Small Changes Big Impact

Personal stories from the frontlines during COVID-19 with Dr. Nadia Alam

June 24, 2020 University of Toronto - Department of Family & Community Medicine Season 1 Episode 31
Small Changes Big Impact
Personal stories from the frontlines during COVID-19 with Dr. Nadia Alam
Chapters
Small Changes Big Impact
Personal stories from the frontlines during COVID-19 with Dr. Nadia Alam
Jun 24, 2020 Season 1 Episode 31
University of Toronto - Department of Family & Community Medicine

In our season finale of Small Changes, Big Impact, we have Dr. Nadia Alam, a family doctor and anesthetist in Georgetown, Ontario, and the past president of the Ontario Medical Association. In this episode, she talks about her family, and shares stories of the work she's doing in her local community to help her patients and other allied health providers during COVID-19.

Recorded April 29, 2020.

Show Notes Transcript

In our season finale of Small Changes, Big Impact, we have Dr. Nadia Alam, a family doctor and anesthetist in Georgetown, Ontario, and the past president of the Ontario Medical Association. In this episode, she talks about her family, and shares stories of the work she's doing in her local community to help her patients and other allied health providers during COVID-19.

Recorded April 29, 2020.

Dr. Rezmovitz:

Small Changes, Big Impact: a DFCM podcast. I'm your host, Dr. Jeremy Rezmovitz. Good morning. We're having another candid COVID conversation with coffee this time with Nadia Alam. She's a family doctor and anesthetist in Georgetown, Ontario, past president of the Ontario Medical Association, and she does a hell of a lot of everything else from teaching to consulting. And today we're just going to talk. Let's have some fun.

Dr. Alam:

Rezmovitz. Is it Rezmovitz?

Dr. Rezmovitz:

Yeah. It's still Rezmovitz. I haven't changed it yet. Although my father-in-law wanted me to change my name to his name and - when we were getting married - and he said "you don't want Rezmovitz. It's too ethnic." And I said, "that's exactly why I want it. You know, I want that." And the people that don't come to - Yeah. So he said, "but it's so hard to pronounce." I said, "I know it's hard to pronounce. It's okay . It's okay ." So.

Dr. Alam:

People learn. People learn because they like you and they respect you. And they'll learn . And I have to admit , I'm very excited about today's podcast. I'm also kind of afraid you're going to get me into trouble, but we'll see. We'll see how things go.

Dr. Rezmovitz:

I think we're both troublemakers.

Dr. Alam:

Yes.

Dr. Rezmovitz:

I think we're both trouble makers , you know, just on the changing name thing though, it strikes me as odd that we expect women to change their name so easily when they get married. But as soon as you ask a man to change his name, forget about it.

Dr. Alam:

Interestingly, my husband, when we got married - oh god, 10 years ago? 11 years ago? Maybe 12? I don't remember. It must be over 10. And my oldest son is 10 years old. So it must be over 10. He never asked me to change my name. One: because Nadia Ma didn't have quite the same ring as Nadia Alam, and two. I didn't want to go through the paperwork. I just flat out refused. So I am -

Dr. Rezmovitz:

I didn't want to go through the paperwork either. My wife didn't change her name. It's a lot of paperwork. A lot of paperwork. Okay. So how are you keeping busy during these extraordinary times?

Dr. Alam:

I'm still working. I've still got my day job.

Dr. Rezmovitz:

As a chauffeur? My first job was a chauffeur with my kids. So that actually got canceled. We're staying home mostly. So what's your day job now?

Dr. Alam:

So my day job is working in my family medicine clinic and working as an anesthetist at my local community hospital. And then also coming home and trying to homeschool my children using Ontario's curriculum. Luckily their teachers are very forgiving because I'm pretty sure we've missed the deadlines already.

Dr. Rezmovitz:

How many kids do you have?

Dr. Alam:

Four.

Dr. Rezmovitz:

You have four kids?

Dr. Alam:

You know, it didn't seem like that much until we were all shut into the house together.

Dr. Rezmovitz:

Yeah.

Dr. Alam:

And now it's a lot.

Dr. Rezmovitz:

What age are your kids?

Dr. Alam:

My oldest is 10 years old - Connor. And then Sully is 8. Isa is 6 and Freya is 4.

Dr. Rezmovitz:

Oh, wow. I also have four kids.

Dr. Alam:

No way. Tell me about them.

