To help unpack the change, three Sunnybrook experts provide their perspectives. They say the change is welcome – but patients in their 40s should still speak with their primary care provider about whether early mammography is right for them.

Dr. Lisa Del Giudice is a family physician and the regional primary care cancer lead for the Toronto Regional Cancer Program.

Dr. Ellen Warner is a medical oncologist at Sunnybrook’s Odette Cancer Centre who led a practice-changing study of breast cancer screening for high-risk patients.

Dr. Martin Yaffe is a senior scientist, Physical Sciences at the Odette Cancer Research Program.

How will this change current screening protocols?

LISA: Currently, only patients age 50-74 can self-refer for a screening mammogram. This means they can book their own appointment directly through the Ontario Breast Cancer Screening Program without a doctor’s referral. Patients in this age bracket also receive a recall letter every one to two years inviting them to be re-screened for breast cancer.

The change coming into effect this fall will mean patients in their 40s will also be able to self-refer for a mammogram if they wish. They can also continue to seek guidance and a referral from their primary care provider if they prefer. This will be a big shift from the status quo, where currently people age 40-49 who want a screening mammogram must discuss it with their primary care provider first, who will then refer them for the procedure.

Until now, how commonly have family doctors referred patients in their 40s for a screening mammogram if asked?

ELLEN: I think most (but not all) patients in this age group who have asked for a mammogram got a referral. Having a mammogram at this earlier age should be a nuanced discussion between a patient and a doctor.

LISA: I have heard of the rare situation where patients were told they did not qualify because they weren’t 50. Not all family doctors are aware they should discuss the pros and cons with the patient but still refer them if they want to be screened; there is definitely some confusion and room for improvement.

In the months ahead, we also expect that health authorities and regional cancer programs will be offering educational programming for family doctors to increase their understanding around screening protocols. Several new patient resources will also highlight the benefits and risks of screening people age 40-49, especially for people who do not have easy access to a primary care provider.

What are the pros and cons of screening mammograms that patients in their 40s should consider?

MARTIN: In 2023, Canadian researchers compared data from provinces which regularly screen patients in their 40s with data from those that don’t and concluded that earlier mammography screening leads to improved breast cancer survival rates.

Lowering the age at which people can self-refer gives them more control over decisions around earlier detection to prevent advanced cancer. That’s important knowing that people diagnosed with breast cancer earlier face the possibility of more years of life lost.

Also, by treating cancers found earlier, you may reduce the need for extensive surgery or other aggressive treatments, like radiation or chemotherapy.

Among the cons is the need for a screening recall, which happens when the result isn’t clear and secondary imaging is needed. Even though only a small number of these recalls will result in a diagnosis of cancer, the process can cause anxiety. If after that recall imaging there is still some suspicion, a biopsy may be done. While that’s not surgery, it involves needles which can be stressful and uncomfortable. There is also the risk of overdiagnosis. That means finding a real cancer, but one that is very slow growing and might have otherwise caused no harm because it wasn’t serious. Despite the fact it doesn’t cause risk, that patient is now a cancer patient. The challenge is that until a cancer is found and evaluated, the doctor doesn’t know if it’s slow growing or one that will be more aggressive.

One way we could reduce the anxiety associated with screening is to reduce the time it takes for a patient to be told that ‘everything is okay’ after recall imaging or a biopsy.

 LISA: For people in their 40s, there is an increased risk of ‘false positives’, or screening recalls that do not find cancer, due to factors such as having denser premenopausal breasts. As Martin noted, this process can then lead to biopsies and other tests which can be anxiety-provoking. Patients need to consider their tolerance for false positives and whether they will be okay if they have to wait to have further tests done.

It is also worth noting there is weaker evidence to support systematic breast cancer screening among people age 40-49 compared to those age 50-74. On the other hand, there are people in their 40s who may be at higher risk of developing breast cancer, such as those with a family history, certain ethnic groups, and those of late childbearing age.

When family doctors are discussing screening mammography with patients, they need to help them weigh out all their individual risks and benefits.

What do you think of the change to Ontario’s breast cancer screening protocols?

ELLEN: Patients who want a mammogram should be able to get one. But it shouldn’t be misinterpreted as an endorsement for every single patient in their 40s to get screening mammography.

LISA: Cancer screening has many potential benefits and people have wanted this for some time. But I have also seen a lot of anxiety that can come from a false positive; it happens to more patients than you might think. In a perfect world, primary care providers will have the time to thoroughly discuss the pros and cons with individual patients.

 MARTIN: Primary care doctors are busy and some may not fully understand the issues around screening, so better educational tools will help them. It’s worth noting that having a screening mammogram is not mandatory at any age. Providing clear and accurate information will help patients make the decision that is best for them.

As I referred to above, researchers have found that earlier screening leads to improved survival rates. Overall, this is something I’ve been pushing towards for over 20 years, so I think it’s great news. And it brings Ontario in line with several other provinces where patients can self-refer for a mammogram starting at age 40.

Any other thoughts regarding breast cancer screening?

MARTIN: There are other groups, including Black patients and other ethnic and racial minorities, who are at a higher risk for breast cancer in their 40s. Right now, we don’t have any special considerations in place around reducing barriers to care and providing more equitable health care for these individuals. Moving screening to age 40 will help some of these patients.

ELLEN: Screening everyone the same way based on their age and sex isn’t a terribly efficient way to do things. It would be nice to approach this in a more nuanced way. That means screening patients with a family history and those with a first pregnancy after age 35. There are a lot of models that look at risk and can help predict those patients who are most likely to get breast cancer, and therefore benefit from earlier screening. Continuing to research these risk-prediction models would be helpful.

LISA: It’s important to note that screening mammograms are for people who do not have any symptoms. Anyone who feels a lump or notices changes in their breast(s) should be assessed by a doctor or nurse practitioner and get a diagnostic mammogram and possibly an ultrasound. A diagnostic mammogram provides more detailed views of the breast and does require a referral.

The post What to know about screening mammograms in your 40s appeared first on Your Health Matters.

They are all topics covered by Sunnybrook’s Youth Safety Lab, an innovative one-day program for high-school students that explores and enhances awareness of personal and community safety.

As home to Canada’s first and largest trauma centre, Sunnybrook is deeply committed not only to treating critically ill and injured patients, but also to building capacity to help people avoid traumatic injury in the first place.

