this is all stuff that can have a home in primary care. Um, it may require a bit of work, but it's totally doable. In terms of support , absolutely. Like if someone's out there listening and has questions I'd be happy for them to contact me. I do run - my clinic is still a general family practice clinic. So I'm typically seeing my own patients, but there are a number of us at St. Michael's who work in this space who have seen folks for consults. And often we've kind of modeled it on some of the shared care models, for example, that we might have with psychiatry. So the psychiatrist who works with our team may see a patient once to do a full assessment, get a diagnostic workup, and then propose a management plan of "okay, do steps one, two, and three. If two doesn't work, here's steps four and five. T-his is what you need to think about in the longterm . Here's your monitoring" and so on. I think that many of us will sort of feel that we can generate something like that, that we can then give back to the primary care provider again, so that it's not like the patient's going to need to necessarily see me every three months or six months beyond that. Like maybe do one or two follow ups and then I can sort of pass them back to the MRP. Because I think that that's important as well in terms of capacity building. Right? You know, we need more doctors who can do this type of care and I'm personally passionate about kind of bringing it into the fold of family medicine. So I want people to feel like they have some support but can also kind of venture a little bit of their comfort zone to provide care directly to their patients without having to completely offload it to somebody else. But that's not to say that I am ignoring the fact that there are - for all of us, there are huge demands on our time. And I recognize that the sort of - not every provider is in a position where they can take the time to review some guidelines that they've not seen before or sort of like research some stuff that is really outside of their comfort zone. So I think all of us as family doctors and as generalists - I think we've come to be flexible. And I myself believe in that as well and I think that as long as we're all thinking about how we can adapt and push our boundaries a little bit, I think that's important.

Dr. Rezmovitz:

Great. Leading question - and thank you for bringing that up about pushing boundaries and challenging yourself and learning because that's what this podcast is really about. It's about being better. And so tell me a time where you were better. That you made a small change with a patient that resulted in better.

Dr. Owen:

Better for me or the patient or both? That's a really interesting question.

Dr. Rezmovitz:

Oh, I mean , it's about "bettership". Have you heard about "bettership " ?

Dr. Owen:

"Bettership" sounds like a cool word. I have not heard of "bettership."

Dr. Rezmovitz:

Yeah. We made it up.

Dr. Owen:

Okay. So "bettership" copyright.

Dr. Rezmovitz:

Yeah. Do you know friendship?

Dr. Owen:

Yes.

Dr. Rezmovitz:

It's about being friends. What's better ship about?

Dr. Owen:

I guess being better.

Dr. Rezmovitz:

Right. So get on the better ship. Let's travel to an unknown place and challenge ourselves about being better. And so - but I'd like to root this in what primary care is all about, which is the patient. And so can you tell me about a time where you made a small change in - and through a patient story that really demonstrates the impact that little small changes can have?

Dr. Owen:

So the first thing that comes to mind - and I don't know if it's going to feel quite like a small change when I tell this story, but it really was I think - was a patient who came into my practice who is a long- term survivor living with HIV, I think for 15, 20 years, if not longer, and also was hepatitis C positive. And he came into my practice - he was seeing another provider and he was starting to feel a bit frustrated because - as he described it to me - he said, "I have lived so much of my life in the last couple of decades in medical spaces. I come into the clinic, I wait an hour for the doctor - I understand that people get behind, but you wait, you see the doctor, you're rushed in and out and I'm kind of done with all of this stuff. And if you want to be my doctor, I need you to know that this is my frustration." And I said to him, "OK, I hear that and I respect that and I understand what you're saying. I cannot promise you that I will always be able to see you quickly on time and so on, but we'll talk about essentially things that we might do, like booking you as the first patient in the morning so that I'm always going to be on time" - almost always going to be on time with that first patient, hopefully. So I can get him in and out of the clinic fairly quickly. I won't beat around the bush with things that I want to talk to him about. And we had this agreement that he would be honest with me as well. And so once we'd sort of set that up , we said, "okay, let's talk about your hepatitis C". And I was very open with him and I said, "I have never actually prescribed the medications to - these new medications. It's 12 weeks worth of pills. They're ridiculously expensive, but I know that we can do all of the appropriate workup, order the tests, get the ODB coverage -we can prescribe this." And we said, "okay, are you willing to work with me to make this happen?" And he said "yes." And I think over the subsequent visits - there were a couple of visits to kind of get things worked up, get him going with the medication and sort of continue on with the 12 weeks of medication and then follow up. We really started to build a rapport and by the time that we were done, and I actually sort of treated hepatitis C and we had a viral load that was undetectable. We were at 12 weeks. We cured his hepatitis C. It was a really exciting moment for him and I. We'd sort of had this almost a shared journey together. And I had been very clear that this was my first time doing this. He knew that. He trusted me. I trusted him to sort of engage in this journey with me. And it was really - I do genuinely think that it made something better cause this was another thing that he could just sort of offload from his mind. He didn't have to have this constant pressure of like, "I've got another medical problem and I don't know what to do with it." We were able to sort of at least take that off of his plate. And of course it has huge health benefits to him to no longer have a hepatitis C virus in his system.

