E94 Mental health and surgery with Rebecca Afford, JJ Sidhu and Morad Hameed
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Rebecca Afford 00:00
Mental illness is so prevalent in our population and more recently, there's been so much more of a focus on it. But yet there is not a whole lot of published work that's out there that is looking at these disparities and looking into this really important patient population.
Chad Ball 00:31
Welcome to the Cold Steel surgical podcast with your hosts Ameer Farooq and Chad Ball. We've had the absolute privilege of chatting with some amazing Canadian as well as international guests over the past year. While the topics have been brought in range, whether clinical, social, or political. Our aims for the podcast continue to remain the same. We hope to inspire discussion, creativity, scholarly research, and career development and all Canadian surgeons. We hope you enjoy our second season as we continue to highlight some incredible guests, deliver detailed masterclass sessions on a myriad of clinical topics and introduce some fresh new features such as debate and companion formats. We hope you relish the podcast as much as we do.
Ameer Farooq 01:31
With all the recent attention to inequities in the surgical community and beyond, sometimes the invisible disparities go unnoticed. Mental health and its impact on surgical outcomes have been relatively poorly studied. And so on today's episode, we invited the authors of a new narrative review on the topic to talk about what they found. The title of the paper is Improving surgical quality for patients with mental health illness, and narrative review, and was published this August in 2021 in Annals of Surgery. Dr. Rebecca Afford, Dr. JJ. Sidhu and Dr. Morad Hameed join Dr. Ball and I to discuss mental health and its impact on surgical outcomes. We would love to hear your thoughts. What is your institution do to better manage surgical patients with concomitant mental health disease, email us at [email protected] or on Twitter, @CanJSurg.
Chad Ball 02:26
We're so excited to have three really, really interesting guests on Cold Steel today. Thank you to each of you for joining us. I think we're going to talk about a really important topic here. Before we do that, though, I would love it if Rebecca followed by JJ and then of course, you know, friends and listeners to the show no more at me very well. I was wondering if you could introduce yourself and just sort of give us your career path and how you ended up in BC.
Rebecca Afford 02:56
I'll get started. I'm Rebecca. I'm currently an R2 in the general surgery program at UBC. I did my undergraduate training at Queen's University. After growing up in Nelson, British Columbia. I took a year off actually after my undergraduate degree and I lived in Australia. But afterwards, I was accepted into UBC for medical school. And I did my training in the northern medical program in Prince George.
JJ Sidhu 03:26
And I'm JJ. Sidhu. I'm a psychiatrist, console liaison psychiatrist here in Vancouver General Hospital, which means I mainly work on the medical and surgical units. I'm also the department head for psychiatry. We're acute in community and the Medical Director for mental health and substance use here in Vancouver acute tertiary and urgent services.
Morad Hameed 03:55
Hey, Chad and Ameer. It's Morad Hameed. I am a trauma surgeon intensivist at the Vancouver General Hospital and the head of the Division of General Surgery at VGA at the University of British Columbia and just wanted to say how thrilled I am to be with you both and with this team. Thank you for having us.
Ameer Farooq 04:17
Well, as always, we're always delighted to have you on the show. And our listeners love having you on the show. And we're so delighted to have J.J. Sidhu and of course, the illustrious Rebecca Afford on the podcast with us. And we really have a great topic lined up for us today. And we're going to send her our discussion mostly around a paper that's published in the Annals of Surgery. Rebecca, you're the lead author on this paper and congratulations again for all the hard work that you put into this and for getting this published and accepted to Annals. What exactly interested you in this topic and why did you get into this?