Dr. Rezmovitz:

Yeah. 10, 6, 3, and 1. And it's busy. And we live in a small house and it's - you just pull kids off of each other all the time. Like when you're working as an entertainer right now, and as a teacher and as a police person and as an educator and as a parent and as a doctor - it's a lot. It's a lot.

Dr. Alam:

It's a lot.

Dr. Rezmovitz:

It can be exhausting, but there are moments of brilliance. Tell me what your kids have said that have made you been like, "Oh, wow. Wow." You know, through this whole coronavirus thing.

Dr. Alam:

Well, my kids have told me that - my kids have grown up wanting to be all sorts of things. They've wanted to be in turn a Lego master builder. They've wanted to be a soldier. They've wanted to be a zookeeper or a zoologist. They've wanted to be all sorts of things. They've now all coalesced and agreed that none of them are going to be doctors because they think it's too dangerous. However, they are very proud of the work I do. But at the same time, it's - you can tell that the anxiety's kind of getting to them. They're worried. They're playing, they're wrestling, they fight all day, every day, they do their homework - they do all the normal kid stuff. And then every once in a while , their anxiety will leak through, they'll wake up with nightmares or they'll hug me tighter before I leave. They particularly get anxious when I'm at the hospital for my call shifts because they know that's probably my highest risk. Although I would argue some of the family doctor's offices and the specialist clinics, or even some of the community organizations where a lot of allied health providers work, they are probably just as much at risk because of the fact that they have such lack of access to personal protective equipment.

Dr. Rezmovitz:

Yeah. Tell me about it .

Dr. Alam:

They're going to be faced with patients who have COVID-19 and they may not know it and they may catch it - I mean, this is what we saw happen with longterm care homes all around the province, right?

Dr. Rezmovitz:

Yeah. So are you doing anything specifically to try to facilitate PPE deliveries to anyone? You seem like the type of that would advocate for other people - just getting to know you over the last like few weeks and stuff like that. You just strike me as that type of person.

Dr. Alam:

I am very dependent on my community to be functional. I am very dependent on the midwives being able to do their work, just like the obstetricians being able to do their work. I'm very dependent on my patients being able to get medications from their pharmacy - their local pharmacies. I'm very dependent on home care being able to function. And so, yeah , about early March, I started noticing how more and more community organizations were talking about how they don't have masks, gowns, gloves - the usual basic PPE. And so I started a group in Halton Hills. I started a group in Milton. I started a group in Oakville - so all of Halton region to start doing drives for - community drives - for PPE. We asked the community to make donations. We didn't want money. We just wanted any extra spare masks, gloves, gowns. So the dentists who had closed their offices right now, they helped a local glove factory in Acton , turned out boxes of gloves for us. So we're set in that respect. 350 approximately sewers in Halton Hills banded together and started sewing us gowns. All the fabric stores have closed. So they're using bedsheets. We're Sound of Music-ing this shit . I apologize. We're being inspired by Sound of Music to make gowns and personal protective equipment like scrub caps and all of that out of people's bedsheets and so I'm touched that someone's taken their six year old's Spiderman sheets and made a gow that's going to protect me. It's kind. And then we also got in touch with a lot of the 3D printer hobbyists and makers in our community, and they turned out face shields. And so this is all being spread out through the community. Last week, I did drop offs in Halton Hills. The Milton docs are doing their own run. And then this week - last night, I did a pickup with the Oakville docs. And we've supplied shelters. We supplied retirement homes for longterm care facilities - the government's trying to supply them in a more timely and effective way, but a lot of the families for palliative care patients, they kinda need PPE as well when they come to visit. And so we supplied that for them as well. It's been very [inaudible].

Dr. Rezmovitz:

It's been very what? Sorry?

Dr. Alam:

It's been satisfying.

Dr. Rezmovitz:

Of course.

Dr. Alam:

But I mean, Jeremy, you are involved with conquer COVID-19.

Dr. Rezmovitz:

Yep.

Dr. Alam:

You know how unsustainable this is. We need the global supply chains to open up. We can't keep mining the community for stuff. Like it's just - it's not really possible to sustain this for long. Especially as more community organizations start ramping up their businesses. Especially as people start going back to work. They're going to need PPE too to prevent transmission to one. To prevent cross contamination. It's a bit scary.

