Dr. Tavis Apramian: Resident’s Research Highlights Barriers Residents Face in Learning Advanced Care Conversations

“Learner-directed funding is critical to build skills in team leadership and direction and to create unique projects that tackle issues that learners themselves experience. I’m grateful to PSI for having the foresight to develop the next generation of scientists and education scientists in a deliberate way through the Resident Research Grants.” – Dr. Tavis Apramian

As both a learner and a researcher examining medical education, Dr. Tavis Apramian says he sometime felt as though he was navigating two worlds. During his residency in family medicine at McMaster University, he led research investigating how family medicine residents learn how to advance care planning conversations, with the goal of eventually improving education and training around this skill set.

“Studying medical education while acting as a learner is a little bit like living two lives at once,” says Dr. Apramian, now a palliative care fellow at the University of Toronto. “It helps me put some of the challenges I face into a broader systemic perspective, but it can also be challenging when I know that more evidence-based educational practices are available, but they might not be applied in a given situation.”

Dr. Apramian has long been interested in learning patient and physician stories and using storytelling to improve patient care. He studied English and biology at Carleton University and Narrative Medicine at Columbia University. He then focused his career on research and medicine, completing a PhD and MD at Western University.

When Dr. Apramian started his family medicine residency at McMaster University in 2019, he wanted to undertake research on medical education to try to affect positive change in how medicine is taught. He was specifically interested in how learners gain skills in advance care planning conversations, which require a complex skill set and are not typically taught in medical school.

Advance care planning conversations are often iterative conversations meant to help patients, typically with serious illness, understand the course of their disease, consider their values as they relate health care and make decisions about their future care.

Research has shown that fewer than 40% of family doctors regularly have these conversations with their patients with life-limiting illness, which suggests that residents may have limited opportunities to observe or participate in these conversations during a family medicine residency.

In 2020, Dr. Apramian received a PSI Resident Research Grant to investigate how family medicine residents learn to approach advance care planning. Working with Dr. Erin Gallagher as mentor and Dr. Michelle Howard as senior author, Dr. Apramian and the research team interviewed residents about their experiences to better understand if and how residents are learning these skills during their training and the factors that shape how they are taught these skills.

Residents face unique barriers to learning advanced care planning skills

Previous research has found that advance care planning conversations are challenging even for experienced physicians. These conversations are time-consuming and may take place over several appointments, and physicians often lack the time or flexibility in their schedules or access to clinical records to have these conversations effectively. In addition, physicians and patients often have cultural aversions to conversations about death and dying.

In the interviews led by Dr. Apramian’s team, residents described facing these same barriers, plus some specific to residency: lack of authority to shape clinic flow and schedules, short-term relationships with patients, navigating their preceptors’ clinical priorities, lack of encouragement from their preceptors, and limited opportunities to practice.

“The interviews demonstrated that the preferences and principles of family medicine preceptors affected how much time, energy, willingness and supervision that family medicine residents had to practice this skill set,” says Dr. Apramian. “These are really complex skills that require iterative and adaptive conversations. There’s certainly no training on advance care planning in medical schools, and little didactic or deliberate practice in the workplace once medical students reach residency, which is concerning.”

Importantly, the research team noted that, without this training in the primary care setting, many residents shifted to learning related skills during emergency department or internal medicine rotations through practising goals of care conversations, which are focused on an immediate clinical decision in a time of acute crisis.

“You can’t have conversations about values when patients are scared and uncomfortable and with physicians they don’t know or trust,” says Dr. Apramian. “I hope that what we found in our study will lead to more deliberate thinking about how to help residents practice the skill of building illness understanding and eliciting patients’ values in a family medicine setting.”

With the team now publishing and presenting the results, Dr. Apramian hopes that more awareness of the gaps in education will lead to changes in training that dedicate more time to practising this skill to increase future physicians’ comfort in leading these conversations and ultimately helping patients experience health care more aligned with their values. In his fellowship at the University of Toronto, he is planning to continue this research to examine advanced care planning in other clinical domains, including pain management.

Dr. Apramian says that the funding from PSI Foundation was critical to his research and has helped him to build a research program focused on medical education and the dynamics between learners and their supervisors.

“Having my own funding allowed me to hire team members to move the research forward while doing my residency,” he says. “Getting this grant allowed the research to continue and improve over the course of my residency in a way that wouldn’t have otherwise been possible.”

 

2022 PSI Symposium Recap – Improving the Health of Ontarians: Past, Present, and Future

After two years of pandemic push back, PSI opportunely welcomed back our grantees, committees, and doctors to the 2022 PSI Symposium. This year’s symposium included a full day of PSI activities, including a resident presentation by Dr. Raed Joundi, open-floor and roundtable discussions, and three certified and accredited educational presentations* by Dr. P.J. Devereaux, Dr. Deborah Cook, and Dr. John Marshall. 