The Youth Safety Lab is one of several programs and resources offered by the Centre for Injury Prevention, which is part of our Tory Trauma Program. Each year, the program welcomes more than 1,000 high-school students from dozens of schools across Toronto to learn strategies and techniques to reduce serious and fatal injuries.

Injury Prevention Educator Shaelyn Fitzpatrick leads students on a tour as part of the Youth Safety Lab

Students attending the program spend the morning exploring ways to reduce the likelihood and severity of injury through the P.A.R.T.Y. (Prevent Alcohol & Risk-Related Trauma in Youth) Program. Following a pizza lunch, they then spend the afternoon becoming certified in STOP THE BLEED®​, a course designed to teach competence and confidence in applying life-saving skills to critical bleeding incidents.

The program combines hands-on exercises and workshops with presentations given by a range of speakers, including physiotherapists, occupational and respiratory therapists, nurses, doctors, paramedics, and people with lived experience.

Shaelyn Fitzpatrick, Injury Prevention Educator, says the program is constantly evolving to meet teens where they are in order to provide a truly engaging learning experience. As one example, the program now includes an activity focused on mental health and ways to cope with stress. Students are divided into ‘stressor’ and ‘coping strategy’ teams to ‘go to battle’.

“The point of the exercise is to acknowledge that we will always experience stressors in our lives,” Fitzpatrick says, “but there are ways to cope and resources available in schools and elsewhere to help.”

Students take part in a demonstration about life after traumatic injury

New content on cannabis has also been incorporated into the program. Although cannabis is illegal for anyone under the age of 19 in Ontario, Fitzpatrick says it’s important for young people to understand what chemicals are contained in cannabis, and the effects they can have.

“We take a harm-reduction approach,” Fitzpatrick explains. “This means we say, if you are choosing to use cannabis or alcohol, here is what you need to know to make safe and informed decisions.”

Students are taught about THC (tetrahydrocannabinol), a chemical in cannabis that causes mental and physical effects known as a “high”, and CBD (cannabidiol), a different chemical in cannabis which does not produce a high. They are also shown how to interpret the information printed on cannabis product labels, which are regulated in Canada.

“We want them to know what the product is so that they can mitigate a serious outcome,” Fitzpatrick explains.

This reflects another important evolution to the program in recent years, which has been its tone.

“Our approach has shifted away from educating youth with graphic, vivid content,” says Fitzpatrick. “Our current focus is on ensuring our content is evidence-based, providing youth with the skills and resources they need to manage risk and make safe, informed decisions through both a harm-reduction and trauma-informed approach.”

The program has also evolved to offer more practical takeaways for students, including a new injury prevention student leadership guide. The guide aims to encourage participants to continue spreading education and awareness about safety and injury prevention in their school community.

Students visit the Trauma Bay in the Emergency Department

Sean Chen, an 18-year-old student, says attending the Youth Safety Lab and reading the student leadership guide gave him a different perspective on injury prevention and ways to be a changemaker in his community.

“It was very eye-opening,” Chen says.

After noticing over the years that some of his peers knew how to cycle but were hesitant to do so on busy urban streets, Chen wanted to find a way to boost their safety skills and confidence. He credits the student leadership guide with providing a roadmap about how to turn that grain of an idea into action.

“I wanted to help make cycling safer and more comfortable for people because at the end of the day this is their community, and biking is an excellent way to get around,” he explains.

Chen organized a two-day event at his high school called “Cycle Your City”, which focused on bike maintenance skills, safe cycling practices such as hand signals and how to navigate streetcar tracks, and building road confidence. The event culminated in a group bike ride and picnic on the Toronto Island accompanied by community police officers.

 “I hope this sets a precedent and provides a framework for other students who might want to run injury-prevention initiatives like this again in the future,” Chen says.

Student Sean Chen displays certificate recognizing his leadership in the field of injury prevention

 Fitzpatrick agrees, saying the initiative is just the sort of thing the guide aims to spark.

“The event Sean organized demonstrates how our work at Sunnybrook extends beyond the hospital, helping to shape and empower future leaders in improving community safety,” she says.

She says it’s also an example of why working with teens to learn injury prevention skills is such a rewarding experience.

“Teens are heavily influenced by their peers and it can be hard to get through to them,” Fitzpatrick says. “But when they attend the program and then continue to share the information they’ve learned afterwards in their school communities, it’s very rewarding to see we are having an impact.”

The post How Sunnybrook’s Youth Safety Lab is evolving to meet teens where they are appeared first on Your Health Matters.

At first, the only thing that set the day in September, 2019, apart from past mountain bike adventures was the fact Devin (who asked that only his first name be used for this story) agreed to borrow his friend’s spare helmet for the ride.

“It was just a normal, perfect morning,” Devin says.

But after riding along the winding and hilly trails for a while and picking up speed, Devin’s normal and perfect day took an unexpected and traumatic turn.

“At the bottom of a hill, I came around a bend and saw a tree root above ground,” he says. “That was the last thing I saw before I lost consciousness.”

When Devin came to, he realized he had hit the tree root and flipped over the handlebars of his bike, landing hard face down on the ground. His arms were pinned underneath him and his mouth was full of dirt. He struggled to breathe but managed to call out to his friend up ahead.

“I said, ‘I can’t move, I can’t feel anything below my neck! I feel like my body is floating in the air,’” Devin recalls.

His friend quickly called 911 and the two men waited for help to arrive in the form of an air ambulance. Given the secluded area, it took more than an hour for the helicopter to get there – a harrowing wait that presented Devin with a mental challenge on top of his physical crisis.

But after a brief moment of panic, Devin – a manufacturing manager by profession who is accustomed to forward planning – turned his attention to mapping out how he would adjust his day-to-day life to accommodate his new injury.

“I started thinking, okay, we’ll need to bring the bed into the living room and build a wheelchair ramp to the house, because I thought I wasn’t going to be able to move again,” Devin explains.

Just before paramedics arrived, however, Devin felt a glimmer of hope when he noticed a tingling sensation in his right big toe. Then, once paramedics were on the scene and carefully turned him over to put a neck collar on and place him on a stretcher, Devin says it was like a switch flipped. He suddenly went from not being able to feel much at all to experiencing agonizing pain.

“It was like fire, lightning, electric shock, someone hitting you with a baseball bat and being jabbed by two million needles all at once,” Devin explains. “It was every kind of pain you can think of to the hundredth degree.”

Despite the pain, Devin says he was relieved: “I was just glad I could feel again.”

