Alice Cavanagh: Understanding How Physicians Learn About Intimate Partner Violence

As a volunteer at a sexual assault crisis centre before starting medical school, Alice Cavanagh would occasionally accompany people who had experienced sexual violence to access emergency health care. While health care professionals’ roles include the important and difficult tasks of collecting samples and evidence, their interactions with the survivor were very different from hers as a volunteer trained primarily to listen and be supportive.

“I became interested in what physicians are actually learning in the course of their professional training about intimate partner violence and sexual violence, and how that shapes their practice,” says Cavanagh. “There is research that quantifies how much education Canadian medical students get on intimate partner violence, but I was really interested in looking at the impact of that education. How are physicians experiencing that training and what are they taking from it?”

When Cavanagh started the MD/PhD program at McMaster University a short time later, she was able to examine these questions, receiving a PSI Research Trainee Award to support her research. With supervision from Dr. Meredith Vanstone and mentorship from Dr. Harriet MacMillan, she led research on how physicians learn about intimate partner violence (IPV) and how that affects the support they provide to patients, and recently defended her dissertation.

In the first part of the study, Cavanagh examined policy and training materials for physicians related to IPV. She then collaborated with the RISE project, a study funded by the Public Health Agency of Canada examining the family violence learning needs and preferences of Canadian social workers and physicians, interviewing physicians and residents across Canada from five medical specialties (emergency medicine, family medicine, obstetrics and gynecology, psychiatry and pediatrics) about their IPV education and the support they provide to patients. She also interviewed health and social service providers outside of medicine about their perceptions of the IPV training that physicians receive.

Physicians often feel unprepared to support people experiencing violence

Cavanagh’s analysis of physician’s training materials found that IPV has become increasingly medicalized, where it is often viewed solely as a health issue, instead of a structural issue with many facets, including poverty, racism, ablism and other forms of oppression. She also found that physicians are taught to identify patients experiencing IPV, provide them with support, and direct them to resources.

At the same time, physicians and residents revealed during the interviews that, while they understood IPV is important to their patients’ health, they largely felt unprepared to support their patients. However, they also spoke about how much they valued experiential learning, which Cavanagh says may offer opportunities to collaborate with IPV experts in other fields to learn directly from patients and other IPV experts.

Interviews with experts outside of medicine confirmed that physicians need to understand IPV and be prepared to support their patients. But they also highlighted that physicians need to be more aware of power dynamics in intimate partner violence, both in terms of the power dynamics between the person who is enacting violence and the person experiencing violence, but also the power that physicians hold in society to make a difference for individual patients and in dismantling the structures that uphold violence.

“It’s not just about understanding, it’s also about engaging with power to move from knowledge to action,” says Cavanagh. “This is a problem that can’t only be addressed by the health care system. By creating opportunities for health care providers to learn about IPV as an issue that is complex and connected to lots of different facets of people’s lives, my hope is health care providers will have opportunities to engage with the type of collective action that is critical to address complex, structural issues like IPV.”

PSI support was instrumental to kickstarting research career

With her dissertation complete and one more year of medical school remaining, Cavanagh is looking forward to continuing research that will improve health policy.

“My goal for my career is to be able to use my clinical work to look at questions about policy and health and to be able to use my research skill set to answer and think through those questions,” she says. “I really believe in the value of clinician-scientists, including those who work outside traditional bench-to-bedside research, and funding from PSI was really instrumental to me in being able to do my work and kickstart my career.”

Cavanagh says the PSI Research Trainee Award provided important financial support during her studies, and PSI meetings gave her important opportunities to connect and collaborate with other researchers.

“In very practical ways, being a part of the community has been really helpful to me in finding and developing new opportunities to grow, which is so important at this stage of my career,” she says.

Cavanagh hopes that the results from her research will help to inform medical education about IPV, particularly in developing opportunities to collaborate with experts from other fields and fostering physicians’ connections with community resources and services to support people experiencing IPV. With more than one quarter of women worldwide having experienced violence, she emphasizes that this issue affects people from all communities, including physicians.

“Violence and structural oppression are pervasive and touch every corner of our lives,” she says. “In health care, if we can have more sensitive conversations about these issues that acknowledge that this isn’t an issue that only affects ‘other’ people, that it affects everyone, I think that we can come toward creating safer places for both patients and providers.”