The day commenced with PSI president Dr. Robin Walker giving his opening remarks for the first ever in-person symposium since 2019, updating attendees on PSI’s 2021 impact report and activities during the COVID-19 pandemic. Notably, PSI began a COVID-19 funding stream to maintain support for our researchers during the pandemic, all the while giving a one-year blanket extension on all research funded during that period. PSI also increased grants funding support salaries through the PSI Graham Farquharson Knowledge Translation (KT) Fellowship award. 

PSI’s focus on Equity, Diversity and Inclusion (EDI) was discussed by Ms. Giselle Bodkin. Commenting on the state of EDI at PSI, Ms. Bodkin stated: “if you don’t consciously include people, you unconsciously exclude them” – our slogan to intentional inclusion as a research grants provider in the Ontario healthcare space. Ms. Bodkin walked us over the steps PSI has taken so far, including having grantees self-identify in order to analyze the statistics and fill in any missing diversity gaps with such data. With the newly instated EDI committee, PSI hopes to create a more inclusive, diverse space for our grantees.  

PSI Governance Committee Chair Dr. John Drover presented a governance update, including what the committee will be focusing on for the next year. Dr. Drover’s focus is on revitalizing the governance committee to be more effective in support of research in Ontario. In regards to revitalization, Dr. Drover told the symposium that “we’ve been focusing on [next steps] to move us into the future.” This will be achieved in partnership with external firm Overlap Associates by utilizing strategic planning exercises in the upcoming months.

Our first presenter, Dr. P.J. Devereaux of McMaster University, focused on his Perioperative Care Program. 

Dr. Devereaux discussed perioperative cover (silent) stroke and its association with perioperative and 1-year outcomes, understanding the effects of perioperative aspirin, and research for the relevance of atrial fibrillation and chronic incisional pain. 

Our second presenter, Dr. Deborah Cook of McMaster University, gave a heartfelt presentation on how opportunities for early career investigators make a difference in their career: including how PSI helped to fund one of Dr. Cook’s studies early on in her career. “In most studies, the same senior investigators do the work. PSI focuses on enabling new investigators – I was one of them. It was the first validating grant I’ve received,” she noted. 

Dr. Cook commented on PSI’s support for her over the years, stating that groups have an organizational culture. “I think of the way a personality is to an individual, organizational culture is to a group,” she said. “I was struck early on by the open-minded, communicative approach of [Executive Director] Sam Moore through PSI, and learned a little more of the organizational culture beyond the myth and the vision that is being actively refreshed.” 

Dr. Cook then focused on three women physician-led PSI funded studies that made impactful changes in the critical care realm: including Dr. Jennifer Johnson’s study on probiotics in the immunocompromised, Dr. Joanna Dionne’s study on diarrhea, and Dr. Brittany Dennis’ study on end-of-life care during the pandemic. 

PSI Resident Research grantee, Dr. Raed Joundi, presented his 15-year study on temporal trends in stroke incidence and outcomes in Ontario. Dr. Joundi thanked PSI for the support he received, which he ascribed as vital to establishing his career early on. 

Presenter Dr. John Marshall of University of Toronto spoke about PSI’s three decades of support in his research, and how, as he stated: “support from PSI Foundation has been critical to allow [him] to move forward” in his research since the early 1990s. His presentation included the topic of how biomedical research in critical care can change medical practice and patient lives. Dr. Marshall’s first funded research project looked into the role of gut liver axis in the pathogensis of Multiple Organ Failure. “I see PSI as the seed that can allow grant visions to take shape…my first funding came from PSI Foundation,” he said. 

Dr. Marshall spoke of the importance and “extraordinary power” of collaboration; especially that of PSI’s collaboration with grantees, peer reviewers, and researchers; and how it is vital to furthering the world of medical research. With the analogy of the Hubble Space telescope and an “unprecedented collaboration of scientists,” Dr. Marshall connected PSI’s grants funding streams to how PSI has helped further research – especially during the COVID-19 pandemic. 

A panel discussion was then hosted by panelists Dr. John Marshall, Dr. Andrea Gershon, Dr. Naana Jumah, Dr. Ishrat Husain, and Dr. Deborah Cook. This discussion was based on key guiding questions, such as ‘what the future of physician-led medical research should look like,’ ‘what role physicians should play in shaping the future of medical research,’ andwhat the greatest challenges and opportunities facing clinician researchers are now and moving forward.’ PSI has taken into account the feedback provided to us from these needed discussions, and plan to integrate it into our organization moving forward.

We thank all who attended our symposium this year. PSI will continue striving towards fulfilling our mission of improving the health of Ontarians, through the support of physician-led research and education in the years to come.

Check out our YouTube playlist for exclusive video content from the PSI 2022 Symposium.

*This event is an Accredited Group Learning Activity as defined by the Maintenance of Certification Program of the Royal College of Physicians and Surgeons of Canada, and approved by the Continuing Education and Professional Development Office at the Northern Ontario School of Medicine. 