Devin being prepared for air ambulance transfer to Sunnybrook (photo provided by Devin).

Devin says he overheard paramedics briefly discuss whether to take him to a regional hospital or Sunnybrook Health Sciences Centre, home to the Tory Trauma Program and Canada’s first and largest trauma centre. Once they realized the extent of his injuries, the decision was clear.

“Someone said, ‘He needs to go to Sunnybrook!’” Devin recalls. “And it was like, boom, end of discussion.”

Once Devin arrived at Sunnybrook, doctors and nurses in the trauma bay, which is a special part of the emergency department used only for the care of trauma patients, immediately sprang into action.

Devin in Sunnybrook’s trauma bay, nearly five years after he was brought in for emergency care following a devastating mountain bike accident.

“They were absolutely incredible,” Devin says of the trauma team that quickly mobilized around him. Trauma teams include specialists with the training and skills to provide emergency care and life-saving procedures.

“By that point, I had some degree of feeling in my lower extremities, but I told them I thought I had shattered all the bones in my arms and wrists because I was in so much pain and couldn’t move my arms,” Devin says. “They had the X-ray machine out within seconds.”

After reviewing the results from Devin’s X-rays as well as other tests, including an MRI and CT scan, doctors informed him that none of his bones were broken. They explained the pain Devin felt was nerve pain resulting from compression on several discs and a spinal cord injury known as central cord syndrome. The accident had also left Devin with a dislocated shoulder, a concussion, and permanent damage to his brain’s frontal lobe.

“Many people told me they were amazed that I survived the impact of the accident,” Devin says, adding he believes the helmet he borrowed from his friend played a part.

Devin after being admitted to Sunnybrook (photo provided by Devin).

Doctors recommended Devin undergo neck surgery to relieve the pressure on his nerves and restore movement to his arms. But they said first, he would need to be able to tolerate lying on his side long enough to undergo and recover from the procedure – something Devin found hard to fathom given the extent of his pain.

That’s when Jason Sawyer, a pain management nurse practitioner with Sunnybrook’s Acute Pain Service, was brought onto Devin’s highly-specialized interprofessional care team to assist.

Devin calls Jason “a godsend.”

“Jason asked me where I was from zero to ten on the pain scale, and I answered five hundred,” Devin says. “He said we needed to figure out how to get me onto his pain scale.”

Using a pain neuroscience education lens, Jason worked with Devin to help him better understand his pain – which was so intense that even the sensation of air breezing past was excruciating – and the emotional distress that went along with it. Together, they devised a unique pain management plan that included pharmalogic and non-pharmalogic components.

“I was going to do whatever was required to have some sort of normal life again,” Devin recalls.

About a week later, Devin was cleared for surgery.

A few days after that, with the support of an occupational therapist and physiotherapist, he was able to begin walking again. He was then discharged to a rehabilitation centre before eventually returning home.

Devin at rehabilitation centre following hospital stay (photo provided by Devin).

Jason says there were many important factors that contributed to Devin’s remarkable recovery.

“Having access to many pharmacologic interventions, particularly lidocaine and ketamine infusions, was an important component of navigating pain management in this complex case,” he says.

He also credits Devin’s “positivity, strong support network, and relatively good physical health” at the time of injury.

Asked about his positive attitude, Devin says: “If you focus on negativity then you can’t focus on healing.”

But he is quick to add the support of his family, especially his wife, and his Sunnybrook care team was just as essential to his recovery.

Now, nearly five years after he first arrived at Sunnybrook as a trauma patient, Devin is finding satisfaction in a new job, enjoying time with his wife and their two adult sons, and looking forward to new adventures ahead such as travelling abroad.

The path to get to this point, Devin admits, was long and difficult. After he was discharged from the hospital and rehabilitation centre, his return to health took several years. Ongoing nerve pain made things like showering while standing, wearing long sleeves, sleeping on his side, or venturing outdoors on a crisp day without gloves years to achieve.

Even now, Devin says he is restricted in certain movements and copes with ever-present but manageable mild pain, including nerve pain in his arms and hands. For example, the sensation of water hitting his arms in the shower still hurts. His neck sometimes bothers him too if he has neglected his physiotherapy exercises for a few days. But Devin says he is happy with how far he has come, and he is more focused on what he can do than what he can’t.

“It was a goal of mine to get at least this far and if this is the best I will be, that’s fine,” he says. “I can’t skate or go mountain biking but things could be worse.” He adds that he now enjoys leisurely bicycle rides with his wife for exercise instead.

And in his spare time, he has started playing guitar again for the first time in years.

“My hands will never be the same, but I am okay with that because I can still strum my guitar,” Devin says.

Adds Devin simply: “It’s a busy life. I am thrilled to be here.”

The post Former trauma patient on his journey of healing, and why despite ongoing challenges, he is “thrilled to be here” appeared first on Your Health Matters.

She also lives with anxiety, depression, and obsessive compulsive disorder (OCD).

At the latest Sunnybrook Speaker Series, Cassie described the toll OCD took on her life — and the unique treatment program which finally helped her get better and reach her goals.

Cassie, who lives in Regina, Saskatchewan, received care at Sunnybrook’s Frederick W. Thompson Anxiety Disorders Centre, as part of its innovative residential treatment program for people with severely impairing OCD. The program is the only one of its kind in Canada and open to clients from across the country as well as the United States.

According to the Centre for Addiction and Mental Health, “the main symptoms of OCD are recurrent obsessions or compulsions that interfere with a person’s life.”

Cassie shared that her anxiety and OCD first surfaced in childhood. She was often late for the school bus because she had to adjust her socks and clothing so they felt “just right”. After she once saw a spider inside the mailbox, checking it for insects each time she passed became a ritual. As a teen, she worried about everything from winter driving to what others thought of her.

“My brain would automatically go to the worst-case scenario,” Cassie said. “I started to do whatever I could to gain control and get that ‘just right’ feeling to calm the panic I felt inside.”

By the time she was in her final year of nursing school, at age 21, Cassie started to really struggle with her mental health. She sought care at her local hospital and took a medical leave from school so she could focus on her health.

Cassie credited the psychologist who she began working with during this period for having a tremendously positive impact on her life.

“It’s so important to find a psychologist or a therapist that you mesh with,” Cassie said.

Over time, however, Cassie’s anxiety, depression, and OCD got worse.