Rebecca Afford 04:54
I just like to start out by thanking everybody who is co-authors with me. It would just not be possible without them. And I'm really excited for this paper to undergo publication. In terms of the title of the paper, it's called Improving surgical quality for patients with mental illness and narrative review. And what it is it's this is a systematic review, looking at patients with mental illness and their surgical outcomes and how that compares to their counterparts who undergo the same surgeries, but do not have mental illness and the disparities in their care. How I got interested in this topic? I think, started predominantly when I was on trauma. And that was my very first rotation of residency. But what I started to notice on trauma is that some people presented to the trauma bay, if they had a gastric illness, sometimes when they rolled into our trauma bay, that was their first presentation of their mental illness. And unfortunately, it ended in a trauma that we would manage. And the other part of that was also in seeing firsthand their post-operative care. And just anecdotally seeing that these patients staying a little bit longer in hospital with post-operative complications, and I really didn't understand why.
Chad Ball 06:13
That's a great story Rebecca and I think we all know that research projects that come to fruition are published in targets, like Annals of Surgery usually start, the the seed of them is usually something that we see that's clinically interesting or unexplained on the ward or in the operating theatre or in the hospital in general. So that's great. I'm going to focus you a little bit here and ask you some specific questions. So, one of the interesting things about this review is that it's a narrative review, rather than a systematic review. I think, certainly more than I have published a lot of those. And I'm sure J.J. has too. Can you explain to our listeners what may be the difference? What makes this a narrative review as opposed to a more traditional, either meta-analysis or systematic review?
Rebecca Afford 06:58
Yes, so what we did with this paper was do the classic review and in looking through the big databases like Ovid, Medline and the Cochrane Review files, and we ended up pulling those papers and looking through abstracts, like you would in systematic review. But from those papers, what we ended up doing was looking for underlying themes and recurrent trends that kept coming up with the papers.
Chad Ball 07:34
What were some of the holes in the methodology or some of the concerns you had that you described in your manuscript?
Rebecca Afford 07:44
So in terms of things that we found that were holds was; overall, we were only able to find 19 papers, that gave us a good idea, or that had a good look at comparing surgical outcomes between patients with mental illness and patients who did not. So mental illness is so prevalent in our population. And more recently, there's been so much more of a focus on it. But yet, there is not a whole lot of published work that's out there that is looking at these disparities. And looking into this really important patient population, I think that would be the largest thing that we found. Another thing that we found is a lot of the papers that are out there are looking at specific cohorts, such as bariatric surgery where psychiatric care is a big part of their surgical process in terms of preoperative planning, and post-operative counseling. But that wasn't exactly the patient population that we were looking for and that we were targeting with our definition of mental illness.
Chad Ball 08:56
Yes, that's well stated. J.J., can we ask you, what's your sense over a longer period of time maybe then Rebecca has been involved in this topic. As to why there is such a paucity of sort of well described studies and I would suggest maybe even study in general, in the overlap between surgical care and mental illness.
JJ Sidhu 09:19
Yes, that's a really interesting question and in my particular area, and psychiatry, it's a challenge in itself. We're often looking for papers that describe the patient in front of us where we have a medical or surgical condition and a mental health condition that are interfacing. But when you look at the papers, many of the studies exclude unwell, patients that are unwell, if they're looking from a physical health standpoint, if you're looking primarily at a mental health outcome, we'll exclude those patients that are over the age of 65. So the group or the patient population that we're often seeing in hospital is not what historically, researchers have been examining. So much of what we're seeing in terms of literature is pioneering probably related to that reason. I think, as mental health is now becoming more of a discussion, point in the media, in society at large and even within healthcare, people are asking these questions. So my hope is that we're going to be seeing more of these papers.
Ameer Farooq 10:40
Yeah, it's such an interesting and rich area of study. And I think you find a lot of benefit from actually studying the intersection of two different fields. And in some ways, it's kind of surprising that this hasn't been done more. And one of the things that I found super interesting from the study was the outcomes were quite dramatic for an interview. The differences between patients with mental illness versus those that didn't interview surgical outcomes. To get to quote one data point from the paper, we talked about the fact that the incidence of perforation in appendicitis with patients who had schizophrenia was 53 to 66% of patients with mental illness, compared to 17 to 30%, and controls in one included study. The review highlights so many different ways in which surgical care and surgical outcomes continues to be a problem for patients with mental illness. And I think we're unique to have you on this team as someone who gets to straddle both those worlds and is involved in both of those sides of that equation. So, can you break this down for us a little bit? Is this a provider problem that we don't know how to deal with patient illness? Or is this a patient problem where patients don't have access to care? Or a bit of both? Can you break that down for us a little bit more J.J?