Dr. Rezmovitz:

You know what? It is really scary. We're going to see a second wave. And I think it's because people don't realize that flatten the curve doesn't mean eliminate the curve. Flatten the curve means reduce the impact on the hospitals. It's been very acute care centric and we lost focus of the whole population, I think, in that when we resume - people are clamoring to resume their activities, and this thing will spread again. I just heard this morning that there's a chance. There's a really big chance that first infection doesn't necessarily mean protection against second infection, right? That it will - the antibodies actually don't mean that you're going to be able to resist a second infection, which scares me a lot, that this thing is, is really, really, really deadly - for those most at risk, obviously, right? I'm not talking about - because most of the population recovers. We're not - right? We're not talking this is a hundred percent mortality here, but what we're seeing is that people are not listening or heeding the advice to limit contact. I was driving home yesterday. I see groups of people playing on the street - like kids playing on the street. You know, it's just a matter of time before you open up the doors and the kids start playing together and then they bring it home and they give it to their parents and the parents go do a drop off at their parents' house for groceries. And then we're back to where we started. But it's an inevitability I think. And the problem is, is that doing the - what you said the drop-offs and the drives are not sustainable. We've been doing this for six weeks. It is exhausting. It is absolutely exhausting. You're just on all the time. There's another email. There's something else to check. There's trying to give permission to all these people to distribute PPE and how do you do it in an ethical way? And so, you know what? If I can just stand on a soap box here for one second? I realized something. So a few weeks ago we were challenged with coming up with an ethical framework for distribution because we're working with the OMA right now at conquer COVID-19. And we're trying to come up with an ethical framework for distribution. And you know, the words like equitability get thrown around. And how do you create an equitable framework for distribution? And I'm going to tell you right now - it's impossible. It is absolutely impossible without information to do an equitable distribution. What we came up with was a distribution that was based on equality, which is not the same as equitability, but I think if you can do - I think this is what needs to happen. I think we need a two stage process. One, we recognize the supply chains are completely disrupted and so we need a bridge and that's what conquer COVID-19 is doing. That's what you're doing with your group to try and bridge these groups that want to continue seeing patients and keep helping people so that they're protected when they go and do that. And so that's an equality - we're trying to give as much to everybody, but it's the same amount. So it's an equality based distribution. The equitability will come when people share what they have with people that don't have. We need to share. The message has to get out that you're going to have to share with your colleagues who want to go to work at the bank, with your colleagues who want to work at the grocery stores, with your colleagues - with the people in your community. We need to share our personal protective equipment because when are we going to have the kids play together again? When are we going to have the parks reopen? Who's going to go to a concert and go moshing, right? I know that's like - that's your biggest thing is moshing. That's like -Nadia's thing is get in the mosh pit . I know you.

Dr. Alam:

I did, I did, Oh my God. It was so much fun.

Dr. Rezmovitz:

I know. You're totally a mosh pit person. 'Cause you look to get in there and get your hands dirty and experience it. And then you get out. And when are you going moshing again? You know, you're not. For awhile . And so I just saw last night, a text from a group that I'm on of dentists, actually - friends of mine are dentists - packages of 50 masks are going for - what are they - they're going for a hundred dollars a pack. They're $2 a mask now.

Dr. Alam:

That's insane. That is insane. I heard the same thing. It was - I forgot what the name of the home care agency, but they're one of the biggest home care agencies for Halton Region.

Dr. Rezmovitz:

[ inaudible] Saint Elizabeth.

Dr. Alam:

This one starts with an 'A'. I'm so bad - see, this is one of the pieces of information that have fallen out of my head. Now , admittedly, I've never been good with names to begin with , but every once in a while, something bubbles up and I surprise myself and I feel like a genius for like five seconds. And , in any case, they were saying that they were looking for isolation gowns. And we spoke to them and my group spoke to them and we were like, "you know, you really got to consider switching to reusable cloth gowns because these isolation gowns are like diamonds now. You can't find them." And she's like, "I know they used to be 50 cents. Now they're eight bucks a pop for one single use gown that maybe you can use for one patient." And I was like, "you've got to change your business model. The world is the world. This is it. This is our new reality." We're not going to be able to afford some of these PPE - especially as funding begins to dwindle. And as our economy struggles to recover, this problem isn't going away anytime soon. We've all got to be thinking out of the box.

Dr. Rezmovitz:

Yeah. It's interesting. About 200 years ago, people didn't even wash their hands between surgeries, right? And now, you're spending $8 on a reusable gown? We've come a long way, but it looks like we're going to regress a little bit. You know, I went back and I started wearing my lab coat again, which I could wash. It's for contact precautions - it's for contact. We need to remember - we really need a lesson again in infection, prevention and control. It's for contact precautions. Your clothes are not gonna transmit. Like yeah, droplets can fall on you, but that's - it's contact you take off the lab coat - you take it off, you wash it, you call it a day. You do your best. Right? Well , people are going to the liquor store. They're not wearing lab coats and disposable gowns. And yet people are still buying liquor and they're going to the grocery store and the grocers are not wearing lab coats. So I don't understand why - I know the risk is there, but like you gotta still be able to do your best.