Dr. Rezmovitz:

You know, I listen to that story and I think about the huge benefit to you because it built your confidence in your ability to then do it again.

Dr. Owen:

Yeah.

Dr. Rezmovitz:

And how often as providers do we not take that risk and realize that I'm taking that risk? I mean, it was a calculated risk. You followed guidelines obviously, but taking that risk and taking the time - so it's really about investing in the time? Or is it really investing in the patient? And forget about the time that it takes some times to end up building your skillset so that you can have an even greater impact to what you're doing.

Dr. Owen:

Yep. Absolutely.

Dr. Rezmovitz:

Yeah.

Dr. Owen:

Yeah. And I think that there's certainly a number of things that I would love to do that I just don't feel comfortable doing myself without some sort of expert input or potentially even connecting my patient with a specialist. So I do try to go about this in a thoughtful way so that I'm not just practicing recklessly, I guess. But you know, if there is something that I think, okay, I feel like I've done all of my due diligence and I understand - I know this is something that my patient would benefit significantly from and something that I can offer to them, you know, it, you know, if I'm doing something new, it does build my confidence to say, okay, now I can write this prescription for another patient. And what happened subsequent to that was over the next year or two, I actually did an EMR search of all of my patients who had a detectable hepatitis C viral load, identified all of them flagged when they were going to come in and we said, okay, let's see if we can treat this. And as far as I'm aware anyway, all of the detectable hepatitis C in my practice was treated - is now no longer an issue. And you know, there were some emails back and forth with hepatologists , for some support, but most of it was led - almost all of it was led by me.

Dr. Rezmovitz:

I think that's amazing, right? Like I think you should be really proud of what you've accomplished.

Dr. Owen:

Thank you.

Dr. Rezmovitz:

It sounds like you did - I hope you did - you filled out the linking learning to assessment through the CFPC and the five credits that you get for doing a quality improvement project?

Dr. Owen:

Of course I did. Thanks Jeremy.

Dr. Rezmovitz:

It's available if you want to fill it out. You get another five credits for doing an assessment of your practice and the impact that it had. Linking learning to practice from the CFPC. That's your college. I also work for them. [inaudible].

Dr. Owen:

[inaudible] your disclosures.

Dr. Rezmovitz:

No, I think it's important to realize that if any of these podcasts have an impact on people listening who are required to do continuing professional development credits, like family doctors through the College of Family Physicians of Canada, there's a program called linking learning to - there's one to practice, there's one to education and there's one to assessment. And they give you five credits and it takes about 10 minutes to fill this thing out. And you've already done the work and you get five certified credits and there's no limit to the number of things that you can fill out. So concurrent to your clinical practice, you also have an education role.

Dr. Owen:

That's right.

Dr. Rezmovitz:

Can you tell me about some of the stuff that you're doing and maybe some of the changes that you've instituted as a course director to improve the education of our learner ?

Dr. Owen:

Yeah. So currently I wear two hats within the MD Program at the University of Toronto. So I'm the LGBTQ2S health education theme lead for the MD Program, and then I'm the course director for complexity and chronicity, which is a course, which is the last 11 weeks of the second year of medical school. So the first two years at U of T is the foundation's curriculum so the last 11 weeks is, is CNC or complexity and chronicity, and that's the course that I oversee. So I kind of have these two hats . One which goes the LGBTQ2S lead position -

Dr. Rezmovitz:

dot, dot, dot.

Dr. Owen:

- encompasses the full four years of the curriculum and then I have a heavy focus on 11 weeks at the end of second year. And those have both been for me really exciting roles to have because I really believe passionately about - in education. I also love to do it. I would actually say that at the core, I just love being able to work with people, interact with people , and having these roles enables me to do that. And hopefully - potentially - hopefully have an impact on all of the medical students that are coming through U of T. The course is an interesting one because it was a new creation within the foundation's curriculum. So a lot of the material - I think nine out of the 11 weeks did not have some sort of analog within the old curriculum, and we were able to create some brand new material - really around sort of care of complex populations, marginalized populations , recognizing as well complexities in medicine related to systems for example. We were able to build a lot of really interesting stuff into the curriculum that was all brand new and as well get I think really like a good, strong kind of primary care lens to this as well because I personally believe that many physicians can provide excellent care to complex patients. But I actually - I truly think that there's something special about what a family doctor can do because we can, for example, address someone's diabetes, hypertension, do their cancer screening and manage their HIV and all sorts of things all together -

Dr. Rezmovitz:

In one visit.

