Small Changes Big Impact

COVID-19 in the context of global health and vulnerable populations with Dr. Praseedha Janakiram

May 06, 2020 University of Toronto - Department of Family & Community Medicine Season 1 Episode 26
Small Changes Big Impact
COVID-19 in the context of global health and vulnerable populations with Dr. Praseedha Janakiram
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Small Changes Big Impact
COVID-19 in the context of global health and vulnerable populations with Dr. Praseedha Janakiram
May 06, 2020 Season 1 Episode 26
University of Toronto - Department of Family & Community Medicine

In studio today, we have Dr. Praseedha Janakiram. She is a family physician at Women's College Hospital, the program director for the Enhanced Skills Program for global health and vulnerable populations. She works at the Crossroads Refugee Clinic. She is the faculty lead for the Toronto Addis Ababa Academic Collaboration and an assistant professor in the Department of Family Community Medicine at the University of Toronto. Today, she talks about COVID-19 in the context of global health and vulnerable populations through all of her different roles.

Show Notes Transcript

In studio today, we have Dr. Praseedha Janakiram. She is a family physician at Women's College Hospital, the program director for the Enhanced Skills Program for global health and vulnerable populations. She works at the Crossroads Refugee Clinic. She is the faculty lead for the Toronto Addis Ababa Academic Collaboration and an assistant professor in the Department of Family Community Medicine at the University of Toronto. Today, she talks about COVID-19 in the context of global health and vulnerable populations through all of her different roles.

Dr. Rezmovitz:

Small Changes, Big Impact: a DFCM podcast. I'm your host, Dr. Jeremy Rezmovitz. In studio today, we have Dr. Praseedha Janakiram. She is a family physician at Women's College Hospital, the program director for the Enhanced Skills Program for global health and vulnerable populations. She works at the Crossroads Refugee Clinic. She is the faculty lead for the Toronto Addis Ababa Academic Collaboration and an assistant professor in the Department of Family Community Medicine at the University of Toronto. Welcome.

Dr. Janakiram:

Thank you, Jeremy. It's a pleasure to be with you today.

Dr. Rezmovitz:

Thank you. So let's talk about what's going on. I don't know if you've heard recently, but there's a pandemic.

Dr. Janakiram:

Indeed.

Dr. Rezmovitz:

So how are you juggling these multiple roles? Holy smokes. That's a lot.

Dr. Janakiram:

There's been a lot of juggling - that is for sure. I think we are - I think everyone I know, every colleague I have - we're all in the same boat together right now. And I think we're all thinking about how to serve our patients best, but also I think in our educational role, in my educational role, and certainly in liaising with my colleagues in Ethiopia, there's been an additional layer of support that we're trying to offer to both our students but also to our faculty and friends in Ethiopia.

Dr. Rezmovitz:

So tell me more about that. How are you offering support and so - and if you can, is there any way you can comment on what the conditions are in Ethiopia versus Toronto?

Dr. Janakiram:

Certainly. Maybe I'll start by thinking a little bit about just the juggling at home and juggling at Crossroads and then we can sort of shift through to the other sort of layers, if that sounds reasonable.

Dr. Rezmovitz:

Sure.

Dr. Janakiram:

So needless to say, at the Crossroads Clinic, we've shifted from basically seeing every patient in person to a virtual model, which I think in particular for the refugee population is an important consideration because this is a group that maybe orienting to the concept of primary care in the first place in the Canadian system and also to the concept of visits that are pre-booked and pre-planned. And now we've shifted them to a virtual model of telephone visits and some video visits as needed. I will say that the majority of our patients have been incredibly receptive to this and I think we are innovating in terms of trying to keep patients safe but also to maybe create this new platform as a way of reaching our patients in their homes and being more accessible to them, to a group that has many challenges to accessing us within our own four walls. A group who has transportation barriers and logistics barriers around caring for their families, attending English to second language courses, et cetera. Many are isolated right now and I think being able to speak to patients by phone has made a world of difference to keeping them healthy and safe and addressing their fears and concerns. So that's been a juggling act for sure, the last few weeks. In addition to that, we're all juggling at home right now, I think with our families. I have a little four year old at home and it's been a challenge to be a full time JK teacher in my spare time and to think about how to give her some reassurance and some security at a time when she's felt fairly isolated from all of her normal supports in terms of school and friends. And I know a lot of other parents are in the same boat right now.