Dr. Alam:

Yup . This is, I think, one of the best explanations I've found for contact precautions. And it's a meme that starts with do face masks make sense. And then they said, "let's explain it for dummies. If we all run around naked and someone pees on you, you get wet right away. If you are wearing pants, some pee will get through, but not as much. So you are better protected. But if the guy who pees also is wearing pants, the pee stays with him and you do not get wet." And I was like, somehow it just confirms - it just seems to make a lot more sense now.

Dr. Rezmovitz:

What if you rub up against each other?

Dr. Alam:

Please don't go rubbing up against people on the street.

Dr. Rezmovitz:

Yeah, that's called it's a psychiatric disease called frotteurism [inaudible] rub up against you for no reason. I mean, they have a reason, but anyway. Useless facts you learned in medical school that don't tend to come up again until you podcast with Nadia . That's your new podcast, by the way [inaudible]

Dr. Alam:

Surprisingly, they stay in your head.

Dr. Rezmovitz:

Yeah . Podcasts with Nadia. We're going to do that over and over again. It's fine . Okay. So tell me, do you have any interesting stories from the front line that you'd like to talk about today?

Dr. Alam:

So I found one of the stories that I'm struggling with - she's a 90 year old lady. She's like a light. She is beautiful and smart and engaging. She's a total extrovert. She lives in one of the local retirement homes. And she's spicy. So I fell in love with her right off the bat. When she became my patient - she became my patient maybe about half a year ago, about maybe six months or so. So we haven't known each other very long. Before COVID-19 hit, she and I were talking and I had noticed that sometimes our conversations would get repetitive. And while you kind of expect that as people get older, these conversations were becoming very repetitive. She was forgetting everything I said between one conversation to the next, even if I wrote it down, even if I emailed it to her, even if I repeated myself three or four times in the same conversation and then started the next conversation by reminding her, by the end of the conversation she was forgetting again. So her short term memory was an issue. You know where I'm going with this? We tested her and she has dementia.

Dr. Rezmovitz:

Oh, I thought you were going with it was like talking to your husband.

Dr. Alam:

Kind of is, actually. Although his memory is more selective. It's not so much everything.

Dr. Rezmovitz:

His is deliberate. Hers was [inaudible] I get it. Okay.

Dr. Alam:

And so this was a new diagnosis. COVID-19 hit. She became - the retirement home, went on lockdown because there was an outbreak there, particularly among asymptomatic carriers. That's how they found out the outbreak was spreading. So everybody got locked into their own rooms, got isolated into their own rooms. As an extrovert, she was in tears. She was just devastated. She would call me sobbing because she couldn't deal with the isolation or the loneliness. Sure, there's FaceTime. Sure, there's phones, but it's not the same as in person contact. And I found it really challenging because normally I would do a house call. I would sit down with her. I would talk to her. And in this instance where I am at high risk - I probably carry a higher viral load without even knowing. My risk of transmission is higher. And so I'm trying to avoid making house calls. I'm trying to avoid seeing my patients - particularly the frail ones or the elderly ones or the complex ones, unless it's totally necessary. And so it was hard to comfort her because talking on the phone or even talking on FaceTime , it's just not the same as being there in person. I can't hold her hand. I can't hug her. She can't even see most of my face because I'm in clinic and I was wearing a mask that day. So anyways, she ended up moving in with her son and her daughter in law to try and get away from the outbreak. She's followed the isolation measures and all of that. But again, the family's struggling because they've got a patient whose memory is - they've got a loved one whose memory is significantly impaired and they don't know how to deal with it. And holding a family conversation, holding a group conversation about this - it's it's beyond - I can't even be polite and call it challenging. It's just - it's freaking impossible. I don't feel - I feel like a phone jockey. I don't feel like a real doctor and that frustrates me because this is part of my job and I can't do it just because of the pandemic.