Dr. Laureen Hachem: Clinical Experience in Neurosurgery Provides Valuable Perspective for Lab-based Research

Dr. Laureen Hachem has long been interested in neurosurgery and the potential of endogenous stem cells to repair spinal cord injuries. She started her research career in her last year of high school, volunteering in the lab of Dr. Charles Tator, a researcher and neurosurgeon at Toronto Western Hospital, and she continued working in Dr. Tator’s lab throughout her undergraduate and medical school education at the University of Toronto.

In 2017, she graduated from medical school and started the Toronto Neurosurgery Residency Program, which combines clinical and lab-based research training.

“When I’m on clinical service, I see questions or problems that I can critically analyze and think about how I would address them in a systematic, hypothesis-generating way,” says Dr. Hachem. “When I go back to the lab, I have an important perspective because I’ve seen what is relevant and feasible in the clinic, and the patient is always top of mind.”

In 2020, she started her PhD research, supervised by Dr. Tator and Dr. Michael Fehlings, continuing her studies of endogenous stem cell regeneration, with the aim of identifying therapies for spinal cord injury.

She had previously found that high levels of the neurotransmitter glutamate activate the AMPA receptor, which stimulates a response from endogenous stem cells. With a PSI Resident Research Grant, she began to look for clinically relevant methods to therapeutically activate AMPA receptors to stimulate endogenous stem cell regeneration, focusing on a class of drug called ampakines.

Ampakines bind to AMPA receptors to improve neuron signalling and have been used in neurodegenerative diseases, such as Alzheimer’s disease and Parkinson’s disease and in the setting of opioid-induced respiratory depression, and have been tested in clinical trials for some neuropsychiatric conditions. But until Dr. Hachem’s research, ampakines had not been examined for their potential in enhancing endogenous spinal cord stem cell regeneration.

Dr. Hachem says that PSI’s Resident Research Grant is a valuable tool for residents to develop their own research program and gain valuable skills early in their career.

“Because this grant funds residents as principal investigators who are asking the questions and leading the work, it gives residents ownership over the project,” she says. “It sets you up for the future in developing your career as a scientist and your own research program.”

Repurposed drug shows promise for neural stem cell regeneration

With PSI funding, Dr. Hachem used a clinically relevant rodent model of spinal cord injury to test whether an ampakine drug could stimulate the AMPA receptor to regenerate endogenous stem cells and restore function.

She found that the treatment increased the growth and division of endogenous neural stem cells and the production of beneficial growth factors, which was associated with increased neuron survival, reduced inflammation and improved functional recovery.

Dr. Hachem notes that other more invasive strategies – including stem cell transplantation – have been studied to repair spinal cord injuries, and while they show promise, her research is the first to show that ampakines have potential as a less invasive approach to regenerate neural stem cells.

“With this work, we’re trying to harness the body’s own regenerative potential with these stem cells. Since the discovery of these cells, it’s been a long-standing question of how we can actually use them to repair the spinal cord after injury, and this study is a critical step in answering that,” she says. “The relevance of the therapy and translation to the clinic is always top of mind, and ultimately the goal is to translate this drug and this approach of positively modulating these cells to patients in a clinical trial.”

With these first results, Dr. Hachem is continuing her research to understand the mechanisms at work, as well as examining the use of ampakines in chronic spinal cord injury. She plans to continue pursuing lab-based research along with clinical care to build a career that ultimately improves care for patients with spinal cord injury.

“Funding from PSI Foundation allowed me to do this first critical experiment to show the feasibility and efficacy of the drug, as well as optimize drug dosing, timing and duration, and this work paves the way for larger scale studies and ultimately clinical translation to patients,” says Dr. Hachem. “This line of research has really grown with me throughout my medical education. Looking forward in the future, I aim to have a career where I can integrate my research interests with my surgical practice.”

Frequently Asked Questions (FAQ): PSI Mid-Career Knowledge Translation (KT) Fellowship

In March, PSI announced a new funding opportunity: the 2023 PSI Mid-Career Knowledge Translation (KT) Fellowship. Through this award, we aim to provide salary support for a mid-career physician researcher in Ontario to conduct high-impact knowledge translation research with a goal of improving the health of Ontarians.

In this article, we cover the most frequently asked questions that we have been receiving to clarify our application requirements and award expectations. We hope you find this article helpful in determining whether this award is suitable for you. We will continue to update this article frequently as we receive new inquiries, until the Letter of Intent (LOI) submission deadline of June 1st, 2022 at 5pm EST. We encourage you to revisit this page to help you until you prepare your application and submit your LOI.

If your question is not answered here, or if you have further questions, please get in touch with us; we are more than happy to assist you.

FAQs for the 2023 PSI Mid-Career KT Fellowship

About the Award:

Is this a one-time funding opportunity? Will PSI have this funding opportunity again next year?

The PSI Grants Committee will review this topic of whether PSI should continue this funding stream and hold annual competitions.

What is the success rate of this funding stream?

Since this is PSI’s first time launching this award, we do not have data for approval ratio.

Application Process:

Can you clarify the application process, including the different stages and timeline?

