E132 Donna Kimmaliardjuk on Breaking Down Barriers and Caring for Indigenous Patients

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Chad Ball  00:12

Welcome to the Cold Steel podcast hosted by Ameer Farooq and myself, Chad Ball. We consider it an absolute privilege to bring you guests from around the world who are truly experts in their craft. Our mission is to offer you a combination of not only masterclasses on clinical surgery topics, but also insights into achieving personal growth, productivity and fulfillment as both a surgeon and, perhaps more importantly, as a human.

Ameer Farooq  00:42

On this week's episode, we had the pleasure and privilege of speaking with Dr. Donna Kimmaliardjuk. Dr. Kimmaliardjuk is the first endocardiac surgeon in Canada and has won numerous awards for her trailblazing work. We were lucky enough to catch up with her and ask her about her career, and to get her thoughts on how we can make surgery a more inclusive profession, as well as how we might better serve our business patients. Be sure to check out the links in the show notes. Can you tell us a little bit about where you grew up?

Dr. Donna Kimmaliardjuk  01:10

I grew up in Ottawa, but, really, kind of, the background to that, or kind of more meat to that answer is, I'm Inuit — well, the singular is Inuk — and I was born in Winnipeg, but I lived back up North where my mother's family is, but only for a brief time when I was an infant; and my father is non-Indigenous. And they had the foresight — or, understood the importance of education — and decided to move what we call up North "down South" in quotation marks, I put it, because down South is any big city not in the Arctic. And so they did that because they wanted to have better educational opportunities for their children, that their kids would have all the same, you know, extracurriculars and opportunities and experiences that all other Canadian kids get to have. And so they settled in Ottawa, because they could both work there, but also, there was a large Inuit population there, so we could still be connected to our culture. And I'm really, you know, thankful for that and owe a lot to my parents, that they, kind of, had that foresight back in, you know, the early 90s, that this would be an important thing to do for their kids.

Chad Ball  02:41

That's such an interesting, sort of, origin story. You know, at the risk of sounding really ignorant — and I certainly don't mean it that way — but for some of our listeners who may not know, could you define for them, sort of, what Inuit means, and what that encompasses?

Dr. Donna Kimmaliardjuk  03:00

Absolutely. And no, it's, like, you know, it's not ignorant at all, and I love that people ask, you know, because it's really becoming a little bit more publicized; kind of, you know, Indigenous Canadians and our cultures and the history of colonization. And, you know, most recently, in the last year, all the discovery of the unmarked graves all at residential schools, and so, you know, more and more Canadians are kind of learning a lot more about this. But anyways, Inuit is the correct term to use. So, a lot of folks would know or have heard the term Eskimo, which is a racial slur, okay. That is coming from an Inuk. That is a racial slur. You know, you might hear Inuit say that to each other, and that's fine, because that's them, or us, using it amongst ourselves. And you can make certain comparisons to other cultures, right? I won't get into that, but you can understand that, you know, that happened. And so, you know, we are the people that inhabit the Arctic — the Canadian Arctic — but also, you know, the Arctic around the world, or, well, almost around the world. And so, really, the Inuit spanned from northern Alaska all the way to Labrador, here on the East Coast, and it's a very distinct culture from First Nations, which what, again, people would have called Indian. And so, First Nations is, again, the correct term, because there are many different types of First Nations within Canada and North America, and they all have their own cultures; they're all distinctly different. And so, Inuit is distinctly different from First Nations, which is also distinctly different from Métis, which is the other large group of Indigenous Canadians. So, Inuit are, you know — we were the ones that inhabit the North with our own culture. We're the ones that, yes, did live and make igloos. In fact, my maternal grandfather was born in an igloo. There were no white people up there at the time, there were no settlers yet, up where he or my family's from. He legitimately was born in an igloo. And, you know, dog sleds; yes, my family had dog sleds. You know, when my mother was a child, that's how they got around. And then, you could talk about like the, you know, dog sled slaughter and what the Canadian government did to colonize, and, kind of, really, force Inuit into communities, because we were historically a nomadic group of people that, you know, followed animals, basically throughout the seasons, to hunt and survive. And so we are, you know, historically, you know, from the North; there's a lot of Inuit, though, in major cities all across Canada. Our language is called Inuktitut. And I think, yeah, the other important takeaway is, you know, we are distinctly different from First Nations.

Ameer Farooq  06:11

You know, your parents are really fascinating people, and I had a chance to read a little bit about them. Can you tell us a little bit about your parents' start?