Dr. Rezmovitz:

Yeah. It's been really tough. I cover a retirement home also and I've had patients who are expressing thoughts of suicide. There was an outbreak there. They don't like being isolated. I never put it into context of extrovert versus introvert. But I think probably now that I reflect back on it, this one patient is probably an extrovert and she is craving people, right? She gets her energy from people. And she doesn't know how to get her energy from being isolated. You know, I saw one of those memes on the internet. I think it's the interweb? Internet? Interpol? And it said, "introverts, please call your extroverts friends. They don't know what to do." They don't. They really don't know what it's like to be isolated, right? Because it's really hard for people who are extroverted. And so, I had to counsel this one patient who said, "I'm just going to go outside and stand in front of a streetcar and get hit and just end this already."

Dr. Alam:

Oh my God.

Dr. Rezmovitz:

Yeah. And I had to think of something to like tell her to try and talk her off the cliff, if you will. And so I told her - now, again, she's one of those individuals that has some cognitive impairment - and I told her, I said, "you know, the streetcars can stop, right." And she's like, "what?" I said, "like, you want to stand in front of a streetcar , but they stop . Like they have breaks , they'll stop. They won't hit you". And she said, "Oh," and I said, "yeah, you're going to have to come up with a better plan, I think." She said, "well, do you have any ideas?" I said, "you know, I'm fresh out, but why don't you give me a week and I'll think about it. And I'll get back to you next week on how you can - some other ways that you can take care of yourself." I'd appreciate that. No problem I'll pray . Right ? It's like, you can obviously see the insight just isn't there, right? She's just not thinking fully what's going on. And I saw her a few days ago and I said, "how are you?" And I've given her a medication - she was having trouble sleeping. So I gave her a medication that would help her sleep - Mirtazepine. Using its side effect profile and looking at the fact that maybe she's got some depression going on here, maybe we can use both. And it was interesting to see that , the nurses at the retirement home came and gave it to her at seven o'clock and she said, "no, I don't want the pill. I'm not tired. I'm not going to sleep right now." 'Cause I told her it was a sleeping pill. Or at least I explained to her how the pill works and that'll help her go to sleep. And so she interpreted that as it's a sleeping pill. And so, the nurse came back at 10 and she said, "I'm still not tired. I'm not taking that pill." So a woman has refused to take the pill. And so when I saw her this week I said, "so? How are you feeling?" She's like, "I'm great." Okay. We'll just call it a day. There's so much richness to the people that we see. And it's just so interesting. I really wish I had cataloged a lot of the stories in the last six weeks. But , as much as you say, you haven't been doctoring - you don't feel like a doctor , you've been busy doctoring. You know, what is doctoring? It's caring for people just because the medium is different, doesn't mean that you're doing it any less. You're just - it's a difference that you're just not used to probably .

Dr. Alam:

That's fair. I'm one of those people who enjoys the face to face - who derive pleasure from it. But I do have to say the lesson that's driven home to me with virtual care, particularly care on the telephone, is you don't know what you don't know. So I had another patient and he became my patient because he had no family doctor. His previous family doctor retired. Just before retiring his family doctor tried to treat his reflux disease - put him on Pantoloc, right? Common medication for reflux disease. And then sent him on his way and said , "I'll try and provide care for you for about six more weeks, but you've got to try and find a family doctor." Trying to find a family doctor is trying to find a unicorn in Ontario now. But he found that his reflux got worse and worse despite Pantoloc, and he went to emerge. He was referred to one of the surgeons in town, ended up getting a gastroscopy and was diagnosed with esophageal cancer. And it's sad. It's horrible. That's how he became my patient. She called in a favor, asked me to take him. And I said, "yes, of course. He needs a family doctor." The pandemic hit. Just before it hit, he was seeing his oncologist. His oncologist just did a routine chest X Ray on him. Patient seemed fine, and the oncologist found signs of pneumonia on the chest X Ray, but the patient had no fever. The patient had no shortness of breath, which to be honest, I don't find surprising because he's on Tylenol - a thousand milligrams, four times a day. So if he has a fever, it's being treated. And he's on high dose opioids for his pain. So he's not going to feel short of breath. He might look short of breath, but he's not going to feel it. And so he won't realize he won't be able to show the classic symptoms of pneumonia. So I'm grateful that his oncologist did the chest X Ray found the pneumonia. I started treating him. I followed up with him the following week to check up on him and make sure his pain was controlled. And as I was looking through the oncologist's notes, I was like, this guy isn't going to feel short of breath. The oncologist had told him - giving him strict instructions - "if you feel more short of breath, if your symptoms worsen, or if you start feeling symptoms, go to the emergency department." I was talking to him on the phone and I don't know what it was - I still don't, like I've thought back to our conversation multiple times. And I don't know what it was that made me switch from just talking on the cell phone on speakerphone with him and his wife to FaceTime. But we switched to base time and you could see he was in full on impending, respiratory failure. He was struggling to breathe his nostrils flaring, you could see in drawing all of that. And he was completely insensate to it because of the high dose opioids. And so I sent him to the emergency department, his thoracic surgeon and his oncologist helped save his life. But it really drove home the lesson. The phone is great for certain things, but you do risk not knowing what you're missing. You risk missing all of the other subtle cues. If he had come into the office, I would have seen right away that he was in respiratory distress - that he was working really hard to breathe. You can't always see that on the phone. And so you miss clues like that, right? You - being a doctor, it's not just about the problem the patient comes in with or about the issue of the day. It's everything else - their body language, their posture, the way they walk into the office , the way they're breathing, whether their pupils are dilated or not. All of those give you clues as to what's going on in the body and that is the piece that I find missing in virtual care. I think there's no putting this genie back in the bottle. Virtual care it's been adopted for a ton of medical care now - we are not going back. It's very convenient for some patients. It's very helpful in certain instances. But I think at some point when we start finding a new normal, we're going to have to rebalance how much virtual care we do and what we do at for and be very aware of the risks that - again, we don't know what we don't know.