Below is an outline of the different stages and timeline of this competition:

PSI Mid-Career KT Fellowship – Application Process

Submission of Letter of Intent (LOI)

  • The submission deadline is June 1st, 2022 at 5pm EST.
  • LOI must be submitted via PSI Grants Management System at https://psifoundation.smartsimple.ca/. Emailed applications will not be accepted.

Initial screening of LOI

  • PSI staff will screen all submitted LOI for eligibility and completeness.

(if needed) Revision of LOI by candidate

  • If your LOI needs revision or clarification, then PSI staff will contact you via email.

PSI Grants Sub-Committee Review of LOI

  • PSI Grants Sub-Committee will review each LOI submitted at their meeting in July/August 2022.

LOI decisions sent

  • Decision on whether you are invited to proceed to the next stage will be sent via email in August 2022.

(If LOI approved) Full application submission

  • If you are invited to submit a full application, then you will receive an email with instructions on how to access the online application form.
  • Full applications must be submitted via PSI Grants Management System at https://psifoundation.smartsimple.ca/ by November 4th, 2022 at 5pm EST.

Initial screening of full application

  • PSI staff will screen all full submitted applications for eligibility and completeness.

(If needed) Revision of full application by candidate

  • If your application needs revision or clarification, then PSI will contact you via email.

PSI Grants Committee review of full applications

  • The full PSI Grants Committee will review each full application submitted at their meeting in December 2022.

Final funding decisions sent

  • Final funding decisions will be sent within 10 business days from the December 2022 PSI Grants Committee meeting.

Is there a limit to the number of applications that can be submitted per institution or faculty/department?

There is no limit to the number of applications that can come from a specific institution or faculty department.

I currently hold/am applying for a PSI operating grant (e.g. Health Research grant). Can I still apply?

PSI allows principal investigators (PI) to concurrently hold one PSI operating grant and one PSI salary support award. Hence, you are welcome to apply.

How many candidates will PSI invite to submit a full application? How many awards will be given out?

PSI does not have a pre-determined number of candidates that we will invite for full application submission. The number of candidates to move on to the next process, as well as the number of awards given out depends on the PSI Grants Committee’s review of the quality of the applications received and their fit with PSI’s mandate.

Eligibility of Candidate:

Are leaves of absence (e.g. maternity leave) taken into account when counting the number of years since the first academic appointment?

Yes, PSI will take into account any leaves of absence when determining the number of years since the candidate’s first academic appointment.

I obtained an MD but I do not practice clinically. Can I apply?

Unfortunately, in addition to being within 5 to 15 years of your first academic appointment, you must also be a CPSO-licensed practising physician in Ontario. PSI must be able to confirm your CPSO license at CPSO – Find a Doctor.

Eligibility of Proposal:

My research involves cancer patients, but the research itself is not about cancer. Can I apply?

As outlined in the funding guidelines, PSI will not accept applications involving research in the areas of cancer, heart and stroke, and pharmaceutical drug development studies.

If you are not sure whether your research falls under PSI’s areas of non-support, then please email us with a brief summary of your research prior to submitting an application so that we can assess whether you are eligible for funding.

What if my research involves sites outside of Ontario? Can I still apply?

While we will accept applications with research involving some sites outside of Ontario, since PSI’s mission is to “improve the health of Ontarians”, the majority of your research should be conducted in Ontario. Your application should demonstrate the relevance of your knowledge translation research to the health of Ontarians. The PSI Grants Committee will review each application and its alignment with PSI’s mandate.

Application Policy/Requirements:

Do I need to obtain matching funding and submit a letter of confirmation in the Letter of Intent (LOI)?

You do not need to provide confirmation of matching funding at the LOI stage. If you are invited to proceed to the next stage, then matching funding should be confirmed in the full application, within the letter of support from the sponsoring institution.

Can my matching funding come be in the form of in-kind support or from other grants from external funding agencies?

Matching funds may not be an in-kind support from the institution nor come from another salary support fellowship/award, operating grant, nor project specific funding.

What if I can’t obtain matching funding?

A lesser amount in matching funding is admissible with explanation from the applicant and institution.

If a sponsoring institution is unable to provide matching funds, then the candidate may obtain matching funds from another source. In this case, please provide an explanation.

Application Content:

What are the formatting requirements for the documents to be uploaded?

PSI prefers all uploaded documents to have 0.5 to 1-inch margins, single spaced, and 12-point font size in a legible font.

For LOI, can I add references to the documents to be added?

You may add an additional page of references to any documents uploaded in your LOI.

Am I required to submit any letters of support or letters of references with my LOI?

At the LOI stage, you are not required to submit any letters.

Other:

If I am awarded, what are my requirements as a PSI Mid-Career KT Fellow?

The funding recipient guidelines for the PSI Mid-Career KT Fellowship is available for download at Grant Recipient Guidelines – PSI Foundation. This document outlines what is required as a PSI Mid-Career KT Fellow.