Dr. Rezmovitz:

So what are some of the comments that your daughter is stating as part of the isolation? Is there anything that comes to mind that struck you as poignant?

Dr. Janakiram:

Yeah, you know what she's such a bright little spirit. She's been putting together so much art to cheer people up. And sees that she's done that and we've placed them in our window, we've mailed art to family and friends to send them messages of rainbows and unicorns and sunshine. I think she's really aware that people might be feeling really sad right now and really lonely and afraid of this virus in some ways. She herself has been very resilient, which I think speaks to children all around the world. I think they have an incredible spirit of hope and making things work no matter what, and I see that in her every day. She's also been very good at telling us about COVID-19. She knows the term. We've talked with her about that - about the fact that we need to help keep each other safe and the way we do that right now is we can see each other and wave to each other, but we can't be closer than the starfish distance, which is spreading our arms out nice and wide and thinking about how far away we need to stay from those who we know and would love to embrace or give a hug to on the sidewalk ordinarily. So she's been very thoughtful of that.

Dr. Rezmovitz:

Yeah. I have a three year old amongst the other children that I have, but the three year old, knows the term coronavirus.

Dr. Janakiram:

Yes.

Dr. Rezmovitz:

And the three year old, he has not listened to any of the starfish physical distance thing. So I've had to tell him that everybody that he sees on the road when we go out - what's the word? Scootering or something is infected and that he could catch whatever they all have.

Dr. Janakiram:

Oh god.

Dr. Rezmovitz:

The faces on all the people when they're walking by, when I yell they're infected, stay away from them. It's really for their purpose to make them laugh a little bit and they're like [inaudible]. So what about people that attend the refugee clinic? Tell me about some of the stories that you've heard now through phone. I mean, you made a comment that you said now that we can use phone calls - part of me wants to say, I think we've always been allowed to use phone calls, but they've - now they have codes attached to them so you can actually do the work through the phone call. So, you know, I understand part of that. So tell me some of the stuff that you've heard. Is there anything that's particularly frustrating for you in that subset of our population that you've heard?

Dr. Janakiram:

I think our biggest struggles are trying to keep people connected to services. I think this is a group, like all of our patients, are patients who were potentially working in precarious work in the first place. And now much of that work has been shut down or taken away. This is a group who are socially isolated to begin with. For example, I had one patient who did have some mild URTI symptoms, presumed - we are working with a presumed COVID diagnosis. She was self isolating at home and as I was speaking to her on the phone, it became so clear that she didn't know anyone. She had no one to reach out to to say, "could someone pick up groceries for me?" And she was truly feeling very isolated and very alone and we're very thankful for a number of neighborhood organizations who are volunteering to provide supports to those who really do have a complete sense of isolation around them, and she was certainly one of them and it was nice to be able to connect her to some neighborhood services. But there are many examples like that where I think for most of us it's probably hard to imagine that you can't think of one person you know well enough to phone or that you don't have a phone number in your cell phone list that you can reach out to. And there are many, many patients just like her out there. I will also say something else that's really resonated with me, has been the number of patients who have simultaneously said thank you. Like thank you for all that you're doing. Thank you for all the phone calls and also to say like, "we look forward to seeing you again." Like we want to see you again in person soon. And that has come through in a myriad of languages and through interpreters and through all the other means we have in our armament to sort of reach out to patients. I think there's a real appreciation that we're trying to stay connected to everybody as best we can when ordinarily the chance to see each other in person bridges so many gaps.

Dr. Rezmovitz:

So what do you think - do you think it's just seeing people in person that we take for granted? The connectedness that occurs by being in clinic with patients versus the gratitude that's spilling out right now by just picking up the phone?

Dr. Janakiram:

I think that there's certainly a gratitude that comes through right now that is particularly poignant because patients - most of them are in their homes trying to follow all the recommendations and public health measures right now and where we all feel a degree of isolation. I think it is multifold worse for this particular community that are new to Canada and are learning a language and often have others to care for or to be responsible for and don't have a lot of social supports and don't have a lot of necessary means available to them either. So I think having that phone call from often the primary care provider teams or from myself or our nurse practitioners or our nurses is a reflection of just us being able to reach out at a time when so many are probably without anyone reaching out to them otherwise.