Dr. Rezmovitz:

So this is going to be one of those stories where I started with "when I was in residency." It starts in medical school and you start hearing the phrase, "lay eyes on the patients." And then in residency, I remember working at the longterm care facility - I had a rotation in longterm care. And I got - I think somebody actually got upset with me that I went in to see a patient at two o'clock in the morning. And I think they were hoping that I would - not hoping - but I think they thought I was trying to game the system by going in after 12 o'clock because the rules were, if you went in after 12, you didn't have to go in the next day, right? They're called payroll rules. They're there to protect the residents from overwork. But at the end of the day, the work has to get done, right? And so at two o'clock in the morning, I got a call and I went in and my wife said, "why are you going in? Why don't you just phone it in?" And I said, "I'm not comfortable." It's that feeling that you get, that you're just not - and every doctor is different and every doctor takes risks and every doctor has their own tolerance - risk tolerance level, right? How much they're willing to risk and I wasn't willing to risk. And so I went in and I said, "it's important to lay eyes on the patient." Because even if the numbers - you don't treat numbers, we treat people and you have to look at the person and not just number . So I agree with you. I learned that lesson early, early in my medical career - you got to lay eyes on the patient. It is so important to get a full picture of what's going on because that's the pattern, right? The role of a family doctor - I know of the stuff we do is chronic care. It is. It's chronic care, but what is it? It's recognizing patterns - when patterns are out of step. So when their gait is off a little bit, when their speech is off a little bit, when the words they're using are off a little bit, when they're perseverating, right? This is what we're there for - to help pick off those things right when they're just coming up at the top, that we can get the care that's necessary. I mean, that's the ideal. Unfortunately, during pandemic times where the question is, are you willing to put yourself at risk to save one patient? And most of the times the answer is, yes. The question is when you keep doing it - this is a statistical question - is it an independent variable or dependent variable? When you go to each patient, is there an independent risk with each patient? Like when you flip a coin, is it 50/50? Or is there a cumulative effect of seeing every patient? So when you go to the first patient and then you go to the second patient, is it an summative risk because you've now increased the risk to the second patient by seeing the first patient. And it's probably the summative risks. The more patients you see, the patient at the end of the day has a greater risk of contracting, whatever you got from the first 49 patients. So there's a risk and you're trying to do your best. And unfortunately we don't have a system that says, put all of your most vulnerable at the beginning of the day and your least vulnerable at the end of the day, because we haven't figured that system out yet. Right now we've been doing what's convenient for us usually, right? Like when we book patients, it's more about trying to balance our convenience and the patient's convenience. The demand for phone calls, when it's convenient for them to do a visit. we're not a grocery store and so it's not like we're just open. We're also doing a lot of stuff. So it's really hard to take into account all the variables that are necessary to really create an equitable system where we can care for our patients.