Dr. Brad Petrisor and Dr. Sheila Sprague: International study builds understanding of orthopedic patients experiencing intimate partner violence

Screening women for intimate partner violence (IPV), which includes physical, sexual, and emotional violence, may not seem to fall under the scope of an orthopedic or fracture clinic. But orthopedic surgeons and researchers who recently led an international study on IPV prevalence among orthopedic patients explain that the fracture clinic can actually be a good setting to address this issue.

“In the fracture clinic, you often see patients with injuries frequently during the first few weeks to months. Follow-up often continues for months and sometimes longer,” says Dr. Brad Petrisor, an orthopedic surgeon and professor at McMaster’s Department of Surgery. “You get multiple snapshots over the course of the year after their injury, so this is a major opportunity to ask about and understand intimate partner violence in people’s lives.”

Dr. Petrisor, Dr. Sheila Sprague, Associate Professor in the Department of Surgery, Dr. Kim Madden, Assistant Professor in the Department of Surgery, Dr. Mohit Bhandari, Chair of the Department of Surgery, along with a large multi-disciplinary team, are leading a research program that is generating more awareness of IPV among orthopedic specialists and equipping them to address it with their patients.

As part of her PhD thesis, Dr. Sprague led one of the early studies of IPV among orthopedic patients, the PRAISE (Prevalence of abuse and intimate partner violence surgical evaluation) study. The research team examined the prevalence of IPV among 3,000 women attending orthopedic fracture clinics in Canada, the US, the Netherlands, Denmark and India. They found that one in six women had experienced IPV in the year before the injury, and one in three had experienced IPV in their lifetime. The study was published in The Lancet in 2013.

In 2015, Dr. Petrisor and Dr. Sprague received funding from PSI Foundation to expand on those results with the PRAISE-2 study, which examined reporting rates of IPV among orthopedic patients during the first year following the injury and how IPV affects outcomes such as return to function, complications from the injury and health-related quality of life.

The team assessed IPV disclosures and clinical outcomes of 250 women from Canada, the Netherlands, Spain and Finland at the first visit to the orthopedic fracture clinic and at one, three, six and 12 months after the first visit.
They found that 33% of the patients disclosed IPV during their first visit, and an additional 12.4% who did not disclose IPV at the first visit did disclose IPV at some point during the 12-month follow up.

The team also found that women who disclosed IPV were slower to return to their pre-injury level of function, experienced more complications from their injury and had lower health-related quality of life during the follow-up period. The results were published in the Journal of Bone and Joint Surgery, the field’s most prestigious journal.

“These kinds of statistics can help inform education so that surgeons know to ask about IPV, not just once but at each visit, because you could be missing a significant number of people who could be helped,” says Dr. Sprague. “And knowing that patients who experience IPV have a more difficult recovery is helpful so that the surgeon can intervene earlier with referrals to appropriate services.”

The research team’s work over the last decade has helped to change the perspective of orthopedic specialists from viewing IPV as outside their scope of practice to feeling better equipped to help patients experiencing IPV. They have published papers in top journals and delivered presentations at major orthopedic trauma meetings, and their work has led to positional statements by the Canadian Orthopedic Association recognizing IPV as a significant determinant of morbidity and mortality.

Importantly, Dr. Sprague, Dr. Bhandari, and their colleagues have used the results from the research program to develop a program called EDUCATE, an open access website for orthopedic surgeons and fracture clinic staff that provides knowledge and skills to assist women who are victims of IPV. By the end of 2021, the EDUCATE program had trained more than 150 health care professionals, and they hope to eventually broaden the program to include more health care fields.

“It teaches them how to optimize their fracture clinic and how to ask about IPV. And it also describes the resources that are available and referrals that health care providers can give,” says Dr. Sprague.

As a practising surgeon, Dr. Petrisor says that the research program has changed his own approach with patients.

“When we started this program of research, there was a lot of discomfort among orthopedic surgeons: how do you ask people about IPV, how can the environment in the fracture clinic be conducive to asking about it, and if a patient discloses, what do I do about it?” says Dr. Petrisor. “Knowing that more than one third of women in the clinic disclose IPV has definitely changed my approach in how I interact with patients. In the same way we ask about smoking, alcohol or drugs without judgment, we can ask about IPV and know what to do after a disclosure.”

Dr. Kamila Premji: Health Policy Research Aims to Improve Access to Primary Care

“It can be hard for physicians who practice in the community to get research off the ground because they don’t have access to traditional funding streams… I look at the community setting as a real-life lab for doing research, and it’s so beneficial to have funding from PSI that supports physicians in this setting.” – Dr. Kamila Premji

Dr. Kamila Premji, a family physician practising in Ottawa, has been interested in research throughout medical school and residency—with a particular interest in health care policy and access to primary care. Now a PhD candidate in Family Medicine at Western University, she has had the opportunity during her training to lead research that has provided important information about challenges with Ontario’s current system of physician compensation.

“I have been able to use my clinical practice experience in the community, see what my patients were struggling with and look for answers to those problems,” she says. “Research was such a natural path to explore those interests and make a difference in health care policy to help improve access to care.”

