Reflections from MHST 601

The decision to embark on a journey to complete a graduate degree was not made hastily, however it did bring some discomfort and anxiety related to re-entering the education system after being absent from it for so many years. The main discomfort was related to insecurities surrounding current technology and lack of experience navigating through it. So when one of the first tasks involved was to assemble and synthesize a digital curation plan and then begin work on a professional e-Portfolio AND blog, a sense of mild panic may have set in. Thankfully, the panic was not needed. This course has been very well organized with clear instructions, and adaptable to meet various levels and needs.

Unit 2 had us reflect on our professional role in the healthcare system and the federal and provincial health systems in Canada. This unit included a very interesting article titled, Modernizing the Canada Health Act, by Colleen M. Flood & Bryan Thomas, which discussed how the Canada Health Act, “ was adopted in 1984, to shore up a health-care system conceptualized in the 1960s”, and discusses the many benefits and scenarios of modernizing the Canada Health Act. One scenario that resonated with my profession in the Emergency Department is how physicians have control over how they bill for services and dictate what services are defined as, “medically necessary”, Flood & Thomas explain, “The main stricture here is that physicians require a fee code when billing Medicare for a specific service, and the menu of fee codes is renegotiated annually between provincial medical associations and provincial health insurers. This is not a rigorous process in which the comparative evidence is adduced for given therapies, and hard choices are made about which should be added or delisted. Instead, the list has tended to expand year after year, as new treatments are added while old treatments remain on the list” (2016). Lists like this should be reviewed on an annual basis, and accountability placed on the decision-makers. There should also be transparency and accountability for how physicians bill for the same patient presenting to different locations with the same complaint and the healthcare system (aka tax payers) being billed for both (or more). For example, a 43 year old male presented to a Medicentre with a complaint of abdominal pain, was assessed by a physician and told to schedule an outpatient ultrasound within the next few days so he went home and called to schedule the ultrasound, but was dissatisfied as he was told the next available appointment was 10 days later. He then decided to present to the Emergency Department (the same day her presented to the Medicentre), where he was again assessed by a physician who recommended the same course of action, to have an ultrasound scheduled as an outpatient within 48 hours. 24 hours later, the same man presented back to the Emergency Department demanding an ultrasound be done immediately as his pain was not any better. He was assessed by a third physician (within 48 hours) who ordered an ultrasound be done that day. The results showed he was constipated and required an enema. While I am passionate about equitable access to healthcare for all Canadians, situations like this need improvement. Three physician visits later which included nursing assessments and administrative work, the patient was discharged with the advice to take an enema at home. This similar occurrence (meaning multiple physician visits related to same non-urgent needs) happens many times per day across the country at an immeasurable expense. Flood & Thomas suggest, “And indeed, the predominant payment model—fee-for-service—encourages over-delivery of physician services. One oftcited study estimates that between 30 to 40 percent of total health care utilization in Canada is unnecessary, attributable to physician-induced demand” (2016). If this is the case, 30-40 percent of healthcare utilization in Canada is related to physician billing, the number one priority should be focused on physician-related billing and costs to the system, and create legislation to manage and decrease it.

The next unit of MHST 601 discussed the definition of health, and how variable the definition can be across the population. It was interesting to find that many cited research articles refer to the World Health Organization (WHO)’s definition of health, “a state of complete physical, mental, and social well-being not merely the absence of disease or infirmity” (2021). This definition has not changed since 1948. Fallon & Karlawish argue that it needs to be updated to, "a more inclusive definition of health-one that works for more people-rather than categorically excluding an entire segment of the life course"(2019). The WHO's use of "complete" in their definition of health is problematic. For example, seniors that require the use of mobility aids arguably do not meet the definition of health as per the WHO. Fallon & Karlawish suggest, "managing multiple diseases, maximizing function, optimizing medication regimens, prioritizing different health risks and outcomes, and preparing for end-of-life considerations are some of the areas that deserve to be included in basic definitions of health” (2019). These areas of health described by Fallon & Karlawish encompass a much larger portion of the population today, and would recognize an increased number of people as meeting the definition of health.