Several of the obsessions and compulsions her OCD presented revolved around the number three, or multiples of three, such as touching the light switch three times or controlling how many times her windshield wipers swiped while driving. Her OCD also told her she had to avoid stepping on cracks on the sidewalk, or could only step on certain tiles.

Soon, daily activities such as taking her dog out for a walk or driving became impossible. She stopped driving altogether, and went on long-term disability from work.

“If I did not do exactly as my OCD thought I should, I felt like a complete failure,” she explained.

Cassie’s OCD also began to involve self-harm. Over the next several years, this led to several stays in hospital. Unfortunately, the doctors treating her did not fully recognize her OCD. Instead, Cassie was misdiagnosed with borderline personality disorder – an experience she says had a negative impact on her.

“It was counterproductive towards my recovery because it put me on a treatment plan that did not fit my needs,” she said. “What I really needed was intensive and specialized OCD treatment that was not available in Saskatchewan. That’s when I found Sunnybrook’s Thompson Centre.”

Cassie described the care she received at the Thompson Centre as “life-changing”.

“Finding a whole team of professionals who specialize in OCD, who truly understand the struggles it brings without judgment, and who see you for you and not your illness, was pivotal in getting my life back.”

Photo provided by Cassie Josephson

Treatment included various form of Cognitive Behavioural Therapy, including Exposure and Response Prevention, as well as Dialectical Behaviour Therapy and Acceptance and Commitment Therapy.

Cassie said she left the program knowing her toolbox of skills and techniques to manage her OCD was fully stocked.

Now living back at home in Regina, Cassie shared that she works hard at using the skills she honed at the Thompson Centre every day. She also continues to regularly see the psychologist she first met years ago.

Cassie said she is proud of how far she has come in her journey.

“I know the mountains I had to climb and the trenches I had to dig myself out of to get where I am today,” she said.

After four years on long-term disability and recovering from a near-fatal case of Serotonin Syndrome, Cassie said she is back to work and finding new purpose and meaning in her job as a pediatric nurse – one of her lifelong dreams. And soon, she plans to purchase her first home.

She added she is now doing the things she loves in life, whether travelling to places like Los Angeles to see a Taylor Swift concert, or exploring new destinations in South America and Asia.

“I accept that in life there are so many things that ultimately we don’t have control over,” Cassie said. “I try to always do things that I love and enjoy, I keep taking steps forward, and I try my best to go with the flow and roll with the punches that life gives.”

Concluded Cassie: “I still have ups and downs and a lot of struggles. But they do not control me and they sure do not define me.”

Learn more about Cassie’s story and the special work of Sunnybrook’s Frederick W. Thompson Anxiety Disorders Centre here.

The post ‘My anxiety, depression, and OCD do not define me’ Former Sunnybrook patient shares her journey – and hopes for the future appeared first on Your Health Matters.

In 1998, Canada achieved elimination status for measles thanks to widespread and successful routine vaccination programs. But public health officials are now warning about a significant increase in measles, due in part to a decrease in vaccinations during the pandemic.

Dr. Theresa Tam, Chief Public Health Officer at the Public Health Agency of Canada, says this trend combined with the upcoming spring break travel season is cause for concern.

“I am concerned that the global surge in measles activity, combined with the decline in measles vaccine coverage among school-aged children in Canada, could lead to an increase in imported measles cases, potentially resulting in transmission in communities in Canada,” Dr. Tam said in a statement on February 23, 2024.

“I strongly advise everyone in Canada to be vaccinated with two doses of a measles vaccine, especially before travelling.”

Dr. Jerome Leis is the Medical Director of Infection Prevention and Control at Sunnybrook Health Sciences Centre. He spoke to Your Health Matters about what people need to know about measles at this time.

What is measles?

Measles is a virus that is highly contagious but that fortunately is preventable as part of routine childhood vaccinations.

Before we had vaccines, measles used to cause large outbreaks with devastating complications. Since we started vaccinating for measles, it has almost disappeared. And yet we still see a resurgence of it from time to time, like when vaccine rates are slightly lower because even small differences in vaccine coverage can give measles an opportunity to transmit. It is the most infectious virus that we know.

Common measles symptoms include a respiratory infection with runny nose, inflamed and runny eyes, and a full body rash. These symptoms are generally mild. But measles can cause serious complications. The virus can lead to a bacterial infection like pneumonia. And sometimes the virus can travel to the brain and cause inflammation, called encephalitis, which can be very devastating especially for young children. This can lead to long-term morbidity due to the brain damage.

It is important to remember that these complications are completely preventable through vaccination. It is always unfortunate to see measles resurge when we know we can be doing better.

You said the measles virus is the most infectious virus we know. What makes it so contagious?

The virus has been recognized for a long time to be spread through the air. It can be inhaled in any air space where an infected person has been, often without being in close contact with the individual.

For example, you can be at a distance, you can be in an air space after the infected person has already left, and you can inhale those particles and become infected if you are susceptible. The rate of transmission for susceptible people is significantly higher than any other virus we know.

Why are we seeing more measles cases right now?

I think the major factor that we are seeing here is a pandemic related knock-on effect of the disruptions to primary care that occurred.

Keeping up to date with vaccines was less likely to occur during specific periods of the pandemic when children were not being seen for their regular vaccine appointments. There have been a lot of efforts to catch up on those missed vaccines, but when it comes to measles, even a one percentage drop in vaccine coverage introduces potential opportunity for measles to resurge.

In Europe, they have noticed a drop in vaccination rates and they have seen thousands of cases of measles in the last several months. In the Canadian context and in Ontario, what we are seeing is mostly cases of measles that are related to people who have travelled into those areas where there is more measles circulating.

The risk in Toronto is currently low but there are cases and even clusters of cases that are occurring, mainly following international travel. Most cases are related to people who are susceptible, meaning they have not had the two doses of vaccines required to provide optimal protection.

What is the MMR vaccine and how does it work?

The MMR vaccine is made up of attenuated viruses – meaning they are viruses that are not capable of causing infection but that will elicit a very strong immune response. In the MMR vaccine there are three attenuated viruses: measles, mumps, and rubella.

As part of the childhood vaccine series in Ontario, as in other provinces and territories across Canada, there are two doses of MMR that are given in childhood. And it is the two doses that give optimal long-term protection against measles.

The majority of measles cases we see, however, are people who have had less than two doses.   Getting measles with two doses rarely occurs, but these breakthrough infections can happen. We generally see this when lots of measles is circulating, and these cases are usually milder.