Dr. Aaron Gazendam: Helping Patients Manage Pain Without Excess Opioids

Over the past several years, and particularly during the COVID-19 pandemic, opioid use disorder has been taking a significant toll on Canadians. According to the Public Health Agency of Canada, between January 2016 and December 2021, more than 29,000 people in Canada died from apparent opioid toxicity, and more than 30,000 hospitalizations were related to opioids.

As evidence has grown in recent years about the risk of opioid use, health care providers are being more careful and deliberate in prescribing opioids to reduce the risk that patients will become long-term opioid users. But this has been a particular challenge in orthopedic surgery.

Research has found that orthopedic surgeons prescribe more opioids than any other surgical specialty. Most patients receive an opioid prescription after surgery, often for more than they need.

“Recovery from these surgeries can be very painful, and as surgeons, there’s a fear that you’re sending patients home with not enough pain control and that they may end up in a pain crisis,” says Dr. Aaron Gazendam, an orthopedic surgery resident at McMaster University. “There’s also been a lack of high-quality research to prove that we can manage this pain without a lot of opioids.”

While working on a Master of Science in Health Research Methodology at McMaster during his residency, he co-led a clinical trial to examine the effectiveness of an opioid-sparing post-operative pain protocol following arthroscopic shoulder and knee surgery.

“Previous research has shown that there is a pretty strong correlation with that initial opioid prescription and the proportion of people who go on to develop chronic use,” says Dr. Gazendam. “We wanted to do an impactful study, and we felt that the results could be implemented after the study to support patients beyond those enrolled in trial.”

In 2021, Dr. Gazendam received a PSI Resident Research Grant to support the Non-Opioid Prescriptions after Arthroscopic Surgery in Canada (NO PAin) randomized controlled trial.

The research team, which included orthopedic surgeons and residents, enrolled 200 patients from three clinical sites in Canada who were undergoing outpatient shoulder or knee arthroscopic surgery. The patients were randomly assigned to one of two groups: the control group received the same prescriptions for opioids that they would typically receive outside of a trial, while the experimental, or “opioid-sparing,” group received a prescription for non-steroidal anti-inflammatories (NSAIDs) and acetaminophen, a “rescue prescription” for a small number of opioid pills they could fill if needed, and education about the risks of opioid medications.

At two and six weeks after the surgeries, the research team asked the patients how many opioid pills they used, how much pain they had, and how satisfied they were with their pain control.

They found that patients in the opioid-sparing group were prescribed and consumed significantly fewer opioids than the control group, yet patient-reported pain and patient satisfaction with pain control were not significantly different between the two groups. Importantly, only two people in the opioid-sparing group needed a refill on their opioid prescription, demonstrating that the opioid-sparing protocol was an effective way to manage pain.

“We included patients who were having major surgeries like ACL reconstruction and rotator cuff repairs, so we were in uncharted territory and unsure of how many refills we were going to get during the study,” says Dr. Gazendam. “Leaving patients without access to adequate pain control is a major concern for surgeons, so the fact that only a couple of people needed to refill their opioid prescription was a pleasant surprise.”

The research team now plans to publish the results and work with orthopedic and arthroscopy associations to develop guidelines and position statements that provide evidence-based information about pain management.

As Dr. Gazendam finishes his residency, he plans to specialize in orthopedic oncology and continue studying opioid use in oncology patients, who have very different medication needs and opioid use.

“The question for this project came directly out of our clinical experiences with patients. Being able to investigate questions that come up clinically that have little or no evidence is very rewarding,” says Dr. Gazendam. “The funding from PSI for the NO PAin trial has given me the opportunity to do meaningful and hopefully impactful research that I wouldn’t have had the opportunity to do otherwise.”


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.”


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.”

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.”

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.”

Dr. Carrie Bernard: New Family Medicine Ethics Curriculum Helps Learners See Ethical Principles in Everyday Clinical Work

As a community-based family physician, Dr. Carrie Bernard examines research questions that are directly relevant to her patients and practice.

“All of my research has come out of the clinical world, and for me, that’s what makes research meaningful,” says Dr. Bernard, physician at William Osler Health Centre in Brampton. “I see myself as firmly planted in the community as a physician. That is my home, and that is what matters to me. I am most interested in research that is going to help my patients in the long run.”

Since she started to undertake research projects over the last decade, she has partnered with researchers to work on projects ranging from humanitarian health care ethics to advanced care planning. One of her most recent projects, funded by a PSI Foundation grant for Medical Education Research that the Post-MD Level, focused on how ethics curriculum is taught to postgraduate family medicine trainees.