Dr. Rezmovitz:

Yeah. I wonder if these codes are going to continue after the COVID crisis. I just want to keep using alliterations.

Dr. Janakiram:

Yeah.

Dr. Rezmovitz:

Will these K codes continue after the COVID crisis? But also what about group visits? What about figuring out innovative ways to keep people together that wouldn't necessarily be together? And I don't know if you guys have done this, but I used to do it with - when we were seeing more patients in clinic, is I would try to book patients who were generally isolated, who were older, and have them sit in the waiting room together, so that they could actually talk before - because that was more of the treatment than I could ever offer. So I don't know if that been piloted or not in the - identifying patients who are at risk for isolation regardless - refugee, not refugee. But if you guys have ever thought about doing something like that.

Dr. Janakiram:

Yeah. Well, it's really interesting. Last year, I was the PI on a project with a colleague of mine at Crossroads to basically pilot a anti-natal, perinatal education group model for our refugee patients - a number of women who were prenatal and postpartum. And we brought this group together and ran multi-lingual education sessions with multiple languages being facilitated in the room at the same time. And it was a pilot project that was overwhelmingly sort of met with such a positive response from all of our patients. And the fundamentally - I think one of the most critical outcomes out of that was the relationship building that happened amongst this amazing group of women. A group of women who are, each of them, leaders in their own families and not only now caring for themselves, but also caring for babies and mothering in the process. And the friendships that were making sort of new levels of connection in that setting was so valuable. And it very much sparks for me sort of what the next tier of that could look like in terms of sort of creating the virtual equivalent in this context of COVID in particular. I think ordinarily we might have immediately thought of another iteration of in person. And with COVID and the multiple stages we anticipate over the next year, I think a virtual opportunity to facilitate something like that would be just remarkable. And I suspect that that will be a model that we see unfolding in many, many settings for a whole range of issues.

Dr. Rezmovitz:

Yeah. Like a virtual waiting room.

Dr. Janakiram:

Absolutely.

Dr. Rezmovitz:

We can do that. We can't do group visits yet. It's difficult. I've noticed that some of the group chats that I've been on have been very difficult to follow. There's just so much going on sometimes. So these are the challenges obviously, that we're going to have to get through. And so you said you wanted to take it step by step. So now let's talk about Ethiopia if you don't mind.

Dr. Janakiram:

Sure, sure. So my colleagues in Ethiopia - so the collaboration we have in Ethiopia is one where we are formally known as the Toronto Addis Ababa Academic Collaboration in Family Medicine. It's a partnership that began around 2011, 2012, with the launch of the first family medicine residency program in the country in 2013. Toronto has been a partner in that launch right from the very beginning and we are now into the eighth sort of year of that program, so to speak. And in so doing, we've seen the first cohort of family medicine doctors graduate from the program in 2016 - the first seven family doctors in Ethiopia. And from that cohort onwards, there are now Ethiopian faculty teaching the Ethiopian family medicine residency program with graduates of that program in lead positions across the faculty. So it's a iterative process, but one that I think just tells a really incredible and courageous story of family medicine and primary care emerging. And I think particularly in the context of what's happening now, I know family medicine is being called upon with all its counterpart specialties to support the response that will be unfolding both in Addis Ababa, but certainly at their major tertiary institution at Black Lion Hospital.

Dr. Rezmovitz:

So what was - for people that don't know the history, you said the first seven family doctors in Ethiopia. So what was there before?

Dr. Janakiram:

So primarily before the family doctors were graduating - and granted they are still a small but growing cohort - that the primary care infrastructure there has been one that has included a strong contingent of healthcare force workers, including nurses, including clinical officers who have maybe a year of healthcare training who can often offer a breadth of care, following the sort of standardized algorithms that are developed to provide rural care as well as urban care. And there's been, of course, a range of midwives and certainly a strong cohort of general practitioners who were medical students, graduated from their program with an internship here and practicing in the workforce. But to have the opportunity to return to residency with the focus specifically on family medicine and sort of a specialty in generalism, if you will over the course of a three year residency is just this unique opportunity to build strong and robust, skilled family medicine clinicians who have the extra training they need in order to work in the diversity of settings across Ethiopia. Whether that's doing C-sections or small general surgery procedures, certainly offering administrative and leadership supportive hospitals across the country. And that I know is certainly part of the vision for what they anticipate for family medicine in that setting.