Dr. Owen:

In one visit - in maybe 20 or 30 minutes. I'm lucky to be in a rostered model so I can buy a little bit more time for my folks, but we can do all of that and not have to sort of send our patients out to sort of different providers. So we have some sort of focused content in that course. And then the LGBTQ2S position has been interesting because there's sort of key learning I think around the care of LGBTQ2S populations that we've been able to have in some very specific lectures , and modules and so on. But also even just very small sort of like very small things like the insertion of a question in a case based learning module related to infertility. One question for example that relates to fertility considerations for same gender couples for example. So it's not like we have tried to avoid siloing the population within a certain period of time saying this is the week or this is the day where we talk about LGBTQ2S health and actually sort of figure out where it integrates well within the curriculum as a whole. So that I think has been, has been really exciting to build.

Dr. Rezmovitz:

That sounds exciting. And what has been the impact of that? Have you gotten feedback over it?

Dr. Owen:

So I think anecdotally, I certainly - I've had feedback that there are a lot of folks who are really pleased to see this content. And I think that there's more awareness, particularly around LGBTQ2S populations that providing inclusive care is something - is a basic skill that all physicians, all providers need to have. You can even see there the January, 2020 issue of Dialogue actually - there was an article on care for LGBTQ2S folks.

Dr. Rezmovitz:

Yes, I read that.

Dr. Owen:

I highly recommend it. There's a couple of quotes from someone who seems sounds really smart in the article aka me.

Dr. Rezmovitz:

Oh, that's why you read it.

Dr. Owen:

That's why I read it. Yeah. I was excited to tell my parents by the way, they know what Dialogue is and they usually hear me talk about Dialogue in terms of everything that's in the back of the magazine. And so I was very excited to tell my parents that I was in the front part of Dialogue for this educational purpose.

Dr. Rezmovitz:

My wife actually showed me that - what's it called? That - not episode - I can't even think that - issue.

Dr. Owen:

Yes.

Dr. Rezmovitz:

And she said to me, "it's horrible what's in the back of this thing." I say , "we're self regulated."

Dr. Owen:

Yeah.

Dr. Rezmovitz:

We need to talk about this.

Dr. Owen:

Exactly.

Dr. Rezmovitz:

It's called dialogue . It's about creating dialogue and hopefully that's what you're fostering with the curriculum.

Dr. Owen:

Yeah . I genuinely think - I mean this is important stuff that all medical trainees need to know and frankly I think all practicing physicians need to know. Not everyone is going to be a hormone prescriber for a transgender patient, for example. I understand that. But there are some basic competencies in terms of how to ask questions about sexual history in an inclusive way, how to ask basic questions like the appropriate name that you use when you're referring to a patient or what are the appropriate pronouns or what are the correct pronouns that you use. These are things that all of us as providers need to be comfortable with. And frankly, I truly don't think that it's that difficult. It's just we have to think about something that we normally don't think about.

Dr. Rezmovitz:

Well, it's mired in somebody else's values, right? And so sometimes it's really hard to get out of your own head and think about other people's values because it's so - our values are entrench our beliefs. And some people have belief that there's he and there's she. An"d so if you said no, I'd like to be referred to as they", they would think that is ludicrous.

Dr. Owen:

Yeah.

Dr. Rezmovitz:

Except in a system where that's acceptable. And so it's becoming in certain systems and circles - obviously it's acceptable. And for those people who are still not adapted yet, it's obviously going to be a conflict for them. And so that's when you get the frustration as a patient going to a provider who doesn't understand or is ignorant to the way the system has evolved. And that's where that comes out of. I don't think it's out of a true, deliberate - what's the word I'm looking for here?

Dr. Owen:

Like out of malice or something.

Dr. Rezmovitz:

It's not malicious at all. That's exactly what I was thinking . It's not malicious. It's just completely foreign and unknown and it doesn't align with the beliefs that they were taught.