Dr. Premji had been working at her community practice for a few years when she decided to pursue a master’s degree, which would give her the skills to undertake more rigorous research, and soon transitioned into the PhD stream.

Early in her graduate training, Dr. Premji was part of a team led by Dr. Richard Glazier that examined whether the physician access bonus led to better patient care.

Ontario introduced the access bonus in 2004 as part of several pay-for-performance incentives in primary care. The access bonus is meant to reward family physicians who organize their practices to be more accessible by providing higher bonuses to physicians whose patients seek less external care, such as walk-in or after-hours clinics. Emergency department visits and specialists are not counted as external care.

However, the access bonus has been a controversial incentive, particularly because patients in urban and rural communities have different access to external health care services. With patients in rural communities often relying on emergency departments, it results in bonuses that may not accurately reflect whether physicians are making their practices more accessible.

“The access bonus creates all kinds of unintended consequences for the way services are delivered, and it can even impact the patient-physician relationship at times,” she says. “It’s such a big part of the dominant payment model in Ontario, so it seemed like something that warranted further exploration.”

In 2019, the team including Dr. Premji published a study that linked administrative data about patients’ health care use with their physicians’ access bonuses. The study found that physicians who earned the highest access bonuses were more likely to practice in rural or small urban areas and have higher proportions of patients with less complex health care needs; but these physicians did not necessarily offer more after-hours care, and their patients had higher rates of emergency room use.

PSI Research Trainee Award project suggests access bonus is not working as intended

Dr. Premji wanted to examine the results in the urban setting more closely, as well as consider a different measure of patient access. With a PSI Research Trainee Award, Dr. Premji and the team examined the access bonus for physicians in large, medium and small urban centres from the perspective of whether it improved patients’ experiences and perceptions of access.

“This is such an important part of understanding what the access bonus payment does from a patient perspective,” she says. “From their perspective, are patients experiencing a better level of service and access with this bonus? Is the bonus doing what it is meant to do?”

The team used data from the Health Care Experiences Survey, a patient experience survey conducted quarterly and funded by the Ontario Ministry of Health, and health administrative data from ICES. They were able to link patients with their physicians and family health teams and find associations between patient perceptions of access and their physicians’ bonuses.

The team found that in large and medium urban centres, where walk-in clinics and after-hours care are easily accessed, patient-reported experiences of access were positively associated with their physician’s access bonus. But this association did not hold in small urban centres, and as in the previous study, higher bonuses did not actually mean that patients experienced better access to their physicians.

“In large and medium urban centres, the higher the bonus, the more satisfied patients were with their access, which suggests that the bonus may be motivating physicians and clinics to organize their services in a way that improves the patient’s experience of access,” she says. “But the availability of resources and patients’ choices are still driving the bonus and having more of an impact, and these are out of physicians’ control.”

The results of both studies suggest that the access bonus is not necessarily doing what it is meant to do and may need to be redesigned to account for the differences in geography and patient experience. The results were published in the Canadian Medical Association Journal in November 2021 and have been presented to stakeholders including the Ontario Medical Association and the Ontario Ministry of Health.

The PSI Research Trainee Award concluded in 2020, but Dr. Premji is continuing research in primary care access while she finishes her PhD and cares for her patients.

“I find myself more alert to what my patients are experiencing that could be answered through policy solutions and through research. These areas fuel each other,” she says. “My clinical care fuels my curiosity, and my interest in research leads me to do these projects that then may have an impact on my patients.”

New PSI Funding Opportunity: 2023 PSI Research Trainee Award

PSI Launches the 2023 PSI Research Trainee Award

PSI Foundation is excited to announce the launch of the 2023 PSI Research Trainee Award. The primary aim of this award is to provide highly qualified candidates with clinically applicable research training opportunities and support.

Please note: this funding opportunity is not an additional PSI operating grant. Research training must be the fundamental purpose of this award and must be demonstrated in the application.

Eligibility of Candidate

The candidate for the award must be:

  • An M.D. licensed by College of Physicians and Surgeons of Ontario (CPSO) in a Ph.D or MSc. program at an Ontario university

OR

  • A trainee in a combined M.D./Ph.D or MSc. program at an Ontario university

OR

  • A trainee in the Clinician Investigator Program (CIP) at an Ontario university

Amount and Duration of Funding

A maximum of $25,000 per year for two (2) years is available from PSI.

Please note: sponsoring institutions are required to co-fund 50% of the amount requested from PSI. For example, if the fellow requests $20,000 per year from PSI, then the sponsoring institution must provide $10,000 per year.

Important Information in Funding Guidelines

The Funding Guidelines contain important information regarding the award. Please review this document before applying.

How to Apply

Similar to previous years, each of Ontario’s six medical universities may submit up to two candidates; therefore, all applications must be submitted through the medical university. The deadline for medical universities to submit their applications to PSI is July 25th, 2022 at 5pm EST.