Dr. Rezmovitz:

And so what have been some of the COVID-19 challenges in Ethiopia right now? Are they any different than what's going on in Toronto?

Dr. Janakiram:

I would say they're looking very different. In our conversations with our colleagues and particularly the program director of the family medicine program there, their biggest challenges, certainly the lack of PPE. I think that they just do not have the same access to personal protective equipment that we are very fortunate to have here - although we are also well aware of the procurement issues and the challenges in our settings as well. They have very little PPE. The whole process of sort of physical distancing and trying to sort of properly educate and enforce that is a great challenge - not just in the urban settings but throughout the rural environments as well. And certainly for our program director, they're still trying to run their residency programs. So not only are they being called upon to provide strong clinical care and clinical support, but they're also trying to continue educating their residents and their learners, and internet access can be variable and access to devices in order to access the internet can be variable from learner to learner. So they have a range of challenges. I'm often thoughtful of just how fortunate we are to have so many of our learners to have access to the technology that we would rely on so heavily in our environments here. And appreciating how many learners there may not always be able to do the same.

Dr. Rezmovitz:

Yeah. It has been challenging, I think. And every context, obviously is different. Even in Toronto you can, you can see that there are different contexts, whether you have children that are in high school versus children that are in primary school. Whether you even have access to the internet, whether you have then - you have access to [inaudible] don't have a computer for your child to use to Zoom in or to - whatever the Google classroom is that people are using. You know, I used to kid that my primary job was a chauffeur and that medicine is my fallback career when chauffeuring doesn't work out because that's what I find myself. But nowadays it's way better. I get to actually work as a doctor, and my kids are at home. And so I think my primary job now is to support my kids and my wife who's doing an amazing job - this is a shout out to my wife, who's just absolutely amazing as a - I guess the term is a police woman? To make sure my son sits down and does the work that he's supposed to do. It's hard when you've got four kids trying to meet the needs of, uh, all of them during the day while I'm trying to do meet the needs of my patients. So there are obviously differences. I can just - I can't imagine what it might be like working in a rural environment in Ethiopia and not having access to - obviously PPE and internet. But I can tell you that there are difficulties here in Toronto for community based physicians - whether it's family medicine or whether it's what we in the in the Department of Family and Community Medicine like to call our partialists brothers and sisters, right? Do you know about this term? The partialists? Not specialists, but partialists [inaudible] Not all. Not all Royal College because you've got people that do general stuff, right? Like pediatricians and general internal medicine, obviously. But I'm just making a joke about the specialists because family medicine tends to get depressed sometimes, right? We've got, "Oh, you're just a family doctor" and we've got specialists, but you know. just something to talk about this morning. And so my question is, to you going forward what can we do? Like you work at Women's College Hospital and you guys have PPE and you guys are in - are you in an Ontario Health Team yet?

Dr. Janakiram:

So interestingly, I do work at Women's College and I also have a small community HIV primary care practice. So I am in this - I have a unique opportunity to see sort of both sides - both the sort of academic environment and the hospital based support that we're able to receive, and also to work in a small community office and to appreciate sort of the different challenges that we have in the community setting. And sort of to benefit from the knowledge and the expertise that comes out of the hospital environment, but to also be able to share that with my colleagues in my community setting, where to be honest, we are facing very different challenges in that environment because we're a small office of four in that environment.

Dr. Rezmovitz:

So tell me about some of the challenges you're facing in your community office.

Dr. Janakiram:

So the community office is such a small team and I think that what becomes important there is to appreciate many of the challenges that I think lots of practices - whether it's specialists or generalists are facing right now, which is supporting the staff that we hire and appreciating that we are still trying to manage sort of the appropriate infection control practices and ensure that we are also able to access PPE. But even ordering those supplies and appreciating the delays or the lack of supply in many respects are very relevant. And I think that a lot of providers across the country are facing the same thing and still trying to keep their offices accessible and moving very swiftly without sort of strong IT support from an outside source to a virtual model, and really having to be very innovative amongst the team as to how to make that happen. Also appreciating that we're a small team and so if a healthcare provider or two on the team are sick or unwell or need to remain home, how do we carry that burden as well? And I think at both of the Crossroads Clinic and here in my community office, I noticed that we're struggling with the very same challenges of just staffing and capacity and ensuring appropriate patient coverage in the meantime.