Dr. Alam:

And sometimes patients themselves - like a lot of - a significant portion of my day is for patients who have self initiated a visit for some reason. They may not realize how serious something is either. And that could be for a number of different reasons. It could be from simply not knowing all the way to full on denial, right? I've had patients who - I had a woman once come in with her child for well-baby check. My nurse started off the well baby check by doing the height, weight , that sort of thing, and going over some of the education pieces. And then I came in and there was something about the woman, how she was holding herself. And I couldn't put my finger on it. She kept saying she was fine and I didn't want to let her go. So I brought her into the office by herself, apart from - away from the nurse. And I said, "you know, something's going on. I can tell something's going on. Tell me what's going on. Maybe I can help. And if nothing else, at least you get it off your chest. It might be nothing. It might be something." She burst into tears. She was suicidal. Her husband was violent towards her. A simple 20 minute well-baby check ended up having counseling added onto it. She was in denial with how serious it was and it's - [pause]. And I get it. Patients who face domestic violence, patients who are struggling with mental illness - there's a lot of stigma and safety issues around that. And they may not want to disclose what they're doing, what they're going through, just because - just out of fear of how it'll be received, of what it will say about them, of what it will do to them. And so, I would add that in some ways we kind of are like grocery stores in the sense, we don't know who's going to walk through our door. We don't know who's going to bring a problem that looks on the surface simple and then turns out to be much more complex. We don't know when a patient will choose to come in - I've had patients whom I've tried to bring in for followup visits, who've canceled and canceled and canceled. And then finally come in and they're [ inaudible] heart failure at that point or something like that. And they've just delayed their care too long because life gets busy. They've got stuff they need to get done. Or their diabetes is out of control because they've been so busy taking care of everybody else and have forgotten to take care of themselves and have put off taking care of themselves. Like it's - in that sense, I would argue that we're actually a lot like grocery stores, because there is an element of patient choice that you just can't - that you have no control over.

Dr. Rezmovitz:

Okay. So then let me ask you this. When that patient walks in heart failure, or when their diabetes numbers - the A1C is like 15, and you haven't seen them in a while . Why do I - I need you to get into my brain here - why do I feel like I did something that was - like I did something wrong? Like, I feel guilty that I missed something. That I was like, "how did we not support you? Where did we go wrong? Like , what did I do?" I'm like , no . And I checked [inaudible] Like the grocery store clerk doesn't feel like that when I come in and I've run out of eggs? [ inaudible] not a grocery store.

Dr. Alam:

All right . So that's because of that level of altruism that you have in you. Physicians, medical students - when you - when you were part of the selection process for medical students, you look for that altruism.

Dr. Rezmovitz:

Do you?

Dr. Alam:

You do. Like, I think medical schools select for altruism. They select for empathy. And it's not something that you can quantify - or maybe you can quantify it . I don't know. I haven't researched into it , but -

Dr. Rezmovitz:

I think they can.

Dr. Alam:

I think it's almost a gut check. You see how they connect to you during that interview.

Dr. Rezmovitz:

I'm going to tell you - that's you. That's you. That's not everybody on the admissions committee. Because you strike me as an empath. You strike me as you have the sixth sense where I'm going to tell you something - and tell me if I'm completely off here, but you're really good at making people cry.

Dr. Alam:

It's true.

Dr. Rezmovitz:

I know we smell our own. You know, I got accused of making people cry. You make people cry. I said, "I know it's such a good thing. Crying goes to recognize people's vulnerabilities and means they understand that the space is safe? That's great that I make them cry." "No, you don't understand. You're making them cry." "That's awesome. I made them cry. Fantastic. I'm there to support them." "No, you don't understand." "Oh, okay. I don't understand." [inaudible] Crying is a good thing, right? So yeah. You definitely strike me as like - sorry?

Dr. Alam:

It's opening up.

Dr. Rezmovitz:

Yeah, of course. It means I've challenged you with something and you care about something. Obviously we're - I'm just going right to it. So that's what you strike me as. Somebody that cares, somebody who's empathic enough to understand through an emotional intelligence, that crying is a reflection of vulnerability and that it's okay to open up and cry. It means you've actually hit the nail right on the head. And so for you, when you do admissions to medical school and you bring in a medical student, that's what you're looking for because it's what you value. It turns out from my research - years and years of anecdotal research - I have no real methodology to support this, but it turns out, I think doctors are not all the same. That's what my research shows. People have different values. Some don't value crying, and don't value this insight - that gut. Some of them are not willing to spend the extra 25 minutes because they say, "you know what? Something's off here. Let me go exploring, let me be curious here." I know because I have conversations with people and what the end result of the conversation is, "Oh, I have my consult note done," but before the patient even leaves the room. "And how much time do you spend with the patient?" "I don't know , like three minutes." And I was like, "yeah," they said, "I don't know how you counsel patients." I said, "I don't know how you only spend three minutes with a patient." And that's what makes up our system.