It is clear that two doses of MMR is extremely effective against preventing these infections including measles. You can just look at how infrequent and rare measles has become since widespread vaccination with the two-dose schedule was introduced, as evidence. If vaccination rates decrease even a little, we experience outbreaks of measles.

Which groups are most vulnerable to measles?

Young children are particularly vulnerable to complications such as pneumonia and encephalitis, which can have devastating consequences.

Those complications are also more likely to happen in immune-compromised patients such as people who might have an underlying cancer or be receiving immune-suppressant treatment, or who have had an organ transplant. Those individuals may be susceptible and we cannot vaccinate them, so we need others to be vaccinated to protect them.

The other vulnerable group is pregnant people. Measles can cause pregnancy complications if the pregnant person becomes infected. We cannot give the vaccine to pregnant people because it is a live attenuated vaccine, so it is important to vaccinate people before they conceive.

Public health authorities are recommending people ensure they’re up to date on the MMR vaccine, especially if they’re travelling. What should people consider at this time?

If you are planning to travel, it is an opportunity to look at your vaccine record and make sure you are covered, especially if you are going to travel to higher risk areas.

If you have children who might have missed their usual vaccine appointments during the pandemic, or if you have recently come to Canada and might not have had the vaccine schedule that is in place here, or if you are planning to get pregnant in future, it is a good time to talk to your primary care practitioner to make sure you and your family are up to date on your vaccines and as protected as possible.

The post What to know about measles right now appeared first on Your Health Matters.

That’s the message from medical professionals who say that inclusive and affirming healthcare for transgender and gender-diverse (TGD) youth is essential to mental health and wellbeing.

Recently, there has been a lot of attention on policies and practices impacting TGD youth, whether at school, in the community, or in healthcare settings.

Clinical experts say the medical case for supportive and inclusive gender affirming practices is clear.

According to the Canadian Pediatric Society, TGD youth are at elevated risk for adverse health outcomes, including depression, anxiety, and self-harm – but the “risk may be mitigated by affirming experiences and environments…”.

Dr. Lauren Riggin is a youth and adolescent psychiatrist at Sunnybrook Health Sciences Centre. She spoke with Your Health Matters about the importance of gender-affirming care.

How would you define gender-affirming care? What does it look like?

I think it’s important to start with what is it not. It is not exclusively hormone therapy or hormone blockers. To me, gender-affirming care does includes those clinical components but it also includes treating people with basic respect and dignity, and creating an environment where they feel heard, included, and supported regardless of their gender.

An example of what I mean by that is using more gender-affirming language. For instance, instead of asking, ‘Are you male or female?’ care providers could ask, ‘What gender identity is the best match for you?’ or ‘How would you define your gender identity?’ Questions that are more broad and open-ended allow the adolescent to answer for themselves.

It also includes listening to people and treating them how they want to be treated. That means if they have a preferred pronoun or name, use it when addressing them. To me, gender- affirming care is as much about that supportive and respectful approach as hormone therapy, medication, or surgery.

What do you think people need to know about gender-affirming care involving hormones?

First, there is no pressure to pursue gender-affirming medical options. It is very much the youth’s decision based on what feels right to them. There are youth who choose to start treatment right away and others who prefer to delay it, and that doesn’t really mean anything in terms of their gender identity or gender expression. In other words, it doesn’t make young people less trans if they are not pursuing hormone treatment.

Treatment usually starts with hormone blockers which are thought to be mostly reversible with no long-term consequences – so that is good to know, especially for younger youth who are maybe more uncertain.

And gender-affirming hormone therapy (prescribed estrogen or testosterone) is a partially reversible intervention. This is often a big concern for parents who wonder, ‘What if my youth is not making the right decision for themselves?’

It is also important to note that there is a lot of evidence that suggests that physically appearing more similar to your identified gender is tremendously helpful for your mental health and reduces the risk of depression, anxiety, and suicidal behaviour.

As a youth and adolescent psychiatrist, what can you tell us about the mental health impacts of gender-affirming practices for trans and gender-diverse youth – whether at the doctor’s office, school, or home?

The research has mostly focused on what happens without gender-affirming care. What we know is that people who are not supported — who are not accepted within their home, school, or healthcare environment — have much worse mental health outcomes. That includes things like depression and anxiety, suicide attempts, and eventual suicide deaths. That evidence has been very well documented. And researchers believe it’s because of what’s called ‘minority stress’, in other words that people who experience discrimination are at much higher risk of depression and suicidal thoughts.

The opposite has been studied as well, although slightly less so. The evidence tells us that gender-affirming care does mitigate some of these problems. People are less likely to experience depression and suicidal thoughts if they are treated with gender-affirming care. A study conducted in the U.S. and published in the Journal of Adolescent Health in 2018 found that even something as simple as addressing someone by their chosen name leads to a reduction in depression, suicidal ideation, and suicidal behaviour among transgender youth.

I also point to the Canadian Pediatric Society position statement called “An affirming approach to caring for transgender and gender-diverse youth”, which describes the ‘minority stress’ effect and how affirming care can help reduce it.

“Transgender or gender-diverse (TDG) youth are at elevated risk for adverse health outcomes, including depression, anxiety, eating disorders, self-harm, and suicide. This elevated risk is thought, in part, to be attributable to ‘minority stress’, defined as the ‘distinct, chronic stressors minorities experience related to their stigmatized identities, including victimization, prejudice, and discrimination’. Consistent with this theory, Canadian TGD youth report high levels of exposure to harassment and violence. Risk may be mitigated by affirming experiences and environments, such as supportive parents, early social transition for those who express this desire, and inclusive and non-judgmental interactions with the health care system.”

–  Canadian Pediatric Society position statement, June, 2023

What do you hear from the transgender and gender-diverse youth you care for about what it feels like when they are not supported?

The youth that I see feel tremendously ostracized. They feel they are not living their authentic lives because they feel like they have to fake it in front of other people. That disconnect between the true authentic version of themselves and the masks that they show to other people is very distressing for them. Anyone can imagine how it would feel to not be treated with respect.

What are some of the common symptoms of depression and anxiety?

For youth with depression and anxiety, it means they are not able to enjoy the life they want to live. It could mean social withdrawal and spending less time with friends, spending less time doing preferred activities like sports, arts, or other extracurriculars, having a hard time focusing in school or falling asleep at night, low energy throughout the day, or appetite changes. It could also mean feeling like life is not worth living, that it’s hopeless and will never get better. And that can ultimately lead to suicidal thoughts.