Dr. Donna Kimmaliardjuk  06:18

Sure, yeah. And, you know, and I'm happy to talk about that, because, again, like I said earlier, I owe so much to them. And they really do come from humble beginnings, and, just, kind of, I see them both as trailblazers a bit themselves in our families, and just really driven individuals in their own ways. So I, you know, owe a lot of my drive and determination to them. But, yeah, so, as mentioned, my mother is Inuk — so, singular for Inuit — born and raised in Nunavut, in the Arctic, there were houses at that price she was, she grew up in like a traditional North American–type house. She was the first child — or, the only child, actually — in her family to, quote unquote, leave the nest. And she just felt she wanted something more for herself than to just be at home in her home community, which is a community of about 300 people, so it's a small place. And so, she joined the military, and, kind of, was in a few different places within Canada, as you are when you're in the military, and that's where she met my father. And my father, you know, his parents were Eastern European immigrants. They got displaced by the war. They settled in Toronto. And his father was really the inspiration for why I wanted to become a surgeon. So my paternal grandfather, who I never got to meet, died of amyotrophic lateral sclerosis when my father was 12. And I was very close to all my other grandparents, so I'd asked my dad, like, "Well, why don't I know, you know, other grandpa? Like, how come I don't know him? And so I was 6, and he explained to me, and I remember, like, very honestly, but kindly, you know, to a 6-year-old that he had died of this disease called ALS and, you know, he explained that it's a neurological disease and, kind of — I remember him saying it eats away at the nerves in your body, so you lose all control of, like, the ability to do things, but the whole time, your brain is working perfectly well, so you understand what's going on, but you can't do anything, and there's no cure. And I remember feeling a bit scared that I didn't want that to happen to my parents or other kids' parents. I thought, you know, nobody should have to live without their parents as a kid. And so I said, "Okay," or I thought, "Okay, I'm going to become a neurosurgeon, and I'm going to invent a surgery to cure ALS." I was 6. But that literally was my motivation all throughout elementary and high school, and even university, to get into medicine, and I truly thought I'd want to do neurosurgery. And so he, you know, was raised by my Oma [grandmother]. She was German, you know, a single mom, she cleaned dishes at St. [Michael's] Hospital. They were on welfare in order to also support the family, and he then joined the military. That's where my parents met. He was the first to then pursue postsecondary education in his family, which he did when I was actually an infant. And so nobody in my family is in medicine; like, nobody's a nurse, a doctor, a dentist, or a physiotherapist, pharmacist, like, anything that you could think to do with medicine, nobody in my family has been involved with it at all, so I had no, kind of, exposure to any of that life or lifestyle growing up, but I just felt this call. Like, this sounds corny, but literally this calling within me that, like, this is what you should do, Donna; this is what you need to do to help people in the world, that you're going to do this. And I, again, I'm just super thankful that my parents were really supportive. I remember all they said when I told them that I want to be a nurse, is, they said, "Okay. You're going to have to work really hard in school." I said, "Okay. Sure." And I guess I did. So here I am now.

Ameer Farooq  10:23

Yeah, and our listeners should know that you went on to train in some very, very prestigious places, and we'll talk about that some more at length, I'm sure. What eventually made you switch from the heart to the brain — or, sorry, from the brain to the heart, rather. What drew you into cardiac surgery?

Dr. Donna Kimmaliardjuk  10:44

Yeah, so, you know, I went to the University of Calgary for medical school. And a couple of things that drew me there: I really loved that it was a 3-year med school, so you're in school 12 months out of the year. And I remember, I don't remember — I think the Dean of admissions or Dean of the undergraduate medical education — he said, you know, "When you're a pro athlete, you don't train hard for 8 months, and then do nothing for 4 months, and then come back in September and expect to be at the same level. You train 12 months out of the year." And that really stuck with me. I was like, "Yeah, that makes perfect sense." Like, that's how I want to learn medicine. And I just, like, in my gut, it felt right. Like, that's how I've made a lot of my decisions in my life, is, like, what feels right to me, and it just felt like I'd fit in there and I'd have fun. And so I was in med school, and I started shadowing general surgery — or, pediatric general surgery, actually, which I really love. There's a fantastic group of pediatric surgeons in Calgary. I mean, I think I just loved working with them, like, as well as the surgeries, and I thought, "Okay, well, maybe I want to pursue general surgery." And I hate to say this, but I had reached out to a neurosurgeon — I don't even remember their name — because I'd heard that, you know, they're really good with students and really accepting of having students, and they never responded, so that actually really turned me off from neurosurgery. And then it came to our heart and lung course, and I just loved the cardiac physiology. Like, I absolutely loved studying it; I found it so interesting. I remember I had post-it [notes] all over my wall on top of my desk with, like, all the murmurs of the heart and all the characteristics and like, the cardiac cycle — like, I loved it. And so I just felt, "Okay. I need to see this." And Dr. Fedak, who's a cardiac surgeon in Calgary, gave a lecture on some of the common surgeries, and I was totally enthralled. And so I thought, "Okay, I need to see this." And, you know, being from Ottawa, I reached out to one of the surgeons in Ottawa, just out of the blue, and said, "Hey, I'm really interested. Can I come shadow you?", because I knew I could come back to Ottawa and be here for a couple of weeks at home and shadow him. And that is actually Dr. Marc Ruel, who then became the Chief at [the University of] Ottawa, and he's the President of the Canadian Cardiovascular Society and a very renowned cardiac surgeon. And so I, you know, I kind of got in with the right person. He's an amazing individual. He's so altruistic and enthusiastic about cardiac surgery that it just really, kind of, drew me in. And again, I felt it in my gut, like, these are the types of people I want to work with. These are the type of people I want to surround myself with. And I really liked cardiac surgery, like, you know, everyone says, "Oh, it's just bypasses and valves", but, like, it's so much more than that, and no 2 patients are the same. And it's this really, kind of, fine, intricate work; like, I'm using a lot of very small needles, so [inaudible] prolines. And I know other surgeries do that, too, but it just felt right. I was just most interested in it, most fascinated by it, and so that's what kind of drew me to the field.