Dr. Bernard says that PSI’s support of family physicians and their understanding of their unique research approach helped her feel valued as a researcher.

“PSI felt like the right place to go for this funding because it represents who I am as a physician first and a researcher,” she says. “They understand and expect that as an MD, you will need to partner with a PhD researcher on your project. You’re not viewed as a lesser researcher because of that.”

New ethics curriculum aimed to increase confidence with challenging situations

Dr. Bernard’s transition to doing research was a gradual one. She had been practising as a family physician for several years when she volunteered on a humanitarian trip to northern Uganda with Médicins Sans Frontières (Doctors Without Borders). The experience left her with many questions about how to do humanitarian medical work ethically, but she realized she needed a research-focused education to properly answer the questions.

So, while continuing to practice family medicine fulltime, she earned a master’s degree in public health at the University of Toronto, focusing on global health and ethics.

Her master’s degree opened up new opportunities in academia, and in 2014, she joined U of T’s Department of Family and Community Medicine as Associate Program Director, Curriculum and Remediation. As part of her role, she began working with a team of physicians, ethicists and education experts to re-design how ethics is taught during family medicine residencies.

“One of the main reasons doctors run afoul with regulatory bodies is because of unprofessional behaviour and understanding how to manage these fraught and ethically challenging situations. It’s incredibly important to make sure you have strong ethical judgment to build trusting relationships with patients,” she says. Yet, “Family medicine trainees and even many practising family physicians feel underprepared and unconfident when it comes to ethics.”

Dr. Bernard worked closely on the new curriculum with Dr. Mahan Kulasegaram, director in the Office of Education Scholarship in the Department of Family and Community Medicine and an expert in learning sciences. They, along with the rest of their team, spent more than a year developing a new ethics curriculum that relied on family physicians – not trained ethicists – to teach the curriculum, as well as deliberately integrated ethical principles with the day-to-day work of family medicine.

“You can do a lecture on the principles of ethics, but if it’s not integrated within a realistic case that learners can understand in a clinical way, it seems remote,” she explains. “Our whole interest was really on grounding it in integration in family medicine and basing it on learning principles.”

Dr. Bernard and Dr. Kulasegaram then applied to PSI Foundation to evaluate the new curriculum. They worked with physician teachers at four teaching sites to teach the new curriculum, interviewed residents before and after they completed the curriculum, and evaluated the residents’ performance in the objective structured clinical examination (OSCE).

Positive pilot results help curriculum become self-sustaining

Dr. Bernard says that she and the team were “blown away” by the results. Residents from the pilot sites performed significantly better in a five-station OSCE focused on ethical issues compared to their peers who learned from the standard curriculum. And in the interviews, residents said they had greater awareness of ethical principles and could use a formal ethical deliberation process in challenging situations, which gave them more confidence to act and incorporate patients’ values into ethical deliberations.

Dr. Bernard says she was most pleased with what happened next: based on these results, the pilot sites not only continued using the new curriculum, but also supported the other training sites in implementing it. Having the curriculum become self-sustaining at the training sites was exactly the kind of result that the curriculum redesign team had hoped for.

“Now every single training site in our department is teaching it, and the original sites are acting as helpers,” she says. “We had hoped this would become a ‘train the trainer’ mentorship community of practice, and it just happened naturally that as these teachers became empowered and confident, they started teaching others.”

Having demonstrated these positive results in one department, the team hopes to generate more awareness of the curriculum results among physician teachers and residency program directors at medical schools across the country. In the long-term, she hopes that the curriculum will help more family physicians be more confident in their ethical deliberations and build positive patient relationships.

“Funding good educational research means we’re going to have good doctors in the future,” she says. “PSI’s support of this project is amazing because it directly affects the people – that is, the medical residents – who are going to make a difference in the future.”

Dr. Joel Fish: Laser Therapy Improves New and Mature Severe Burn Scars in Children

“PSI Foundation It is one of the few granting agencies that funds clinical research. Its reviewers understand good science and good methodological design, but as clinicians, they also see the clinical problems. I feel that, as a clinician, I can be competitive with PSI because they understand that type of work.” – Dr. Joel Fish, plastic surgeon and Medical Director of the Burn Program at the Hospital for Sick Children, Toronto

Hypertrophic scars – thick and stiff severe scars that are often the result of burns – can affect children’s lives in many ways, interfering with a child’s growth, mobility and even confidence. And children with these scars haven’t had many effective treatment options to reduce the scar’s appearance and size.