The definition of health unit and discussion lead to the next topic in the course, the social determinants of health. Knowledge of the definition of social determinants of health (SDH) can help guide a person to make important lifestyle decisions can improve potential of leading a long and healthy life. According to the WHO, “research shows that the social determinants can be more important than health care or lifestyle choices in influencing health. For example, numerous studies suggest that SDH account for between 30-55% of health outcomes.” This percentage is alarming. The Government of Canada (GOC) identifies the social determinants of health: “Income and social status, employment and working conditions, education and literacy, childhood experiences, physical environments, social supports and coping skills, healthy behaviors, access to health services, biology and genetic endowment, gender, culture, and race / racism”, and include, “Social determinants of health refer to a specific group of social and economic factors within the broader determinants of health. These relate to an individual's place in society, such as income, education or employment. Experiences of discrimination, racism and historical trauma are important social determinants of health for certain groups such as Indigenous Peoples, LGBTQ and Black Canadians” (2020). The GOC acknowledges the complexities involved when attempting to determine how the health of Canadians can be improved as a population.

The next unit in MHST 601 focused on multi-level health models and discussed in order to improve population health, we need to address from the individual, community, and institutional levels. One of the readings in this unit by Dr. Sandro Galea provided an interesting example of individual vs. community level perspective when discussing coronary heart disease (CHD). Galea identified CHD as, “the leading cause of death in the United States” (2015), and explains that most studies of the disease are based on “modifiable risk factors of diet, physical activity, and smoking” which are all measured at the individual level, but do not account for other important social determinants of health such as income, housing, gender, and race. Galea presents the following example to emphasize the importance of examining health at multiple levels of influence, and the findings related to social determinants of health, “In the last two decades, the study of CHD has extended to neighborhood-level social environment. For example, socioeconomic environment is associated with CHD incidence, with greater neighborhood disadvantage predicting higher incidence, beyond individual risk factors, among both blacks and whites. Work led by SPH Professor Yvette D. Cozier and conducted with SPH colleagues Julie R. Palmer, Lisa Fredman, Lauren A. Wise, and Lynn Rosenberg demonstrated that neighborhood median housing value in particular is inversely related to hypertension (a risk factor for CHD) among black women, independent of individual level risk factors. Similarly, neighborhood-level social capital is a predictor of CHD mortality. Therefore, the drivers of CHD rest both at the individual level and the group level, being well in line with a multilevel perspective on the production of population health” (2015). Government legislation and policies along with community-level cooperation will promote improved population health.

The final units focused on vulnerable populations. These populations include indigenous, elderly, minority race, mental illness, addiction, homeless, and veterans to name a few. In order to attain a high index of population health, we must address the most vulnerable populations, and find ways to mitigate gaps in service delivery and solutions to improve overall health and wellness as a whole population. There are many, many resources and services now available to our vulnerable populations with ongoing work and research. I look forward to what is to come for improvements in population health.

References

Flood, Colleen M. and Thomas, Bryan, Modernizing the Canada Health Act. (2016, December 1). Ottawa Faculty of Law Working Paper. Retrieved October 18, 2021 from, https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2907029

Galea, S. (2015, May 31). The Determination of Health across the Life Course and Across Levels of Influence. Boston University School of Public Health. Retrieved October 22, 2021 from, https://www.bu.edu/sph/news/articles/2015/the-determination-of-health-across-the-life-course-and-across-levels-of-influence-2/

Government of Canada. (2020, October 7). Social determinants of health and health inequalities. Retrieved October 17, 2021 from, https://www.canada.ca/en/public-health/services/health-promotion/population-health/what-determines-health.html

Kiernan Fallon, C. & Karlawish, J. (2019, July 19). It's time to change the definition of health. STAT. Retrieved October 6, 2021, from https://www.statnews.com/.

World Health Organization. (2021). Constitution. Retrieved October 7, 2021 from, https://www.who.int/about/governance/constitution