Dr. Rezmovitz:

Yeah, I've had the same thing as a community physician right now. It's a lot. And as a solo family doc, I'm really trying to make sure I don't go down so I can continue to work my practice. Have you had anybody complain about the new changes that have happened? Because I - correct me if I'm wrong, but I'm probably sure based on what you've just discussed, that you're practicing physical distancing and moving as much to virtual care as possible.

Dr. Janakiram:

Yes.

Dr. Rezmovitz:

Yeah. And so has anyone complained? Of your [inaudible]

Dr. Janakiram:

I think so far we've - I think that most physicians are doing absolutely everything they can to stay available and accessible to patients. And I think that for the most part patients really appreciate that. I think there is no doubt that there are some patients who would prefer to be seen in person, and when we try to sort of triage things first at the level of a phone call or a video visit to determine who needs to be seen in person, that sort of feels like an extra step. But I think that speaks to sort of the need for us to really reiterate over and over again the importance of why this measures in place right now. And I think for the most part, public health - and I think all providers across the system are doing a really great job of trying to make that message really clear. So I've been grateful, but not - so far, we haven't had any major complaints about this, but I do anticipate that we're into the sixth week right now and how much longer can this model continue before we do need to start rethinking again the next phase of reintegration of some of the physical visits back into our practices. And I anticipate that that will be - it will be relevant in both the community setting, at the Crossroads Refugee Clinic as well. A lot of important primary care has to happen face to face and with physical exam. And so we're needing to sort of strike that fine balance between how much can we do from a virtual model. And I think there's a lot we can do. I think this has taught us some important and really valuable lessons about just how much we can innovate. And at the same time sort of how do we start to triage out those folks who need to be seen in person and make sure that they do get seen in a timely way.

Dr. Rezmovitz:

I feel like what we're experiencing right now and how we're living right now - or at least existing and the model of care that we have right now is essentially like Harrison's principles of internal medicine versus Bates physical exam. And they're just going up against the other being like, you know - or like every time in medical school where you said, "do I really need to look at Bates physical exam? How much do we really like [inaudible]?" So we're like, "Oh, see, we told you we should have focused on the pathology and the history and-", right? And not so much on the physical - I mean, it's there to confirm or refute the history and the patterns that emerge out of the history. But right now I feel bad for Bates at least in the last six weeks because I mean, the legacy of that book has just not really been a focus of attention for a lot of care that's being given right now. You know, round one goes to Harrison. So you work with a lot of vulnerable populations and so are there any needs that have emerged in the vulnerable populations that- in the last six weeks that you guys didn't realize before because this virus has had a way of exposing certain vulnerabilities and other than isolation, which we talked about earlier, has there been anything else that's emerging?

Dr. Janakiram:

Well, I think that if nothing else, I think what we're more aware of than ever before is the housing piece. I think that across the refugee shelters, the outbreaks that we're seeing in sort of the congregate living settings right now really reflect on the fact that the housing environments that so many of our most vulnerable patients are living in are really sort of highlighted right now in the context of COVID in particular. And what we appreciate the incredible work of the shelter workers, the staff who worked under very difficult conditions to try and make those spaces both welcoming and supportive and also in this context as safe and very importantly, trying to troubleshoot ways to keep isolation practices in place in an environment that isn't meant to do that. I mean, it is not - the purpose of a shelter is not the isolation protocol. And I think that has come out more clearly than ever before. I think what we appreciate also is the significant challenges for housing certainly in Toronto, and not just in Toronto - that we're noticing around the fact that even if families or individuals are ready to transition to optional housing elsewhere, that those housing options are difficult to access right now and always have been actually. It's just more highlighted now than ever before.

Dr. Rezmovitz:

So what can we do? What can we do to improve the living conditions? What changes can we make? Do you have any suggestions with regards to what we can do at the micro level and the macro level, right? At the municipal level or even - not even at a political level, but locally that we can do to improve the lives of these marginalized and vulnerable populations?