Chad Ball  13:56

That's really neat. So we know why you went down the cardiac surgery road, and we know you started out in Newfoundland. Tell us about that pathway and how you ended up essentially where you are now?

Dr. Donna Kimmaliardjuk  14:10

Yeah, so, yeah, so you know, in Calgary for med school, then, you know, applied to residency. I had done a lot of electives in Ottawa, so it was very clear to a lot of people that I was really gunning for Ottawa. Again, I just, I really liked the group there, I knew that they did all types of surgeries, that I'd be exposed to everything. And I was very fortunate to match to my top choice. So I did my residency there, which was great. And it was getting into the senior years, and it's pretty standard in cardiac surgery that everybody does a fellowship afterwards, and a lot of trainees actually do 2 fellowships; that's actually pretty standard. And so it was kind of the first time in my life that I didn't really know exactly where I wanted to go — kind of, all decisions beforehand. I knew where I wanted to go to university, I knew where I wanted to go to med school. I kind of had an idea, and this time I was like, "Oh", you know, "I'm PGY-5, and it's a 6-year program." I was like, oh dear, I don't really, I don't really know. And so I chatted with a couple mentors, and I'm really thankful because both of these guys really, kind of, believed in me. And one night, you know, I was thinking of potentially going to Belgium, because that's where one of my mentors came from. And I mean, just his technical skill is unreal; like, I was like, "Holy moly," like, "I need to be like this". And then another one, he thought, you know, Donna, you've got to go to Cleveland Clinic," like, "You will do well there. You're going to be able to learn that this very specialized surgery that not many surgeons can offer, and that's going to add to your repertoire that'll make you attractive, like, as a hire". I said, "Okay," and I actually felt a little, like, a little intimidated applying to the Cleveland Clinic, right? It's the #1 heart centre in North America and, actually, they just published for the 28th year in a row. They're still #1. And so I remember thinking, "Geez," like, "I don't know. I don't know," like, "Am I? Am I good enough?" You know, will they look at me and think, "Oh, Jesus," like, "She doesn't have enough research," or, "She doesn't have enough of this or that," or whatever. But I interviewed and I got accepted, and so I felt, "Okay. Yeah. I've got to go." And while I was there, I felt I, you know, I was like, I don't think I need to do another fellowship. I mean, you are exposed to literally every type of surgery in Cleveland; the volume is insane. There's so much opportunity to do, you know, any type of surgery, that I felt, okay, I think I feel ready to now go into the real world, and be a big girl, and a staff surgeon. And so I — sorry, it's a very long answer — but I, early on, I felt, you know, I want to come back to Canada. And I'm, you know, considering maybe Ottawa. I didn't feel like it'd be the right fit for me for certain reasons I won't get into. So I started looking, and I saw that Newfoundland was hiring, and I had never been here, never visited, never done anything out here, but I applied and I interviewed, and I just got a great feeling from the cardiologists and the surgeons. And I was very fortunate; they gave me a job offer shortly thereafter, and I took it.

Chad Ball  17:31

I think it's clear you would fit in in any practice anywhere in the world and be a huge added bonus to that practice and an absolutely wonderful person to have. But you have spoken on a number of occasions about being warned about not being the typical surgical, sort of, personality, the typical mold origin, so to speak. Can you talk to us a little bit about how you process those comments and what that's meant to you?