JJ Sidhu 12:03
Yes, great question. And it's probably multifactorial is my sense. I probably look at it more from a patient perspective, provider perspective, and as social or systemic level, at a patient level, certainly there are inherent aspects of the individual's condition or symptomatology that might be making access to care an issue. Patients might present with anxiety or even paranoia that could really make an examination of the patient difficult. Many individuals who suffer from mental illness have had trauma through the healthcare system. And that speaks into some of the stigma or the structural stigma that's embedded within healthcare. There's also issues with lack of insight in some particular cases, associated with certain conditions that also make presenting to other medical providers an issue on a provider level. That's something that might manifest in the form of under estimating risk associated with mental illness and surgical outcomes. If somebody is stable with depression or schizophrenia or appears to be and they're coming in for an appendectomy, or some sort of surgery, we might say, okay, maybe there's not a lot of risk and whereas there's potential for some of these medications complicating postoperative periods and whatnot. So those are those are things to take into consideration. Lack of screening for mental illness and that's fairly a pretty common thing in health care. It's the way that we're set up we're somewhat siloed. So, you know, people, understandably, so people are coming in for surgery, we're really focused on the task at hand. And sometimes, or often we're not considering things like mental illness or depression or some of those other aspects might be on the chart, but in terms of how we're managing it in front of us, it might not be a priority in the moment. At a systems level, we have issues. We have people with mental illness struggle with a lot of the issues with social determinants of health, such as poverty, or higher rates of poverty, higher rates of housing, security, insecurity, even food insecurity. People with chronic mental or psychotic illnesses, you might find them in regions that are where it's challenging to access healthcare as well. So, there's a whole host of issues that I think make it access to care a challenge. You know, interestingly, bariatric surgery was not included, as a population in this particular paper, I was connected to a bariatric outpatient clinic here in the Vancouver region. And I did a lot of screening of folks that were considering those related surgeries, and I was blown away by the amount of depression, the amount of trauma, past history of sexual abuse in that population and certainly, this impacted outcomes. We know that people with depression are less likely to be compliant with all forms of medical treatment. So, there's an association there. People who have had that type of trauma also, the follow up might be difficult, interfacing with their care providers postoperatively. So, some people get lost to follow up. So, some of the inherent challenges I think.
Chad Ball 16:43
There's so many great things in what you just said that we could potentially unpack, but I want to drill down if you have time on a couple of them. From a simple sort of surgical brain like mine, intuitively, it seems clear that the reason for example, preparation with a bowel obstruction or appendicitis, for example, would be more common in patients with mental illness seems to be related to a lot of the issues, you talked about delay in presentation, delay and care and so on. But the equivalent part of it that really is interesting, to me is the back-end component. So, to look at these patients, in terms of hospital acquired issues, whether that's overall sepsis rates, infection rates, acute kidney injury, ICU admission rates, I mean, Rebecca's list is quite long, in terms of them having poor outcomes. I'm curious when the rubber meets the road, in the hospital, why do you think that truly does happen? And then potentially, some of the things that were clearly missing as a surgical or medical or post-operative care team.