Dr. Janakiram:

I think fundamentally being in family medicine and being in healthcare, I think that we have such an opportunity as sort of gatekeepers to the system, but also as frontline staff and workers to engage with patients right at the very beginning. And that's always been the priority for the Crossroads Clinic, to really sort of help our patients integrate into the healthcare system. What it does do is it also opens the door for us to identify healthcare needs, but also to connect to services. And what I realize more and more is that we also have this lens into the challenges where we have room to advocate. And I think that the advocacy role has always been sort of integrated into everything we do in family medicine - now more than ever. I think there's a real appreciation for sort of the understanding of how the shelter system is functioning right now, and there are others who are better primed to speak to, to that piece and all the challenges they face, but also what they see room for improvement around. But I think this highlights sort of the concern that, is there a better way to organize our shelter system, to organize the housing opportunities that are available for our most vulnerable patients so that in fact, we never let this situation unfold again. And I think that the lessons learned from COVID-19 just I think, are going to keep unfolding for the many weeks, months, years ahead, no doubt. But I think this is one of them - is that where can we make improvements in the system so that we do not facilitate outbreaks like this again through the lack of options for patients in terms of housing and safe housing.

Dr. Rezmovitz:

I agree with you. Hopefully we will learn the lessons and not be condemned to repeat them. Do you have any final last words for your younger self, for medical students, for the general public about - maybe take-away from what we've talked about today? Anything else that you want to get out on the plate?

Dr. Janakiram:

I think - final, last words. I would say that I went into family medicine for so many reasons, but one of them was that my family is an immigrant family to Canada. I had an interest right from the get go in working with vulnerable communities and being an advocate. And what I see around me every day is the range of heroes that are in our system right now, across healthcare, outside of healthcare. I want to thank so many of the frontline staff at grocery stores, gas stations, driving our food across the country, farmers keeping stocks and supplies in place. There are so many layers to this right now. And what I've seen is this incredible unity or across the system to try and keep supporting each other and taking care of each other. And what I think of in family medicine is that we do a really amazing job of recognizing all of our roles and collaborating right from the get go. I think that is innate to who we are. And I'm inspired by my colleagues and my patients and the incredible generosity and kindness that we've seen around us every day, including our neighbors - my neighbors who offered to help me out in the smallest of ways so that I can be at work and do what I need to do each day. So I'm very aware of what is very classically Canadian, which is the desire to support each other in times of strife. And that to me has just been so prominent at this particular time. And I think we're all doing our part and that inspires me more than anything that we are working with a system that is designed to do this work and to do it better. And family medicine as well primed for that. I think that the care of our vulnerable populations is such an important piece of the puzzle, but we don't do it alone. We do it together.

Dr. Rezmovitz:

So do you want to talk about you for a second?

Dr. Janakiram:

Sure.

Dr. Rezmovitz:

How are you?

Dr. Janakiram:

How am I? I'm, I'm doing well. I think that this has been without a doubt, one of the challenging times [inaudible] Pardon?

Dr. Rezmovitz:

I've got virtual Kleenex if you need it.

Dr. Janakiram:

Thank you. Yeah. This is absolutely been one of the most challenging times of my life. Without question. And not because of COVID, interestingly enough. I think COVID and the coronavirus as the pandemic has unfolded, it has highlighted for me the incredibly important support roles we play for our patients, for my colleagues in Ethiopia, for my team, but personally as well. My partner is also really challenged right now by his own crisis of sorts. And it is one that is affecting our entire family and I'm a single parenting for the most part right now amidst this. And I've been very aware of meeting the care for myself and to reach out for lots of friends and family to support me virtually. And I've never been more fortunate to have so many people around me, even though physically, we're really quite distanced.

Dr. Rezmovitz:

Yeah. Hopefully they're sending you rainbows and unicorns. [inaudible]

Dr. Janakiram:

Absolutely. Absolutely. Yeah.

Dr. Rezmovitz:

It's really hard being something that you're not used to being, right? Change is hard. You know, nobody really likes change.

Dr. Janakiram:

Absolutely.

Dr. Rezmovitz:

Especially when it's thrust upon you.

Dr. Janakiram:

Yeah.

Dr. Rezmovitz:

So being a single parent, I don't know what that's like, but you could probably ask my wife because that's what -I'm sure, what it feels like sometimes.