Dr. Donna Kimmaliardjuk  18:01

Yeah, yeah. And so these were, you know, comments or, kind of, feedback that I got when I was a resident, you know, transitioning, kind of, from the junior role to more senior role. And, you know, unfortunately, it's something that I see a lot of female trainees share very openly on social media; that, you know, these are the same experiences they have too, right? And so, you know, you're quote-unquote too nice, too timid, you're meek. You know, because part of this is kind of cultural, that I might not speak up as much or speak as much as maybe my male colleagues. And especially — I don't know if you've met Inuit, but there's a lot of Inuit who are very, you know, tend to be quiet, or very stoic, or, you know, you'll be talking with them and you might think, "Well, are they actually listening to me? It's like, we are, but we're processing it; we're not necessarily going to speak just for the sake of speaking type thing. And so these are things that I just don't think cardiac surgery has been necessarily used to, especially — I mean, I was only the second female trainee ever to go through the program in Ottawa, and there's no female staff there. I mean, I think there's only — I think it's maybe 12%, now, of all staff cardiac surgeons in Canada are female. Like, 12%. So it's just not something — you know, I am just not the typical male trainee, perhaps, that they get who might be a little bit more outspoken or a little bit more — I don't want to say aggressive but, like, outgoing and going after what they want. Like, for example, talking with one of my female colleagues in training, we were very similar; we would never ask, "Hey, can I do this in the case?" Or, "Hey, I want to do this [inaudible]. I want to do this whole surgery." Like, that just wasn't our style, but I'd have male colleagues who would be very open in asking, "Well, I want to do this," or, "Can I do that?", which is fine. Cardiac surgery is very, you know, they very much respond to that, but because I wasn't like that, I think it was felt by some people, "Well, does she really know what's going on? Does she know what to do? Can she be a leader in the OR?" Which, I understand where they're coming from, but I think I just had to prove myself a little bit that I did know what I was doing, that I, you know, felt confident, I understood the steps, and that, you know, was in various forms. I remember I worked with a couple retired surgeons and after hours, and I would go practise parts of surgery so that when I came to the OR, I knew my stuff; like, I was ready to go. Like, I just wanted to have no doubt in anybody's mind. And, too, something I knew that I brought to the table that was very strong was my communication skills and patient relationships. And that began to really shine through once you start kind of rounding on patients by yourself and, like, managing them yourself. As you get more senior, I think that instilled a lot of confidence and a lot of surgeons woud say, "Okay," like, you know, "She's working her butt off, patients are liking her, she's doing well managing them, you know; let's give her some opportunity." And I really clicked with the surgeon who became my closest mentor, so I worked a lot with him, and having that consistency in training and somebody who, kind of, really commits to training you, just accelerated my skills that much more. So I, kind of, I understood where they were coming from. I, you know, took it to heart and really wanted to digest what they were saying, even though I kind of felt that they were wrong. But you know, these are senior surgeons, and they're the people training you so, you know, you think, "Okay. Gosh," you know, "Maybe — they must know something that I don't." But I took it to make myself as good as I could be, as strong as I could be, and really just, finally, once I got that confidence, which embraced being myself, and as I had that mentor who really saw how I was growing and developing, he then became a very strong advocate for me, right? With other surgeons, he would say, like, "No, no," like, "She can do it. She's got the hands," or whatever it may be. So, um, yeah, it, you know, it was a bit challenging, but I think that's good; that makes you grow and that makes you reflect and, you know, adjust or tweak things as needed.

Ameer Farooq  22:18

Dr. Kimmaliardjuk, you wear a lot of mantles, a lot of crowns, on your shoulders and on your head; you know, you're the first Inuk cardiac surgeon in Canada, and clearly one of the few women who are in cardiac surgery. How do we make the house of surgery, you know, inclusive, so that more people can do what you've done? I mean, you're clearly a star, but it hasn't been — what you're describing makes it clear that this hasn't been an easy process; this hasn't been an easy journey. What do we do in surgery to make this — our culture — such that, you know, you don't — someone like you doesn't come in and say, you know, "I'm not the typical person." Like, there needs to be in my mind, you know, role models or space for all sorts of people; like, you know, not all leadership styles, or not all personalities, do things the same way. And we need more of that, and especially to make it possible for such talented people like you to come in. So, what do you think? Like, how can we make surgery better?

Dr. Donna Kimmaliardjuk  23:27

Yeah, and I mean, it's a big question, and I think, you know, realistically — or unfortunately, potentially — like, we won't see all the great improvements that we need to see within surgery and medicine for a few years. Because I think it really starts with looking back to, like, university and med school. Like, how do we get young, intelligent, driven, motivated, you know, interested people pursuing medicine in the first place, right? Like, there's potentially young people who were like me, or are like me, who didn't have any of that exposure, right? So what you're not exposed to, you don't necessarily know that you can do or think about it. And so I think it even starts back at that stage, and then, you know, within getting into med school, it's great. We're seeing, like — a lot of classes are split evenly, or there's even more women now than men in med school. But again, talking with young women, which I'm very fortunate to get the opportunity to do so; they're still being told these erroneous, like, silly things of, like, "Well, you can't have a family and be a surgeon," or, you know, "You're not going to get a job," or, "You're going to be in training forever," or whatever it may be that really discourages or frightens women out of surgery, and it's usually by people who are not surgeons or working in that field themselves, which is very frustrating. So we need to stop that narrative that, you know, you can't have — I don't want to say have it all — but you can't have a balanced life or have a family or pursue things that you want to do — that needs to stop. We need to support our women in surgery, like having senior colleagues who understand that women or other minorities or what have you might [be] or are different than the typical white, cis-male trainee that comes through the program, and that's not a bad thing. It doesn't mean you're any weaker or less competent. You need — and I think, too, it's important that we have, like, allies or, you know, folks who — you know, my mentor, who then became a strong ally and advocate for me. It's so multifaceted. Like, it really has to come from within current surgeons, though, because leadership is really going to reflect that attitude, and, like, that will trickle down, right? So I think you have to have programs, whether it be program directors, chiefs, whatever, who get it and who advocate and promote this, like, inclusive environment. That's kind of a vague answer, I think, but I do think that's true.