JJ Sidhu 17:56
I think when people are coming into hospital and have a history of mental illness, the literature does show that, and I think we mentioned it, even in this study, that people are less likely to order diagnostic tests, patients are less likely to get certain interventions. Why that happens, it's one can speculate, but it probably relates to impart some of that stigma that we see toward mental health clients. It also speaks to some of those challenges that I mentioned around examining the patient. The conditions themselves have an inherent there's some inherent differences. For example, schizophrenia, we know that glucose, metallic metabolism is somewhat different. There's some changes there, inflammatory or inflammation and wound healing is different in patients suffering from significant mental illness. There's also associations with multiple medical or different conditions have higher rates of mental illness. We'll see that in neurological conditions and in arthritis in diabetes, or cancer. So, you're more likely to have depression or anxiety and we can understand that. That makes a lot of sense. Just a lot of face validity there. Comorbid substance use that makes it challenging in terms of 1) the management of patients who are in hospital, they might be struggling with addictions, issues withdrawal aspects adherence. care. And then the medication side effects. So the medications that we prescribe, especially in psychotic illnesses can be pretty heavy duty. They come with a whole host of side effects, including metabolic disturbance, you'll see potentially increased risk of aspiration, cardiac arrhythmias, increase levels of potential, or sorry, a decrease in seizure threshold. So all these aspects could potentially contribute to a worse outcome in hospital.
Chad Ball 20:38
You know, one of the things that Ameer and I were really excited to ask you specifically is, I think on the trauma side of things, the injury side, the MRI services, we work with our psychiatric colleagues very, very closely. I can't think of a day where we don't have a psychiatrist, for example, at the Foothills Hospital, wandering by the trauma where they're always involved, as you point out and a large percentage of our patients, but I'm not sure, thinking about the work Rebecca has done that we do as good a job for the emergency general surgery or access services and from there, I can take it even beyond that to, as you would guess, orthopedic surgery or, for example, plastic surgery, a whole bunch of inpatient, you know, general hospital services. I'm curious what your biases in terms of when you like to be called, who you like to be called about, and how you view that interaction with surgical services in general? Again, my bias is that we're probably underutilizing an under consulting or our mental health experts like yourself.
JJ Sidhu 21:46
Yeah, fair enough. I joke, I wear a half joke, I say surgeons are most surgeons I've met him would make excellent psychiatrists. you go deal with scenarios where people are really facing some of the worst circumstances in their lives. And the amount of compassion that I've seen from surgeons that I work with and the surgical residents, it's quite impressive. And in terms of the question around consultation under consulting or whatnot, that's an interesting question. Larger institutions will have psychiatry or services that will, or consultation liaison services, like we do here at Vancouver General Hospital. You might not have that at smaller centers. So, I guess, this concept of resource scarcity, and maybe you don't want to overburden a consultation service, it might be that feeling or perspective, there might be that it might also feed into that, under recognition of illness, or the feeling that a stable psychiatric condition doesn't warrant calling a psychiatrist. But there are scenarios where I think even in a situation where we have, quote, unquote, stable individual, that it might be worthwhile getting someone like myself involved. A concrete example would be perhaps a patient who has schizophrenia and is on the antipsychotic clozapine. Clozapine is a somewhat complicated medication; we use it in those individuals that have refractory psychosis or have been through a few other medications and they've both have not worked. In states of inflammation which could occur during your post-operative period, clozapine levels will increase, and this may manifest in over sedation and increase things like the risk of aspiration, so this is something we're commonly seeing patients and it's not always recognized as a concern. So, a lot of teaching occurs with some of the other specialties unfortunately, we were lucky that we have really good relationships like our surgical colleagues and whatnot. So other times we're quite comfortable of home surfaces and surgical services, having a go at trying to manage situations and if they're comfortable with that and need some backup or just a quick call, we're happy to guide folks through different scenarios. At VGH, we feel really lucky. I first met Rebecca, on our service, she rotated through the consultation, we liase on surface at VGH. And historically, at least for the past decade, and I think even longer, we've had psychiatry residents come through, but we also had first year surgical and first year neurology residents come through our service. And this is great. We really enjoy having these off-service residents come through, and hopefully they learn something, and we jokingly call it delirium bootcamp for the surgical residents. We keep it pretty focused on things like delirium, management, and management of sedation and related things that would be helpful for a surgeon, in practice. Our perspective is, surgeons want to operate, and we want to keep them in the operating theatre. And if we can impart some things that would help them do that and manage patients on the ward quickly then, and effectively then see it as a, as a good thing. But another really great benefit of it is getting to know us and building up the relationships between services. So, Rebecca is no longer with us and it's been a while, but she has these connections to the psychiatry service and my hope is that it’s much easier to consult us to pick up the phone. Our senses that, many of the things that happen are positive in a very large system, are relationship based and in a big center can feel small. And in the end, I think that's a positive outcome for the patients. That's kind of a long-winded answer to your question, Chad. Really, I think it speaks into, we’re always happy to help our colleagues, that's what we're here for is as a consultation service, but we're also keen on building capacity in teaching others and teaching people, teaching other folks how to fish and breaking some of those barriers to care such as, through relationship. Fostering relationships.