Dr. Janakiram:

I agree. I think that we're all probably have done that for phases and stages and I also hope that this is just a stage, but sometimes there are times in our lives where everyone has personal crises and I can see that unfolding right now for my partner. And it's so important to me to be able to give him the space he needs to figure out what he needs to figure out for himself and to support him the best way I can. But I will say that single parenting during global health pandemic was not something I anticipated. And yet I think we are also capable of so much deep courage and strength and I think you don't always know that you're going to find those resources until they're called upon. And I think that on every level right now, we can see that across the country, across the globe. And I certainly have found the same.

Dr. Rezmovitz:

So I'm going to ask you a question completely out of left field, but what do you think makes women such great leaders then? Because look at all the work that you're doing and leading and you've taken on these new responsibilities and you have this great smile on and you've got this wonderful attitude. So what do you think it is that makes women such great leaders?

Dr. Janakiram:

Such a good question. I will say without a doubt, I think women are great leaders because we lead not only with brilliant minds and deep courage, but I think we lead with heart. And I, in every engagement I'm involved in right now on every realm, I will say that the relationships I house are at the foundation of the work I do. And I think I can speak with that same language across all the roles I play and it gives me a sense of courage but also a real gratification and satisfaction that those relationships remain strong. And I think to be able to lead well is to be able to also connect with people and not just to have great vision, but to bring people together to do that work in a way in which everyone feels like we're moving forward together. And that has been fundamentally for me, the approach that I've taken to the clinical work I do, to the global health enhanced skills program, to encourage residents theto think in that light. And certainly with Ethiopia program as well. And I will say that it inspires me. I think to lead is to also ensure that you bring everyone with you. You don't lead alone.

Dr. Rezmovitz:

Yeah. It's funny if you do lead by the other model where you're out ahead of everyone, at some point you're just going out for a walk by yourself.

Dr. Janakiram:

Yeah.

Dr. Rezmovitz:

Right? A leader with no followers is not a leader, right?

Dr. Janakiram:

Absolutely.

Dr. Rezmovitz:

Just a lone nut out for a walk.

Dr. Janakiram:

It's very true.

Dr. Rezmovitz:

I sometimes kind of feel like the lone nut with this podcast because I don't know if anybody actually listens to it.

Dr. Janakiram:

I love that you're doing them because I think you're able to hopefully just tap into sort of just the incredible richness that is our department. And I think when you ask about what makes women great leaders - absolutely for me it's sort of the relational leadership that we're able to bring in a way that is interwoven with thoughtful, reflective and visionary concepts. But I also think about the great mentorship that we have in the department around this. And there's some amazing - so many amazing women leaders here in our department that I think have paved the way for more of us to follow in their footsteps.

Dr. Rezmovitz:

Maybe during the extra time that you have after single parenting and running the program director for the enhanced skills program for global health [inaudible] and your small community HIV clinic and Crossroads Refugee Clinic -maybe - just maybe - I'm going to put a bug in your ear -you think about creating a masterclass with some colleagues in the Department of Family and Community Medicine about women in leadership, right? I know you have the -

Dr. Janakiram:

I love that idea.

Dr. Rezmovitz:

[inaudible] Why not create a masterclass?

Dr. Janakiram:

Absolutely.

Dr. Rezmovitz:

You have a week or two to teach. And only offer it to men. Let us teach you something. I'm kidding, obviously. It wouldn't just be to men because women wouldn't do that. That's not something women would do. It's something other people might do in different contexts. Like a hundred years ago, there was this predominant - I think one, one sex was pretty much in medical school. But, you know, we've evolved. And so, I'd like to see that. I think you'd be great at creating a masterclass in leadership. And why would it be women in leadership? Why can't we just go leadership and then use the way that you lead as an example? I'm just going to take that to the next level. Right?

Dr. Janakiram:

I love that, Jeremy. I love that. It's inspiring a whole range of thoughts in my mind. Just as you speak the word.

Dr. Rezmovitz:

Fantastic. I look forward to our next podcast where we talk about leadership for both men and women. Obviously.

Dr. Janakiram:

I look forward to it.

Dr. Rezmovitz:

Excellent. Then have a wonderful day and we'll be in touch.

Dr. Janakiram:

Sounds good. Thank you Jeremy. Have a great day.

Dr. Rezmovitz:

You too.

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.