Ameer Farooq  26:18

It's a huge question, and it's not a question that's easy to answer. You know, one of the things I've seen that you've talked about is simply just having more role models. Like, how important do you think it is just to have the representation? Is that, you know — should we just be actively recruiting from underrepresented minorities and populations? Do you think that is going to be an important part?

Dr. Donna Kimmaliardjuk  26:50

I do. I do, and, like, you know, a lot of med schools, I think are trying to do that; for example, with Indigenous Canadians, right? And even when I went through med school, which was only 10 years ago, but there were some initiatives, then. And so I do think that's so important, because then you have representation from these communities. These individuals may go back to their home communities to practise medicine, but they can also be advocates for their communities in medicine, and then, you know, be those role models for young people. So I think that's hugely beneficial and impactful. You know, and just to quickly mention, a few years ago, the Truth and Reconciliation Commission came out with a whole bunch of recommendations, and that was one of them; that we should see higher numbers of Indigenous physicians, nurses, and people in health care. And to have these people in these positions of leadership, and quote-unquote role-model positions, so young people — so it can kind of pave the way for young people to — young Indigenous people to say, "Well, hey, I can do that, too." So I think there are some efforts being made to try to quote-unquote recruit or at least, like, motivate or entice young Indigenous folks, but I think that's really what I mean by, you know, we're gonna see these efforts kind of pay off in years to come, because that'll take years for all these young people to go through med school or undergrad and training and that type of thing.

Ameer Farooq  28:36

You know, I think you might think that the barriers seem intuitive, right? Like, the barriers for Indigenous people to get into medicine, or to get into surgery. See, it might seem intuitive to you, Dr. Kimmaliardjuk, but I think a lot of people may not know or may not understand what the barriers really are. Can you try to describe, like, what were the barriers that — what are the barriers that you personally face? And more generally, like, what are the barriers that Indigenous folks face when trying to pursue a career in medicine?