Dr. Owen:

Yeah. And I tend to think about it as - let's say you take the question of pronouns - understanding what pronouns we should be using when we refer to another person. All of us make assumptions everyday when we walk around about what someone's pronouns may be - he, she, they, and so on. You know, you look at someone, you sort of read them phenotypically as a certain gender and you assign pronouns to that person. And the vast majority of the time, your assumption is going to be correct , but there have always been people who felt so that pronouns like he and she did not necessarily - or the pronouns that were being assigned to them by other people do not match their own internal experience of gender. And so all that providers need to do is understand that we just can't assume , and it's just better to ask. And make it part of the routine history that you ask. Just as if someone walks in the door, I walk in the door and someone says, "Oh, your name on your health card is James. Do you know, do you prefer James or Jim?" kind of thing. The best way to ask that question is "your name on your health card is James, what name would you like us to -"

Dr. Rezmovitz:

How would you like to be addressed?

Dr. Owen:

How would you like to be addressed? It's as easy as that.

Dr. Rezmovitz:

And if there's a conflict say, "huh, that seems to be different than what's on the card."

Dr. Owen:

Exactly. And I just want to make sure your health card says this, but the name that we're using is this. I want to make sure that we're using the correct name for you here at this clinic. And same thing - and then it's just another question in terms of pronouns. "I want to make sure that we're using the correct pronouns for you. What are your appropriate, or what are your preferred pronouns?"

Dr. Rezmovitz:

It's just respect.

Dr. Owen:

Yeah.

Dr. Rezmovitz:

It's like when people ask me, "Oh, I heard you had another kid." I said, "yeah, I have another kid." They said, "so what do you have?" I said, "four healthy kids." They said, "no, but what do you have?" And it's this incessant need to classify.

Dr. Owen:

Yeah.

Dr. Rezmovitz:

And I don't know why we need to classify - I don't know if it's an evolutionary thing so that we can procreate. I have no idea that like you're trying to take count like, Oh, it's a he and a she. It's a girl and a boy so that I know how many people I can in the future, procreate with and produce more offspring. I have no idea why people need to classify. Because are there different rules for boys and girls? I have no idea. So when they ask me, "what do you have?" My typical answer is "I have girl, boy, boy, girl - for now." And they say, "what do you mean for now?" And I said, "well, do you know how it works?" And they said, "what are you talking about?" And I said, "well, we assigned girl , boy, boy, girl. And then around puberty we'll figure out if they align or reject the assignment." And they're like, "what the hell are you talking about?" And I said, "well let me explain to you the difference between gender expression, gender identity -"

Dr. Owen:

And then we get into it and all that stuff.

Dr. Rezmovitz:

And so we get into this conversation and then we figure out and they're like, "Oh, I never knew that's the way it works ." I'm like, "well." So I do this and my wife says to me, "why do you insist on just making it difficult? You know they're just looking for girl, boy, boy, girl." Like you know what? Somebody has to make it difficult and so that we can progress the conversation because if we're not progressing the conversation then we're just going to end up with more ignorance.

Dr. Owen:

Yep, absolutely. And if you want to talk about small changes, big impact, that's a really good example of a small change where like it's one of these little incremental things over time where we just sort of challenge the assumptions that we all make to try to get by in our days to say, "you know what, actually we shouldn't be assuming." You know, and the reality may be a touch more complicated, but it's truly not that complicated. You just need to understand that there are people whose experiences may be different than your own. And that's totally okay.

Dr. Rezmovitz:

Okay. I totally get you. That's awesome. I want to thank you for coming on the podcast today.

Dr. Owen:

Thank you so much.

Dr. Rezmovitz:

Do you have any parting words for our audience. If they only knew kind of thing ? Something you could either tell your younger self, something you could tell the medical school program class that maybe if they're listening, readers of Dialogue?

Dr. Owen:

That is - wow. I would like to say - I would love to say something really profound and now I feel like there's a bit of pressure for me to say something good. I think - you know that old saying about everyday do something that scares you? You know, people say that ? I would say everyday think about something that sort of pushes your boundaries just a little bit - pushes you a little bit outside of your comfort zone. And then think about why your comfort zone has that boundary that it does. I think about that in so many different ways in terms of my understanding of my own privilege or my understanding of other people's experiences that may be different from my own. Or for example, in terms of clinical care. The things that I do as part of my practice and a medication that I know exists but I've never prescribed before and you know, this is a patient who is a clear candidate. Maybe this is something that this time I can actually do myself, save the patient a two month wait to a specialist. Kind of think about something that sort of pushes you outside of your comfort zone. And I think that's how we all kind of incrementally grow and evolve and hopefully become better healthcare providers but also better human beings as well.

Dr. Rezmovitz:

Thank you. I hope you had a good time. Because I know I did.

Dr. Owen:

I did. This has been great. Thanks.

Dr. Rezmovitz:

Take care. 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.