Recently we are hearing a lot about gender identity policies in schools, and the debate over whether parents should be informed if students request a change to their preferred names or pronouns. It has been framed as an issue of parental rights versus children’s rights and 2SLGBTQIA+ rights. If we apply a mental health lens to this topic, how might that add to our understanding of it?

If we apply a mental health or medical lens to this, it comes down to an issue of consent and capacity. In general, in medical care we are asked to assess individual youth and decide if they have the ability themselves to ‘understand and appreciate’ the consequences of a medical decision. In other words, doctors have to decide if individual youth can literally grasp the information of, say, the side effects of a medication and apply that information to themselves.

It’s the same concept for health information. Part of our job as doctors and healthcare workers is to assess whether or not a patient has the capacity to give consent about the sharing of their health information. Obviously, a five-year-old does not have the capacity to make treatment decisions or decide if they want their parents involved in any sort of medical discussion. But most teens do have that capacity – they can share with a healthcare provider whether or not they want their parents to be involved, and ultimately they can also make their own health decisions.

That has been very clear in the medical world for decades, and yet in the school system there seems to be a different culture. It’s a very different model than the medical system where we sometimes tell parents, ‘Sorry, you are actually not involved in this decision because your youth doesn’t want you to be and because they are able to understand and appreciate the consequences of a medical decision themselves’. Most youth psychiatrists encourage a family-based model of care, but ultimately, the youth gets to decide how involved their parents are in their medical treatment.

How concerned are you about the stress associated with being caught in the middle of a public divide like this for transgender and gender-diverse youth?

My own transgender and gender-diverse patients have told me how invalidating it feels to have this very public debate over something which to them seems as basic as just calling them by their preferred name. They say it feels like suddenly there is this problem with who they are and what their name should be and that feels very invalidating. They say, ‘Really, I can’t express myself the way that I want to and that’s true to me? Why does anyone else care what I call myself?’

What message would you like to offer youth and their families who may be navigating gender identity at this time?

What I say to patients and families is that this is a process. Understanding who we are at our core is actually a very normal developmental process for teenagers, and people who are gender diverse have an extra level they have to go through to try and figure out what is their place in this world and how do they best express themselves.

For parents, my message is don’t worry, you don’t have to make any big decisions right now. This is a process and your job is simply to love and support your child. And if they ask you to use a different pronoun or name, do it. They are confiding in you about how they feel and view themselves and being able to respect that is really important.

For youth, my message is we’re here for you, we are supportive. Living an authentic life, true to your own identity, can be tremendously liberating. If you need time to figure out who you are, that is okay too. If you need help with your mental health, we are happy to help you at Sunnybrook. We have faith that we can help you to build a life with meaning, authenticity, and joy.

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Anyone can be affected by brain injury – but some groups are at greater risk.

Sunnybrook expert says an equity lens to prevention is key to reducing harm.

If you or someone you care about has ever experienced a traumatic brain injury (TBI) – such as a concussion or injury from a motor vehicle collision – then you know the impacts can be life-changing.

TBI is different for everyone but it often leads to a range of physical, emotional, behavioural, and cognitive changes that impact a person’s health and daily activities.

Some groups are impacted by TBI more than others. At Sunnybrook’s latest Speaker Series, Shaelyn Fitzpatrick, Injury Prevention Educator with the Centre for Injury Prevention at the Tory Trauma Program, discussed some of the reasons why this is the case.

Fitzpatrick explained that social determinants of health are a major factor. These can include race, ethnicity, economic status, gender identity, age and sex. Social determinants of health affect a person’s risk of injury and disease, as well as access to health services and outcomes.

“In order to work towards reaching health equity, we need to address the underlying social determinants that create barriers and disproportionately create unfair distribution and access to services and supports,” Fitzpatrick said.

Fitzpatrick is a registered nurse by training. She is also the host of the second season of a podcast called Injury is NOT Equal, produced by the Centre for Injury Prevention to increase awareness about the inequities in injury risk and experience.

Season two of the podcast focused on TBI, which has a significant impact on society. According to Brain Injury Canada, about two percent of Canada’s population lives with TBI. By 2031, TBI is expected to be one of the most common neurological conditions affecting the country’s population.

Fitzpatrick and her guests on the Injury is NOT Equal podcast explored some of the intersecting identity, systemic and socioeconomic factors that cause certain groups to be impacted more than others.

For instance, according to the World Health Organization, one in three women experience intimate partner violence — placing them at greater risk of sustaining a TBI.

“It is estimated that for every NHL player who suffers a brain injury, approximately 7,000 Canadian women experience the same as the result of intimate partner violence,” Fitzpatrick said. “This equates to about 250,000 new cases of IPV related brain injury each year in Canada.”

Despite these numbers, Fitzpatrick said, there is still little understanding among the public and healthcare providers about the association between TBI and intimate partner violence.

Risk of TBI also increases with age, Fitzpatrick explained. Seniors aged 65 and older are significantly more likely to sustain a head or brain injury, mostly due to falls and car collisions

“On average, older adults with TBI experience higher rates of death and disability, slower recovery and greater impacts to cognition, functional ability and psychosocial outcomes,” she said.

It is a common misconception that falls are an unavoidable part of aging, Fitzpatrick added, but in reality, they often result from factors such as deconditioning which can be prevented.

Prevention strategies which address both the immediate risk factors of injury, as well as the underlying social conditions that create risk factors, is at the very heart of what Sunnybrook’s Centre for Injury Prevention does.

The Centre’s P.A.R.T.Y. Program, which offers injury prevention workshops for teens, and its STOP THE BLEED®initiative, which trains members of the public to manage massive bleeding, are two successful examples.

The Centre also runs the BRAVE Program, which stands for “Breaking the cycle of violence with empathy.” It is a violence intervention program for youth that offers wraparound services to patients and families who have experienced a stabbing or gunshot injury, with the aim of reducing re-injury or retaliation.

The Centre for Injury Prevention also work to improve access to its programs to communities which are more vulnerable to injury.

At the end of the day, prevention strategies that are informed by an equity lens will be more successful at reducing injury such as TBI, Fitzpatrick said.

“If we can address factors such as income disparity, discrimination and systemic racism, we could see a huge impact on many aspects of individuals’ lives including their health and risk of injury,” she concluded.