Please contact the medical university research office regarding internal application process/deadlines. Medical universities must submit their applications to PSI via PSI online grants management system. Please see Tips & Resources – PSI Foundation for instruction manual on how to navigate the system.

New PSI Funding Opportunity: 2023 PSI Graham Farquharson Knowledge Translation (KT) Fellowship

PSI Launches the 2023 PSI Graham Farquharson Knowledge Translation Fellowship

PSI Foundation is very pleased to launch the 2023 PSI Graham Farquharson Knowledge Translation Fellowship. This Fellowship is intended to provide salary support for a new investigator who has demonstrated the ability to successfully complete high impact knowledge translation research. The Fellowship funds, dedicated to salary support, must protect at least 50% of the Fellow’s time to conduct such research. Please note: Knowledge translation must be the fundamental purpose of this Fellowship and must be demonstrated in the application.

Amount and Duration of Funding

This program offers two options for a funding timeline for salary support: A maximum of $150,000 per year for two years; OR a maximum of $100,000 per year for three years.

Please note: the award is intended to protect at least 50% of the fellow’s time to undertake research, regardless of whether the award is taken over two or three years.

Eligibility of Candidate

For the 2023 competition, PSI has set the eligibility criteria for candidates as follows:

The candidate for the Fellowship must be either:

  • Within five (5) years of their first academic appointment and have demonstrated potential for high impact research work
  • Dedicating at least 50% of a full-time schedule to the Fellowship
  • A practising physician with a College of Physicians and Surgeons of Ontario (CPSO) licensed M.D. having direct patient care responsibilities and an academic appointment, thus eligible to apply for their own research grants as an independent investigator.

OR

  • A clinical fellow in Ontario who is a practising physician having direct patient care responsibilities, with a supervisor who has an academic appointment and that can provide the necessary research supervision and infrastructure (including administering the grant at the sponsoring institution). A letter of support from this supervisor must be included in the application.

Important Information in Funding Guidelines

The Funding Guidelines contain important information regarding the award, including PSI’s definition of knowledge translation, sponsoring institution requirements, and funding criteria. Please review this document before applying.

How to Apply

Similar to the previous competition, PSI is launching this competition through a Letter of Intent (LOI) process. Please note that for this competition, applicants are required to submit their applications directly to PSI, not through the institution.

We require all applicants to submit the completed LOI directly to PSI via the PSI Online Grants Management System (https://psifoundation.smartsimple.ca/) by June 3rd, 2022 5pm EST. LOIs will be reviewed by the PSI Grants Committee in July/August 2022.

PSI will invite successful applicants to submit full applications by November 4th, 2022 5pm EST, which will undergo internal review for a final funding decision in December 2022.

Questions?

Please contact the PSI Office to discuss any questions you may have about submitting an application for funding.

New PSI Funding Opportunity: 2023 PSI Mid-Career Knowledge Translation (KT) Fellowship

PSI acknowledges that mid-career can be a challenging time for physician researchers. During this phase, there are often additional academic roles and responsibilities including committee work, leadership positions, and mentoring of junior investigators, while clinical work continues. PSI recognizes the importance in supporting this phase of an investigator’s trajectory.

PSI Foundation is very pleased to announce a new funding opportunity: 2023 PSI Mid-Career Knowledge Translation (KT) Fellowship. This Fellowship is intended to provide salary support for a mid-career physician researcher in Ontario who has demonstrated the ability to successfully complete high-impact knowledge translation research. The Fellowship funds, dedicated to salary support, must protect at least 50% of the Fellow’s time to conduct such research.

Amount and Duration of Funding

Total Support

This program offers two options for a funding timeline for salary support:

A maximum of $400,000 over two years;

OR

A maximum of $400,000 over three years.

The award is intended to protect at least 50% of the fellow’s time to undertake research, regardless of whether the award is taken over two or three years.

Matching Funding Requirements

The sponsoring institution is required to fund 50% of the total award.

For example, if the fellow requests a total support of $400,000 over two years, then PSI will fund $200,000 over two years ($100,000 per year) and the institution is required to co-fund $200,000 over two years ($100,000 per year).

Eligibility

For this competition, the candidate for the Fellowship must be:

  • A practicing physician in Ontario with a College of Physicians and Surgeons of Ontario licensed M.D. having direct patient care responsibilities and an academic appointment, thus eligible to apply for their own research grants as an independent investigator
  • Within five (5) to fifteen (15) years of their first academic appointment and have demonstrated potential for high impact research work
  • Dedicating at least 50% of a full-time schedule to the Fellowship

Important Information in Funding Guidelines

The Funding Guidelines contain important information regarding the award, including PSI’s definition of knowledge translation, matching funding requirements, and funding criteria. Please review this document before applying.

Please note: Knowledge translation must be the fundamental purpose of this Fellowship and must be demonstrated in the application. This is funding opportunity is not an additional PSI operating grant.

How to Apply

PSI is launching this competition through a Letter of Intent (LOI) process. Applicants are required to submit their applications directly to PSI.