Ameer Farooq 27:56
Yeah, I just want to comment, having come from Calgary, and having seen the console, psychiatry liaison service, it's really a great service. I think it's not just the service that we call for when people have suicidal ideation, which is sort of the mental model that I had coming out of residency. Really, the service has been so helpful in a variety of situations, such as post-operative delirium. And so certainly, I've learned a lot from seeing the console service, see my patients here and fellowship, I think it's time now to really roll into to getting a broader discussion on where do we go from here? Where do we take these results, which I think many of us probably felt intuitively makes sense, right? I think we've all had those experiences, like Rebecca talked about at the top of the podcast, where we see how mental illness extends or intersects with so many of the outcomes from surgery and in medicine in general. And so, I think it now's the time to really kind of dig deep on where do we go from here? So, Rebecca, you have a great table in the paper at table two? That kind of outlines some of the potential solutions and strategies for mitigating these negative outcomes in broad strokes. Can you kind of walk us through some of the main strategies that one might propose to help mitigate the inequities in care?
Rebecca Afford 29:23
Yes, so for each theme that arose during our narrative review, we came up with potential solutions to address each of these. So, our first thing was access. So how can we better get patients to come to medical services with their surgical illnesses, and we found that part of that would be relationship building and making sure that patients feel comfortable coming to the healthcare system with their concerns. And part of that would be creating a primary care home for these patients. Where they would be able to have their age specific screening done for them to have their mental illness, care kind of liaison between their community health, mental health care workers, as well as all of their other medical concerns that may be underlying there, as well as, as Dr. Sudo pointed out there, they often have comorbid medical illnesses as well. And treating mental illness like we would for any other type of medical comorbidity. So, for patients, let's say that have diabetes, we want to make sure that their diabetes is optimized before they come into surgery. So, making sure these patients’ mental illness is optimized in the same way that we'd be monitoring it even is and their glucose, preoperatively and postoperatively, we'd have that same kind of model for their mental health, illnesses as well. And part of that, to me, engaging them in their care is also calling on their social supports, whether that's family or friends, to help them to support this individual throughout their care. And having those family and friends and their social network. They're both as allies in their care and both as allies for us to turn to when we need some help, or guidance in their loved ones care. And then second would be the outcomes part of the themes that came up in our narrative review. So, knowing that these patients are predisposed to worse, post-operative outcomes, making sure that the entire surgical team, so residents, staff, nursing, OT PT, are all aware that these patients are predisposed to that. So having an education piece around monitoring and providing prophylaxis whenever possible to prevent any negative outcomes that these patients might face in their hospital stay. And because they are, especially in our big, tertiary quaternary centers are very supportive in terms of all of the allied health care professionals that are available to them. Also using that as a way to engage them back to community and having those types of community supports, both for their surgical concerns, their mental illness concerns, as well as building that primary care base for them to build the rest of their healthcare and future feeling from.
Ameer Farooq 32:40
Dr. Hameed, I really want to get your insights now as to where we can go with this. You know, it's interesting when we think about, for example, internal medicine and the preadmission clinic, that it has sort of wavered, right over the years, I think we had a much lower threshold to send people to the pre admission clinic, do you have them optimized for their various comorbidities? And maybe now we're backing off on some of the testing that we used to do, but clearly in other areas, were things are not being well looked after, such as mental illness? So how does this get properly operationalized? For a Department of Surgery, should everybody be seen by our screen for psychiatric illness? prior to getting an operation? Where do you kind of see things going on a cultural and organizational level.