The post Traumatic Brain Injury appeared first on Your Health Matters.

For others, difficult emotions can also arise during pregnancy and the postpartum period, including the kind of stress or worry that can often accompany a major life change. While that is not necessarily anything to be alarmed about, doctors say that if such feelings interfere with a person’s ability to enjoy or carry out their daily routines, they should speak with their healthcare provider about whether they might need additional mental health supports.

At Sunnybrook’s latest Speaker Series, leading experts in perinatal mental health discussed how depression and anxiety can affect pregnant people and those who have recently given birth — and what treatment options are available.

According to Sunnybrook psychiatrist Dr. Sophie Grigoriadis, head of the Women’s Mood and Anxiety Clinic: Reproductive Transitions, perinatal mood disorders affect about 20 percent of women. That translates to approximately 28,000 people in Ontario each year.

Risk factors can be biological, psychological, and environmental. Experts also say there are some groups, including people who have experienced intimate partner violence, people with disabilities, people with a history of depression or anxiety, and people who have been through a birth trauma in the past, who are at greater risk of developing a perinatal mood disorder.

Symptoms of perinatal depression and anxiety — such as low mood, difficulty sleeping, or recurring anxious thoughts — can persist for several years postpartum if left untreated, Dr. Grigoriadis explained.

The good news is these mood disorders are very treatable with methods such as psychoeducation, psychotherapy, psychosocial interventions (e.g. self-care or breastfeeding support), or antidepressant medication.

New approaches such as mindfulness-based group therapy delivered online to treat anxiety in pregnancy are also being studied, said Dr. Grigoriadis, who is also a scientist with the Hurvitz Brain Sciences Program.

In addition, Dr. Grigoriadis along with research teams at Sunnybrook, Women’s College Hospital, and CAMH are recruiting patients for a clinical study into an innovative treatment called Transcranial Direct Current Stimulation for Depression in Pregnancy.

Transcranial Direct Current Stimulation is a non-drug treatment involving a small device that can be used at home. It is already approved by Health Canada – but Dr. Grigoriadis and her colleagues hope to evaluate whether it is effective in treating depression in pregnancy.

The treatment could provide a useful alternative for patients who are reluctant to take antidepressant medication during pregnancy, Dr. Grigoriadis explained. “If we can show that it is helpful, it will be revolutionary because this is a treatment you can do at home with minimal side effects,” she said.

Sunnybrook obstetrician Dr. Anne Berndl, Director of the Accessible Care Pregnancy Clinic and Associate Scientist with the DAN Women & Babies Research Program, said getting help is key to the health of the person who is pregnant as well as the baby.

Untreated depression during pregnancy significantly impacts quality of life and can lead to an increased risk of preeclampsia or substance use. There are also health risks for the baby, such as preterm birth or low birth weight.

Postpartum depression that is not treated can increase the risk of self-harm for the birth parent. It can also have a negative effect on infant attachment, breastfeeding, and development.

Dr. Berndl encourages people who are experiencing symptoms of depression or anxiety during pregnancy or postpartum – such as a feeling of hopelessness, loss of appetite, frequent irritability or tearfulness, severe sleep deprivation, or simply feeling ‘stuck’ — to reach out for help.

But the first step might be acknowledging that pregnancy and new parenthood doesn’t automatically come easily to everyone.

“One of the things that makes this really hard for people to understand are motherhood myths, which are a real barrier to accessing care,” Dr. Berndl explained.

“There are myths that once you become a mother you will have complete joy and fulfillment, or that motherhood is easy and you will naturally know what to do, or that being a mother always means sacrificing your own needs but these are all myths,” she added. “The problem with these myths is that people have a sense of shame when they feel otherwise, and it can delay asking for and receiving help.”

Mental health supports should be personalized based on a patient’s needs, Dr. Berndl said. For instance, a patient who has experienced a prior stillbirth or neonatal death might need more appointments with an interdisciplinary care team and a greater focus on birth planning.

People with disabilities, who have higher rates of depression and anxiety, also benefit from an interdisciplinary approach to perinatal care that includes medical management of the birth parent, pain management, early access to lactation consultants, psychiatry, and if needed community resources.

The take home message, Dr. Berndl said, is that “anxiety and depression during pregnancy and after birth can happen to anyone – but they are treatable so talk to your care provider about it.”

 If you are looking for more mental health resources please speak to your doctor or see some of the resources listed here.

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With so many viruses circulating, from the common cold to influenza or – you guessed it — COVID-19, many people are wondering how to stay healthy.

Dr. Alison Culbert is a physician with Sunnybrook’s Academic Family Health Team, where she treats patients, including older adults with complex chronic care needs, through many of life’s ups and downs such as seasonal illnesses.

Dr. Culbert spoke to Your Health Matters about how to stay healthy this respiratory virus season.

Respiratory virus season is in full swing. What are you noticing among the patients you treat?

We are definitely seeing an increase in respiratory illnesses in all ages. We have had more calls to the office with our patients looking for advice about what they should do because they are feeling sick or their kids or loved ones are sick.

And we are also seeing an increase in the number of patients that we are bringing in to be seen in the clinic for acute respiratory illnesses.

What reminders can you offer to people about how to stay healthy during respiratory virus season?

The general things I usually recommend are to try to make sure you are getting enough sleep, that you are eating well, and that you make time for physical activity. And it is always a good idea to wash your hands frequently and try to avoid touching your face, especially at this time of year. I also encourage people to take advantage of the vaccines available to them for COVID-19 and influenza.

What should people do if they are experiencing common cold, flu or COVID symptoms such as cough or fever?

Number one is please stay home and try to use available over-the-counter medications like acetaminophen and ibuprofen to manage symptoms like fever, chills, or aches. Resting and staying well hydrated is also important. The vast majority of people will get better within a few days but if they don’t, they should call their healthcare provider for advice and help deciding if it’s time to make an appointment.

This year, health officials are spreading the word that it’s both safe and convenient to get a COVID vaccine and a flu vaccine at the same visit. What advice do you have about how folks should plan to get their vaccines?

Certainly from a convenience perspective, it makes sense to get the flu and COVID-19 vaccines together. We encourage people to get one in each arm. And many people have already had a flu shot or COVID vaccine before, so they can predict how they will feel based on their past experience. Some people might notice a sore arm, but the vast majority of people won’t experience too many side effects.