Dr. Donna Kimmaliardjuk  29:13

And you're right, like, it might seem obvious to me, but to someone who's not Indigenous, like, why would they know about it, right? So, no, excellent question. So, I mean, for example, again, I feel very fortunate that when I look back on my life, I've been very privileged in many senses, right? So I'm very fortunate that my parents tried to facilitate as much as they could for me to pursue my dreams, because they knew it was always my dream to become a doctor. But, you know, too, growing up, I remember that saying, you know, you can be anything you want in the world, like if you whatever you want to do for your career or when you're grown up, you can do that, but you have to get either a university or college degree, because they understood that that could be something I could fall back on, and that'd be hugely valuable — especially as an Indigenous Canadian, that's like a golden ticket. So if I want to go be — try to be a world pop star, and that fails, but I've got my degree in whatever, I can always come back and use that for something, right? To at least be able to support myself and have a job or a career. And so I said, "Okay. That's fine." Like, I want to go to university; I want to do these things. But when the time came in high school to apply to university, I remember this, it cost $105. And I grew up in Ontario, so it would get you this like online account, and it would let you also then apply to 3 universities with that $105. And then if you wanted to apply to more universities, you'd have to pay more for those applications. And I had to pay for my own application myself. Like, financially, my parents were unable to do that at the time. And I had a little part time job that I did, and so I had the money to do it — but I only applied to 3, because I didn't want to have to spend any more money. And I was pretty confident in my grades and in myself that I would get into one of them, at least, and so I applied to the 3. And so, like, you know, finances can be a huge barrier, and I mean, this could be a whole conversation. But if you look at, for example, up North — and forgive me; I'm not going to have the exact stats — but the percentage of Inuit that live at or below the poverty line is astounding, and then you compare it to non-Inuit that live in Nunavut. So there's a lot of non-Inuit now that live and work up there, and their salaries are fantastic and probably even better, because obviously, they're going to pay people higher to attract them to come to the North. So you know, even just things like applying to university or then applying to med school; that was expensive. Now, thankfully, my father was in a financial — he was able to support me and help me and, you know, facilitate that; that's great, but, like, if I didn't have the money, how could I even do that? You know, there's, too, then, if you're coming — so I grew up in Ottawa; I grew up in a big city, so I didn't really experience culture shock going to university or med school, because this is kind of the culture I grew up in. But you know, coming from a small, isolated community where the majority of people are like you, they look like you, or they have the same culture, they have, you know, or they're [inaudible]. And a lot of these small communities are your distant relatives, somehow, and then you go to this big city where, you know, you don't know anybody, the culture is completely different, the language could be — well, I mean, nowadays, most young Inuit are very fluent in English, right? But, you know, back then maybe they weren't as fluent in English, and so it's a huge culture shock to get over and that you're thousands of kilometres away from your family, from your support system. Even when I was in undergrad, or med school, like, there were times it was really hard, right? And you miss your parents or you want to be with them, because you need that support, because you're exhausted and stressed, and, you know, all those things. But you don't have that if your family's thousands upon thousands of kilometres away. And even just the finances of getting home to visit or getting down to med school. I mean, like roundtrip flights to go to Nunavut are thousands upon thousands of dollars, like I can go to Europe first-class cheaper than I can go back home. So, you know, financially, it's going to be a big barrier. I mean, I don't want to get into all that, but if you look at other social determinants of health, like the housing up North, is really, really — I'm just going to say it — terrible. There's so much overcrowding. There's mold. There's still, like — tuberculosis is still a problem up there. So when you're trying to just manage basic human needs to live safely and comfortably, it can be hard to then try to push further beyond that, and I don't want it to sound, like, demeaning or [inaudible], because that's not the case for everybody, right? But, like, if you — if those are such a major, like, problem, like, how do you expect to then focus on, like, "Oh, well, I've got to get an A+ in calculus." Like, it's just not realistic, right? And then you look at, too, then, that brings up the history of, like, residential schools. So that was basically — I'm going to simplify this a lot for people who don't know that history — but basically, [inaudible] boarding schools, but they, in some cases, stole your children from you. My mother went to residential school. And so they were in these schools where they were completely abused in every which way by the teachers, who were Catholic priests and nuns. And so, then, you have your parents or grandparents who went through residential school; that causes a lot of trauma and grief and difficulties for the people who went through all that abuse, and then it creates what we call or what is called intergenerational trauma. And so, then, when people want to stereotype us as drunks, or drug addicts, or whatever, well, there's a reason for that behaviour, or those problems, in some people, because they've experienced, unfortunately, some very terrible things that nobody should experience. And then that leads to, you know, whether it be abuse towards their children or neglect of their children, or, again, I'm over-simplifying and over-generalizing, because that's really not the case for everybody; I don't want people taking that as the take-home [message]. But these are just so many things that can compound. Someone — like, a young person's life and, like, what they have to deal with on top of them trying to think of, you know, "Oh, well, I better do really well in school. I better do all my extracurriculars, my volunteer work, and all this, so I have a great application for university." You can very easily understand why that might not be the case for some people. So I hope that answers your question.

Chad Ball  36:13

Yeah, that's a really important answer, to be honest. You know, just to take it, sort of, back up to 30,000 feet. For those of us that do trauma care, it's clear that, you know, trauma outcomes from major injury or poly-trauma differ tremendously across Canada and across different geographies, essentially, based on travel distance to a Level 1 trauma centre. You were a co-author in a CMAJ paper that showed very clearly a significant increase in the odds of mortality and morbidity after surgery in Nunavut. I'm curious; when you did that work at Ottawa, how you framed it, what came out of it. And maybe you could inform our listeners about that absolutely tremendous paper.