Morad Hameed 33:31
I've been interested in the social determinants of health for a long time. And our groups over the years have done lots of studies, measuring problems with access to care or outcomes of care. In areas like violence related injury, or multi system trauma or critical care or acute care surgery. We've measured the risks of having those conditions based on the social determinants of health. And we've also measured access to health systems, like trauma systems, for instance, where we identified that 7 million people in Canada don't have access to early access to level one or two trauma centers within the golden hour. And when we wrote those studies and published them, it seems so big and so alarming to measure disparities and to show that these disparities exist, to confirm our feeling that there are disparities, even in Canadian healthcare. But now, just measuring it is not enough, like after the measurement comes the real hard work of actually changing things. And that's always been daunting, and maybe an insurmountable challenge to us. But I think what we're seeing now and JJ refer to this is that we're at this moment in history where it's no longer acceptable just to measure disparities without doing something about it. I mean, we have Black Lives Matter and anti-racist movements and the Me-to movement. And what we learned from them is that's just the first step of a tough struggle to change culture and to actually change, experience and reduce disparities. And one of the things I loved about Rebecca's approach was exactly that table two, which is, the paper says: Here's these, glaring disparities according to mental illness. But here's what the papers say that we can do about it. Things like, multi-disciplinary approaches, or disposition or study and community-based resources. So that's the start. But then, how do you do this? How does a busy surgeon, actually execute on this to actually change the experience, the access, the outcomes of patients? And I think part of it is being sensitive to them and being aware of these problems. But I think the other part is exactly what you said in here. It's team building and systems redesign, I think we really have to fundamentally change the way our teams interact and redesign our systems. And that is the way that a busy surgical service can potentially sort of bend, bend the arc of this problem with disparities and mental illness being one of them. And so in BC, I'm sure you're aware about this, but the BC Patient Safety and Quality Council has a health matrix for quality. And so, every surgeon cares about quality. The thing is, how do you define quality, and that group defines quality as the normal things that you'd expect, like safety, appropriateness, efficacy, efficiency, things like that. But within that same framework, there's other dimensions of quality, like, accessibility, respect, equity. And so if we take an approach to quality, that includes things like accessibility, respect and equity, we're starting to redesign a different kind of health system. And, in fact, the American College of Surgeons, and the NIH released a statement that without access, there is no quality, like, how can we even measure the performance of our systems, if we're not ensuring that everybody gets access. So basically it's not a nice to have or luxury, it is fundamental. It's a foundation quality, to ensure things like access respected equity. And so in our, in our group in our division, our health systems redesign has taken the form of something called value based healthcare, in which what we've done is we've deconstructed our division, at least at VGH, and in St. Paul's into 16, small, multi-disciplinary units. And each unit is charged with creating objectives and key results, and then collecting data to measure performance on his objectives and key results. And we also have in our division, as you know, many part of it, that cultural Safety Committee, and each of our clinical units is or will be advised by our cultural safety committee about collecting at least one metric on equity access, social related outcomes. And I think there's something really potential there. But again, those units will measure these problems, perhaps, and they can draw attention to them, but then how do they actually change them? And, we started there for a while, but what we realized is we don't have to do it alone. Every hospital has physician led quality improvement programs or team-based quality improvement programs. A lot of hospitals now have diversity, equity, inclusion offices and Aboriginal Health teams. So once you create a framework within your group, you can then tap into resources in the environment that will help to provide a sort of a more holistic approach to addressing disparities. I don't know if that makes sense Ameer and Chad, but that's kind of the direction of our thinking and what we started to do to try to really take some of these lessons and make a difference with them.