I often tell people to plan to get their vaccines on a day when they don’t have anything really important to do the next day, just in case they feel a little bit achy afterwards. But most people tolerate getting both vaccines at the same time without any issues.

What would you say to people who might be wondering if they need a COVID-19 vaccine now that the virus is no longer considered a global public health emergency?

It’s important to remember that although the vast majority of people with COVID will recover well, we continue to see those people who get sicker than other individuals and end up experiencing long COVID symptoms. So given that we have a safe and effective vaccine against this virus, I recommend taking advantage of it.

What about people who might think, ‘I hardly ever get the flu so I don’t need to get a flu shot’? What would you say to them?

True influenza usually makes you feel quite unwell with symptoms like fever and body aches, so anything you can do to avoid that is a good idea. If you do end up with the flu and you are vaccinated, chances are the illness will be far less severe.

But getting the flu shot isn’t just about protecting yourself. There is also a benefit to getting the flu vaccine to help protect those around you such as young children, vulnerable seniors, or immunocompromised friends or family, for instance, someone going through chemotherapy treatment for cancer.

I’d like to ask you about older adults in particular because this year there are more vaccinations available to them: COVID, influenza, pneumococcal, and — for the first time for people over 60 — respiratory syncytial virus (RSV) vaccines. What can you tell us about RSV and why this new vaccine is being offered to older adults?

Respiratory syncytial virus (RSV) is a common virus that affects both young children and older adults. It is highly contagious. While it causes symptoms similar to a common cold in most people, in more vulnerable populations it can cause severe illness such as bronchiolitis, which is inflammation of the small airwaves of the lungs. It can also cause pneumonia.

The new RSV vaccine has been shown to be effective in preventing lower respiratory tract infections the virus can cause in adults over the age of 60.

My understanding is that the recommendation is adults over age 60 with at least one underlying health condition — such as congestive heart failure, diabetes, or liver and kidney disease — should consider getting the RSV vaccine.

It is not available at primary care offices at this time, but is available in some pharmacies with a doctor’s prescription.

In addition, the new RSV vaccine is not publicly funded in Ontario at this time except for adults over age 60 living in long-term care homes. This means patients would have to pay for it out of pocket unless they have a private drug plan that will cover the cost.

But if people are able to get the vaccine, it is definitely worthwhile and hopefully will help cut down on the number of patients getting this infection and ending up in hospital.

Is there anything else you would like to add?

I would encourage people to take advantage of any of the vaccines they might be able to access in order to help prevent unnecessary illness.

We know that emergency departments are still operating at full capacity and patients seeking care are often experiencing long wait times. If there is anything people can do to lower their risk of having a severe respiratory illness this season, I hope they will consider it.

Vaccines are available through primary care providers, pharmacies, and public health clinics, so there are lots of ways to get your COVID and flu vaccine.

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Ever since it was ushered into widespread use during the pandemic, virtual healthcare has become a much more common tool — including for virtual urgent care.

Sunnybrook Health Sciences Centre partners with University Health Network (UHN) to provide Toronto’s Virtual Emergency Department.

The service offers same-day appointments seven days a week for adult Torontonians with an urgent medical concern that is not life threatening (e.g. body aches, rash, nausea), and who are unable to make an appointment with a family doctor or nurse practitioner.

At Sunnybrook, roughly 6,000 patients have been seen through the virtual urgent care program since it began in December 2020. Most express appreciation for the convenience, privacy, and flexibility it offers.

“Virtual emerg is a great idea…It’s convenient, efficient and it’s working well. Thank you for seeing patients in virtual ER!” – Patient

For patients from equity-deserving groups – i.e. communities that face barriers to opportunities, resources, or services such as healthcare – virtual urgent care is seen to provide additional benefits.

At the latest Sunnybrook Speaker Series, Dr. Sander L. Hitzig, Program Research Director and Senior Scientist at the St. John’s Rehab Research Program at the Sunnybrook Research Institute, spoke about why that is the case.

“The number one benefit of virtual urgent care is that people from equity-deserving populations feel more control over their care experiences,” he said. “They feel safer in terms of their physical and mental health compared to past in-person encounters where they felt prejudiced against.”

Examples of underserved or equity-deserving populations include people who are low-income, people with disabilities, refugees, Indigenous or racialized persons, or members of 2SLGBTQIA+ communities.

Dr. Hitzig, whose research often evaluates new technologies and models of care, began examining the use and impact of Sunnybrook’s virtual urgent care program shortly after it was launched, in partnership with Dr. Justin Hall, Emergency Department physician and Program Lead of the Virtual Emergency Department.

Initial data suggested people from equity-deserving populations faced barriers accessing the service, such as not having reliable Internet access or a private space for their online appointment. Low digital literacy or English fluency were also common barriers.

Drs. Hitzig and Hall, and their colleagues, decided to dig deeper to learn more. Together with Access Alliance, a multicultural health and community services partner, they designed a qualitative study with the goal of better understanding how virtual urgent care met the physical, emotional, and social care needs of equity-deserving patient populations.

The researchers interviewed patients over the age of 18 who self-identified as belonging to equity-deserving groups. Many identified aspects of virtual care that could be improved – such as technical requirements that could be challenging for people with a learning disability.

But most of the patients who were interviewed also had favourable things to say about the service.

“One of the things that came out loud and clear was that people really welcomed the convenience and flexibility of virtual urgent care,” Dr. Hitzig said. “And they appreciated not having to wait a long time to be seen.”

The option to avoid a long wait in a crowded emergency department was especially appealing to people with chronic illnesses who might be immuno-compromised, Dr. Hitzig added.

Some patients who were interviewed also noted the financial benefits of virtual urgent care, such as not having to pay for transportation or parking.

Many also liked the focus and attention they received from staff during virtual appointments and the professionalism of the care providers, Dr. Hitzig said.

He added that several patients said they preferred virtual urgent care to past experiences at physical emergency departments when they had felt belittled or discriminated against.

“There is more work that needs to be done to better understand how virtual models of care can be better tailored to people from equity-deserving populations,” Dr. Hitzig said. “But overall, it is seen as a compassionate tool that is making healthcare more accessible.”

Asked what makes him most excited about the future of virtual urgent care, Dr. Hitzig said it is the sense of empowerment that patients described after accessing the service.

“Having more options to give people greater control over how and when they access healthcare is important because we want to be partners with the patients we are treating,” he said.

“If people have more positive experiences, that will lead to better outcomes for the patient and the healthcare system.”

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