Dr. Donna Kimmaliardjuk  37:04

Yeah, yeah. So, you know, I can't take credit for having that idea to pursue this paper, but I'm really fortunate to have been involved. And so, basically, there was a group of us that did a retrospective cohort study looking at outcomes for patients who were Inuit and patients who were non-Inuit — and, specifically, Inuit patients from Nunavut. And that's because we have a very specific, like, identifier, which I have as well. It's called our n number. And so you only have that if you're an Inuk from Nunavut. And so, that's how we were able to very accurately identify Inuit, and then compare them to, you know, all the other patients that come to The Ottawa Hospital. And this was just the 1 centre that we looked at, because this is where we all, kind of, worked. And we did not look at cardiac surgery, I remember that very clearly. That's mostly I think, because The Heart Institute is a bit separate from The Ottawa Hospital — and forgive me; I don't have the paper in front of me — but I also think we did not look at obstetrical care slash gynecology, and potentially not — there was something else. Please forgive me. But anyways, when we looked at all other types of surgeries, so, you know, orthopedics, plastics, all that stuff. And we were — what was, I think, really important about this paper is this was the first published paper looking at only surgical outcomes for only Inuit. Because other papers have looked at, you know, pan-Indigenous Canadians. So that includes Métis, First Nations, Inuit. And then it can become very difficult to pinpoint, you know, where are these patients actually coming from or, you know, like, geographically or culturally. And so this was the first paper to look at just Inuit, and we wanted to look at, really, the 30-day outcomes for these patients who've had surgery. And, you know, as a surgeon, and as an Inuk, it's not a surprise to see that Inuit had a 25% relative increase in odds of, you know, major complications or death within those 30 days after surgery compared to non-Inuit. And so why that, you know, is not surprising — and, too, even living in Newfoundland, I can see now, like, this is not surprising, because, geographically, I treat patients up in Labrador. And so if they need cardiac surgery, or they need trauma surgery, or what have you, just the time delay in getting someone transferred from thousands of kilometres away down to the hospital; that adds time, lack of access to care. I mean, there's so many communities that don't have a doctor there all the time. Maybe a nurse, maybe a doctor, comes once a month, or maybe a nurse practitioner, so you're getting delayed diagnosis. So then, obviously, you know, delaying diagnosis, you have a more advanced stage of your disease, whatever that disease may be. And so you're presenting to Surgery sicker. And as a heart surgeon, when they have worse, you know, aortic stenosis, or worse coronary disease, and everything's calcified, it makes it harder. Like, there were some of the hardest cases I've seen here for, straight-up, like, triple bypass, or straight-up aortic valve replacement, I'm like, "Holy crap," like, "What the heck?" And it's just because there's lack of access to care. So by the time they do get seen by a specialist and worked up, their valve is so severely [inaudible], or their coronary arteries are so severely calcified. Like, technically, it's a [inaudible]. Or they're sicker, right? Maybe their heart is now weaker, which is no good. Like, then it makes it harder for them to get through surgery. So it makes sense that they're going to have a higher chance of having complications or of dying. So, you know, it's the first kind of paper to look at this. We're then, hopefully, going to look at now, you know, like, 1-year outcomes; if there's any differences there between Inuit and non-Inuit. And again, it's just Inuit from Nunavut, because we were able — first of all, Ottawa was kind of the [inaudible] centre for patients from Nunavut, specifically Baffin Island, but then, also, we're able to very accurately identify who are actually Inuit patients and who are not. And so it'd be fantastic to do similar studies at other hospitals across Canada and, you know, also with other Indigenous cultures. But it can be tricky, because then, you know, how do you identify someone who's Indigenous or not? It can be a little logistically tricky, but it kind of tells us what we, as Inuit, knew, but now, when you have something like this written on paper, to actually quote unquote prove it — that there are worse outcomes — then that can hopefully influence policy, right? And resource utilization and distribution and actually, hopefully, effect change that we would love to see, so that all Canadians have the same access to excellent care and equitable outcomes.

Ameer Farooq  42:11

You know, one aspect of this is the access to care and delays to care, but I'm curious, your thoughts — once once, you know, Indigenous folks actually reach care? Are there things that we could do to better serve those patients in the hospital? Like, are there things that non-Indigenous physicians do, perhaps, and often without even thinking, that perhaps alienate their patients or make it more difficult for them? What are some things that we could do to make care for Indigenous patients within the hospital or within our clinics more inclusive and welcoming?