Chad Ball 39:44
Let me divert it to the question I asked you often, I think on a lot of different topics over the past couple of years on this podcast. How do you get started in an environment where you don't have an informed, nuance leader like yourself, maybe you're in a small town in rural Canada? Maybe you're in Calgary. As you know, JJ sort of insinuated without a psychiatry team available to you. How do you get folks motivated and get folks started? And then also, as I always like to ask you, how do you address maybe the naysayers who don't see the foundational importance of this topic that surrounds mental illness, as you and as many of our larger surgical societies have now begun to comment on.
Morad Hameed 40:38
In my life, I've been blessed to work with people who always ask why not? And let's go, let's do it. I include everyone on this podcast, in that category. I think, optimistically I think everybody wants to do the right thing. And a lot of people put on their website, what they know, the right thing, they have statements about DEI, about Aboriginal health. And so, there's a will to make healthcare more equitable. And it is, you could say, it's one of the core principles of Canadian health care, or health care in general, that, I know, trauma systems, and there's certain systems, identifying vulnerability, and caring, and caring for it is a fundamental priority. So, there's a will to do it. And I think that, as grassroots providers, we have to hold people who draft these statements accountable to those statements. And, I used to think that, if you take a problem to administration, they'll help you solve it. But what I'm realizing more and more is that you have to come with a pretty finished solution and do it on a shoestring budget. They'll endorse your hostile leadership or endorse it, most likely, because they want to see it done. And then they might find some inclined resources to help you or they might link you to other providers with an interest in this area, or you might find some sparks of creativity in the group around you. And I think that's how these team-based quality improvement activities start. You sometimes want to get a grant, or you expect to budget for this. But you can do a lot by tapping into the creativity around you and bringing people on board to solve these problems that's, I guess, kind of a theory because we're only starting down this pathway. But we've certainly seen, a tremendous amount of support for this, not only in our hospital, but across our health region. I think people respect what, physicians and what surgeons say a lot, and if we are passionate advocates, it's very hard for someone to say that's not an important priority.
JJ Sidhu 43:10
Yes, if I may comment, JJ here, you know, the findings of the study, I think, are studies like this will resonate with many people. These are big numbers. These are big differences and disparities, mental health issues, being ubiquitous, every family every person, probably know somebody who was gravely impacted. And if people are coming to hospital and their outcomes are negative, much more negative compared to the average person, I think, my hope is that people are going to pay attention. Just looking at the lifespan of individuals with significant mental illness, it's in the order of 10 to 20 years less than the average Canadian. To me that number has always been shocking. And that's, in a country like Canada, if we're putting these kinds of numbers in front of people, my hope is that individuals and systems and physicians regardless of department, will galvanize and say hey, listen, this is something that needs to be addressed. And that hopefully lead to some sort of impetus to start some grassroots initiatives and in various hospitals and even those people working in small centers, have loved ones that are struggling and illness and regardless of what specialty you're in, you know, we have this perspective, we all do. If we do well, when everyone around us does well, and I mean this from the perspective of different departments and whatnot. So, what we want it's something that I think that potentially can gain more momentum, the more attention we place on it and such. And so, papers like this that are coming out and now into the surgical realm, hopefully start those discussions.
Ameer Farooq 45:27
Want to push back a little bit, JJ. I think everyone on this call agrees that this is an important problem. But I think part of what discussion we're having today, and it's something we've kind of skirted over, is a little bit about this stigma around mental illness, and maybe even around mental illness amongst surgeons. I mean, when is the last time any of us, Rebecca, Dr. Hameed, Dr. Ball has ever talked to our colleagues or know colleagues that have acknowledged their own, perhaps struggles with mental illness? That's not something that we particularly, in the surgical field, talk about, because, I think we all to some extent, and again, I'm generalizing here a little bit, but I think to some extent, we all pride ourselves on being able to deal with these tough circumstances, both in our training and then having to make decisions in tough situations, both in before, after, and during operations. So, mental illness isn't something necessarily that comes up often in conversation, I will go out on a limb and say that I think it's still stigmatized, somewhat in surgical, in the surgical community, even for surgeons themselves. So, what do we do to actually help reduce stigma that surgeons might have towards patients, perhaps with mental illness, or even just the concept in general? And maybe, JJ, you could comment? I don't know if you have any surgeons as patients, obviously, without getting into specifics, but what are some things that maybe we could do surgeons attitudes that surgeons have, that we could work on? To try to reduce that stigma that we have?