We require all applicants to submit the completed LOI directly to PSI via the PSI Online Grants Management System by June 1st, 2022 at 5pm EST. LOIs will be reviewed by the PSI Grants Committee in July 2022.

PSI will invite successful applicants to submit full applications, which will undergo internal review for a final funding decision in December 2022.

Questions?

Please contact the PSI Office to discuss any questions you may have about submitting an application for funding.

Dr. Amanda Mayo and Dr. Sander Hitzig – Largest Canadian Study of its kind Highlights Isolation and Loneliness After Dysvascular Amputation

“Historically this population has been underfunded, so it’s really important that PSI has funded dysvascular amputee research. We were happy to get this PSI grant, and it really built the confidence of the researchers in Ontario so that now we can work together and do bigger things.” – Dr. Amanda Mayo, Sunnybrook Health Sciences Centre

“We’re very grateful to PSI for funding this work because it really lit a spark and galvanized our research community, and it will ultimately improve the quality of life for the limb loss community.” – Dr. Sander Hitzig, Sunnybrook Health Sciences Centre

A PSI Foundation–funded grant to examine the health and quality of life of people with dysvascular limb loss has not only provided important insights into this understudied population but has also helped to develop the limb loss research field in Canada.

“Our overarching goal of is to develop collaborative research so that our patients do better, but to do this, we need to know how they’re doing and the resources they lack,” says Dr. Amanda Mayo, a physiatrist at St. John’s Rehab at Sunnybrook Health Sciences Centre who specializes in amputee rehabilitation. “This funding has allowed us to build a more cohesive and collaborative research program, but also work toward the greater aim of improving clinical outcomes for this patient population.”

Each year, approximately 1,500 people in Ontario have a major lower limb amputation due to dysvascular causes such as peripheral vascular disease or diabetes, making it the most common cause of lower limb loss in Canada. And the problem is expected to grow as the incidence of diabetes increases.

While any type of amputation can be traumatic, people with dysvascular limb loss face different challenges than those who lose limbs due to other causes, such as accidents.

“They’re a very vulnerable and frail population. They are usually older and tend to have a high number of comorbidities leading up to their amputation, in particular heart disease, arthritis and neuropathy,” says Dr. Amanda Mayo. “After the amputation, they’re at greater risk of complications, falls, depression and not being able to get back to community living.”

In 2018, Dr. Mayo and her co-principal investigator, Dr. Sander Hitzig, a scientist focused on aging and disability also based at St. John’s Rehab, received a PSI Foundation Clinical Research Grant to examine the health and quality of life outcomes of people with dysvascular limb loss – the largest study of its kind in Canada.

Study finds that physical and mental health decline post-amputation

In the study, the research team interviewed more than 230 people with limb loss about their physical and mental health, mobility, social connections and quality of life after amputation. They also interviewed 35 people from this group in more depth about their experiences of living in the community after amputation.

The study results showed some troubling trends. The people they interviewed experienced poor physical health, with an average of five comorbidities, most commonly diabetes, pain and high blood pressure. After amputation, mental health also tended to decline, and many people became more isolated; about one-third of interviewees expressed that they were lonely.

But the study also identified factors that could help people to cope better after limb loss; less impactful morbidities, a higher sense of self-confidence, and strong levels of social support were associated with better physical or mental health.

The interviews were done before the COVID-19 pandemic, but anecdotally it is likely that the pandemic has hit this population particularly hard.

“I think the pandemic has magnified how significant being socially isolated can be for anyone, and this was an isolated population before the pandemic,” says Dr. Hitzig. “We don’t have data about this yet, but they may have become more isolated and disconnected due to many of them being immunocompromised, and their physical health may have declined because of clinics being closed, not being able to get to the hospital, or surgeries being delayed.”

Results will help inform supports for vulnerable group

In addition to the interviews, Dr. Mayo and Dr. Hitzig analyzed data from a large cohort of Ontarians with lower limb amputations to understand their health care usage and the economic cost of dysvascular amputation. While this part of the project is not yet complete, early results suggest that people with limb loss are very high users of the health care system, visiting family physicians, specialists and emergency departments multiple times in the year following their amputation.

In fact, approximately 30% of people with dysvascular limb loss are admitted to long-term care and 30% die within two years of their amputation.

“These people are having significant health issues. We try to help them recover as best as possible through rehab, but many continue to decline,” says Dr. Hitzig. “There is a negative impact on the person and their family members, but there is also a health care system cost that we’re now hopefully starting to better understand.”

With a better understanding of the quality of life for people with dysvascular lower limb loss and the related social and economic costs, Dr. Mayo and Dr. Hitzig hope that the results from this project and their larger research program can be used to screen people who may be at greater risk of social isolation, as well as develop or connect people with programs to support their physical and mental health after an amputation.

“Predicting which patients are most at risk of isolation or not successfully integrating into the community would allow us to do more targeted rehab or pre-operative care,” says Dr. Mayo. “Looking at the data from this project, we see many opportunities for future collaborative research and ways to use the results to improve quality of life.”

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