Dr. Alam:

W ell, i t's true. Y ou're, I'll give you that. I'll give you that. [inaudible] for talking about empathy to the guy w ho's researching empathy, b ut t hat was a hidden l andmine there, buddy.

Dr. Rezmovitz:

And I'm just researching it actively like engaging people and empathetic talks and try and understand what makes people tick and it turns out , I think I figured out depression. I have the solution for depression and anxiety.

Dr. Alam:

You found the cure. You got the magic pill.

Dr. Rezmovitz:

Yeah.

Dr. Alam:

Alright. Let's hear it.

Dr. Rezmovitz:

Support.

Dr. Alam:

Yeah.

Dr. Rezmovitz:

Support. Now the question is, what does support look like for you as an individual ? Not you specifically, but as an individual with depression and anxiety, if you can figure out how to support these people and figure out where the trauma started - whether it's intergenerational trauma, whether it's physical trauma, domestic abuse, financial, emotional , existential trauma that happened that people are not willing to take a risk and try something. That's what you need to - you need to be able to support people in their own journey. It's support. That is the cure. And the problem is we don't have the resources to support everybody.

Dr. Alam:

No, we don't. And we don't have the resources to figure out what triggers one depression, as opposed to another. It's so highly individualized, right? I'm bipolar. I have so much to be grateful for in my life. So much. Like I've got a husband who loves me, kids who are amazing and a little smelly, and I've got a house, I've got food, I've got steady income by and large. I am able to do more than my parents were when they immigrated to Canada and struggled to keep us fed and going and all of that. Like my parents could never afford to pay for my education, but by the time I started working, I was able to help pay for my sister's education. Like it's - you pay it forward. And I look back and I think "God, I'm so lucky." I'm lucky that I'm in a position where I can take care of my parents and take care of my family by and large. I'm not in that working poor group that we used to be in. And I can't explain why I get depressed. I just can't.

Dr. Rezmovitz:

Well, maybe it's for another time between you and I, I can help you figure it out.

Dr. Alam:

Are you going to be my personal doctor? I've got a really good family doctor. I've got - he's amazing. They're a couple. They're both amazing. I love them.

Dr. Rezmovitz:

I'm not offering to be your family doctor. I'm just offering to be your friend.

Dr. Alam:

That would be nice Jeremy. I'd love that.

Dr. Rezmovitz:

And support you when you get down because it's possible. And I'm just throwing this out based on the little chitchat we had before this started - maybe sometimes you do too much. Just throwing it out there.

Dr. Alam:

I do have a hard time saying, "no". This is true.

Dr. Rezmovitz:

Right. And so genetically speaking, we have - we are linked. We are linked. I am genetically preconditioned . I have that genetic cellular level difficulty with the switch, right? 'Cause most of the cellular activities that go on is based on a switch of something - a receptor being activated. And it turns out my genes code for saying, "yes." I can't say "no." I have like - I don't know what it is. I just can't say "no."

Dr. Alam:

[ inaudible] bit further. Right? You can - sure, you can spend that half hour helping someone instead of watching TV. You can spend that half hour writing those emails instead of - I don't know , going for a walk. Like you find ways to make yourself stretch, except like you said, you run out of those half hours. You run out of all that time. One of my friends actually practices saying "no" with me every month. I think I'm going to ask her to practice saying "no" with me every week. 'Cause apparently the monthly lessons are inadequate.

Dr. Rezmovitz:

So it comes down to training and learning how to say no. And not - it's not learning how to say "no," by the way. Everyone's like, "you need to learn how to say no. You should learn." I hate being "should" on by the way, that's a recurring theme on these podcasts is we talk about being should on. You should - how many times have you heard someone say you should learn how to say "no." You should say "no." You should say "no." You know what? You should stop saying should. That's what I think. And let me do my own thing. At the end of the day, it's not learning how to say "no," because if people really took the time to understand you, they would understand it's it's learning to say "no" without feeling guilty afterwards.

Dr. Alam:

Yeah .

Dr. Rezmovitz:

That's what it is. It's not about "no." It's about feeling guilt. It's about being programmed to help. It's about values - aligning with your values. And so , I'm sure we can talk about this for another 10 hours. But today, why don't we just go with let's be friends, let's share, and leave everyone with a smile and a chuckle and say stay sane, stay safe, and keep fighting the fight.

Dr. Alam:

Very well said.

Dr. Rezmovitz:

Okay. Thank you so much for joining us today. And I look forward to our weekly podcast with Nadia Alam. 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.