JJ Sidhu 47:11
Yes, it certainly is a stereotype the surgeon, the old school sort of surgeon that that's tough as nails and no matter what is going to keep up that persona. But, you know, I see things shifting, I do see things shifting, again, I have that privilege of working with certain young surgical residents. And the changes that I'm seeing would likely mirror what's happening in society at large, like one, not that long ago, people were, and this is still the case, we're not very comfortable to discuss their mental health issues or challenges. But in this younger cohort of individuals, that dialogue is shifting to the point where people are quite open about their challenges and are actively seeking help, much like they would for any physical condition. And it's really refreshing. On another level, I don't know if our healthcare system is ready for that, given the ubiquitous presence of mental health conditions and the volume that we're anticipating of those seeking care which really is a good thing, though. In terms of, I didn't even mention before that like half-jokingly, that many, many surgeons that I see would make excellent psychiatrists and they've all if you think about when people come to hospital, they're often coming really in the worst periods of their life. Nobody's coming to hospital if they don't have to, and certainly not for really positive things. And people are terrified, and people are suffering the word either about their own conditions or their loved ones. And surgeons are at the forefront of that. The ones that are interfacing with these individuals and are being managing these really tough situations. So, it does feel like that dialog is shifting. I have colleagues that approached me in the hallways and might be by about their loved ones, but that opens up a dialog that opens up some discussions and you get the sense that people are recognizing the importance of managing their own mental health. COVID has really accelerated that discussion. I think it's out in the open how COVID has impacted the healthcare system from a mental health perspective from a quote unquote burnout perspective. And people are savvy to that. This is an issue and if we don't pay attention to it, I might succumb in some way to those concerns. So, there is that shift in dialogue that's occurring. There are those that don't want to speak with it and are going to bury it and maybe feel like, if they open up that door, things might not look really good. And that might lead to some sort of negative follow? You know, my hope is that there are our leadership of the respective hospitals and institutions are putting things in place that are making it easy for people to reach out if, if they can, but it's a challenge for sure.
Chad Ball 51:06
I think that's beautifully said JJ. And, you know, in any closing, I'd like to thank you and Morad and Rebecca for your time today. It's been a real pleasure and I think this is a topic that we can only listen to, and chat about more and more as time goes on. I'm sure the podcast will be very popular. Rebecca, in terms of closing, I'd like to finish off with you. Ameer and I want to ask you, specifically, if you could leave our listeners, maybe with one or two Sentinel thoughts, and things to think about on rounds tomorrow, or in the operating room tomorrow or in the trauma bay or in the emergency department tomorrow? What would you pass along? And thanks again.
Rebecca Afford 51:49
Thank you so much for having us on. I think from doing this review, my biggest take home points would be in meeting patients with mental illness, whatever that may be in your clinical setting. To meet them where they're at, to listen to their concerns, and just take those extra few minutes to listen to how their mental illnesses, is affecting their current presentation of you and understanding that they may have a history of not having the best health care previously due to stigma around their mental illness. And it can be big and brave for them to be coming to you and asking for help and meeting them like you would meet any other patient. We're very lucky as surgeons to meet patients in times of vulnerability when they're really needing help. And using that moment to both reach out to them for whatever logical reason that they're coming to you but also in respecting that they have a mental illness and that is going to be a big part of their care and asking them what you can do to help them with whatever care comes next in their health care journey.
Ameer Farooq 53:16
You've been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you've liked what you've been listening to, please leave us a review on iTunes. We'd love to hear your comments and feedback. So, feel free to email us at [email protected] or connect with us on Twitter @CanJSurg. Thanks again.