Dr. Donna Kimmaliardjuk  42:56

Yeah. Excellent question. So I've been asked this, you know, a few times by different people in different settings. And so one thing that may seem, like, so basic, but I see it way more than I, you know, should see it, is the use of a translator. So, I mean, that's for, like, any person of any — who's not a native English-speaking person, right? Like, it's so basic, but, like, they need to understand what you're telling them, and you need to be able to understand them, too, right? Like, to take a proper history, and then to express, like, you know, your plan of care. We need to be using translators. And it's not sufficient to use family members, or just to rely on them, or to say, "Oh, well, I don't need a translator," like, "I don't know what's going on." Like, that's so, like, not acceptable. So, I get it; sometimes it's a pain in the butt. It's the middle of the night, or you're busy on rounds, or whatever, but, like, we need to do a better job at that to ensure that we're providing care that the patient understands, and that you understand them. So that's, like, I think, really, something that's, like, tangible that is hopefully feasible that should be done. And I think, too, like, understanding — trying to understand, you know, your patient, whatever their living situation may be. For example, when I have patients from Labrador, or from very small, remote communities; like, something so simple, like, okay, well, I'm going to ensure that I'm not going to use staples in the leg, because I don't want them to have to worry about getting those staples out in 10 days, right? Like, even just simple things like that. I know a lot of hospitals are now looking at including — I believe The Ottawa Hospital's doing it, too — places for patients to, kind of, practise their traditional ceremonies or traditional healing practices. So for example, smudging, which that is done within First Nations cultures — it's not part of our Inuit culture — but, can be very healing for patients; maybe, having elders — I can't remember if that's what Ottawa's doing, but elders are very, you know, respected, too, in Inuit culture and can be a great source of healing, like spiritually, mentally, emotionally, as you're going through your illness in hospital. That's kind of, maybe, more on, like, administrative levels to facilitate that. Something else: Don't be racist as a health care provider. Again, this sounds so basic, but I'll share very quickly here. I was a resident in Ottawa, and I don't want to give too many details, but we were involved in the care of a patient, and as I'm going through the patient's chart, I see that a physician had written in the chart — and so, I'll share this: It was a pediatric patient. They were, like, 3 weeks old, and Inuit. And the physician had written in their chart, "Patient is at higher risk for narcotic tolerance" — or, withdrawal; I can't remember the wording, "because they are Inuit from Nunavut." Like, this is a 3-week-old baby. And it was documented in the chart by the admitting team that the mother had never used drugs, but because they were Inuit, this physician just marked her automatically as a drug user, when it was, like, clearly written that she is not. Like, that's so racist! Like, don't be that guy. Don't do that. That's so terrible. And then I reported it, and it was, like, a slap on the wrist. Like, "Oh, we will do some cultural training." Like, this is ridiculous. So you know, you're just, like — just don't be racist. Don't assume. And, like, there's so many stories, right? Like people come in and they've had a stroke, but they think that they're drunk. Or, you know, Joyce Echaquan was crying in pain, and I don't know if — there was this video. I don't know if you've seen it or heard of it, but nurses had been outwardly racist towards her, and she ended up dying at the [Emergency Department]. Brian Sinclair waited like 3 days on a stretcher in [the Emergency Department] in Winnipeg and died in [the Emergency Department] — another Indigenous person. Like, just don't be racist. I know that's easier said than done, maybe, for some people, but, like, at the end of the day, you signed on to be a health care provider to treat all people. Like, if you're not okay treating all people — and that could go — that could be the same for any minority, whether it be, you know, LGBTQ+ patients, or another cultural minority patient here in Canada. Like, if you're not okay with that, then get out. Like, or give them that — like, it's so — you can hear I'm getting worked up. Like, it's just, it's ridiculous. So those would be very tangible basic things to start with. And then, you know, like this type of thing; like, ask questions, like, go learn, go read. It's actually cool that Newfoundland, like, forces — "forces" — all physicians, when they're renewing their license, that we had to do this online module where we learned about the history of Indigenous cultures that were here in Newfoundland and Labrador before colonization, and, kind of, the effects of colonization and, kind of, what those cultures are now and what their practices might include. Like, that's super awesome, that Newfoundland does that, that it's at least something for people who are not Indigenous to learn about Indigenous people, Indigenous cultures here and, kind of, how that might relate to their health and certain health outcomes or, like, attitudes toward health. Those would be really amazing. But let's just start with, like, not being a racist, and use a translator.

Chad Ball  48:41

We try and end every podcast, as you probably know, with a, sort of, a standard question, and it's always really interesting what our guests have to say, but that question really simply is: If you were able to go back to your younger self, whether that's, you know, starting training, or starting your job, or starting residency, or whatever that is, at some point in time, give yourself some advice, what would that advice be? And what time would that have been?

Dr. Donna Kimmaliardjuk  49:08

Yeah. You know, I've been thinking about this, because, like, if I'm going to be honest with you, and I don't want this to come out as, like, cocky, or, I don't know. And it's probably bizarre, but I honestly don't know what advice I would give myself. And I wouldn't really — like, I wouldn't even ask questions. Sometimes I would just say, "Oh, just keep doing what you're doing." Like, but honestly, I don't know. I've always just felt pretty driven, fairly, like, secure — I don't want to say too confident, because, I mean, I'm not the best and, like, I'm not trying to be like that, but like, secure in myself that, you know, I'm going to get there, you know? The training program is set the way that it is because that's going to make, you know, you're going to be able to be a surgeon at the end of that, like, you know, you're going to be able to do this and that, like, I've just, I felt pretty secure. And, you know, I'm not saying every decision I've made is, like, the best decision but, you know, you kind of — it takes you down a path that I think you're meant to be on. And that sounds maybe a little spiritual, but I kind of believe that, so, this might be a weird answer, but I don't really have any advice. And again, I don't want to sound cocky, but I'm happy with the decisions I've made, and again, maybe it wasn't the best, or maybe I could have made another one, and that's fair. But, the path I've taken has been that path for a reason: to shape me into the person that I am today and to give me the experiences that, you know, make me stronger, better, nicer, smarter, whatever. So that'd be my answer.

Ameer Farooq  50:57

You've been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you like what you've heard, please leave us a review on iTunes. We'd love to hear your thoughts, comments or feedback. Send us an email: [email protected] or tweet at us @CanJSurg. Thanks again.