But a new laser therapy may help to treat these scars, whether they are new or even several years old.

Dr. Joel Fish, a plastic surgeon and Medical Director of the Burn Program at the Hospital for Sick Children (SickKids) in Toronto, led a PSI Foundation–funded clinical trial that has provided some of the strongest evidence so far supporting the use of a new laser therapy to treat hypertrophic scars in children.

Lasers have been used in medical treatment for many years, particularly for cosmetic procedures, but recent research had suggested that two specific kinds of lasers, pulsed dye laser (PDL) and carbon dioxide laser, could be particularly useful for treating burn scars – even scars that are more than 10 years old.

“It’s one of the few therapies to come along in many years that has real benefits, not just on new scars but on mature scars, so it’s quite unique,” says Dr. Fish.

But more definitive research about the effectiveness of laser therapy, especially in children, was needed. Dr. Fish and his research team designed a clinical trial to determine whether laser therapy could improve hypertrophic scars in children, and received PSI funding in 2016 to conduct the trial.

Approximately 25 children with hypertrophic scars were treated with three laser therapy sessions over the course of a year. To determine whether the scars improved over the course of treatment, between sessions Dr. Fish and his team measured the scar’s height and thickness, stiffness, vascularity and colour, using validated subjective scar assessment scales and objective tools, such as conventional ultrasound and ultrasound elastography.

After all of the laser therapy treatments, the team found that the height of the scars improved, the thickness and colour improved, and the scars were less itchy, demonstrating that the therapy was highly effective.

“It really did have measurable effects, and not only were they measurable, the scars don’t go back to the way they were,” says Dr. Fish. “Once you achieve the scar being a little bit flatter or softer or less red or less itchy, it doesn’t go back.”

With these positive results, the team now plans to do further work to understand when treatment should start and how many sessions are optimal, as well as examine how the treatment works, all of which will help to refine the therapy.

SickKids has the largest pediatric burn program in the country by a large margin, and children from across the country have been treated in Toronto instead of closer to home. In fact, it is one of the few centres in Canada to use laser therapy to treat scars in children.

But Dr. Fish’s study, along with a handful of other trials, is generating interest in the health care community about the potential for this treatment. Directors of burn programs from different countries have learned from Dr. Fish’s team how to treat children with laser therapy to implement their own programs, and more hospitals across the country are beginning to invest in the technology.

“To our knowledge, this is the most comprehensive study to date that demonstrates that laser treatment leads to significant improvements in children with burn scars,” says Dr. Fish. “We hope that our findings will encourage other providers to invest in this valuable therapy for their patients.”

Dr. Joanna Dionne: International Study Increases Understanding of Diarrhea in Critical Care Patients

A clinical study supported in part through PSI has examined one of the most common complications faced by patients in critical care – diarrhea. Dr. Joanna Dionne, who is leading the Diarrhea, Interventions, Consequences and Epidemiology in the Intensive Care Unit (DICE-ICU) study, says that PSI support was essential to the study, which aims to improve care for patients experiencing diarrhea while in the ICU.

“My Resident Research Grant from PSI was truly transformative. It provided not only financial support, but also encouragement that my physician community in Ontario believed in me and this research,” she says. “This topic may not be ‘flashy,’ but diarrhea certainly affects many critically ill Ontarians, and we could certainly change care and impact our patients if we understood it better.”

Dr. Dionne is a gastroenterologist, intensivist and internist at Hamilton Health Sciences and assistant professor at McMaster University. As a trainee in critical care with her mentor, Dr. Deborah Cook, she realized that not much information was available about the incidence of diarrhea in the ICU and its causes.

This realization eventually led to the DICE-ICU pilot study, a prospective cohort study to establish the prevalence of diarrhea in patients in critical care, identify risk factors and document its consequences on clinical decisions and outcomes. The pilot study began with four sites in Ontario, then added two sites in the US. In 2016, Dr. Dionne received a PSI Resident Research Grant to expand the study to another three Ontario sites, which mean that nearly 900 critical care patients in total participated in the study.

Residents are the principal investigators on PSI Resident Research Grants, helping them gain key research skills to help prepare them for careers as independent clinician scientists.

“Early support will make or break someone’s career and will lead them to becoming a researcher or not,” says Dr. Dionne. “It’s not just about the science, but also getting experience with the administrative work of leading a study that is so vital for your career development. It’s absolutely fundamental.”

DICE-ICU study will provide foundational information about understudied topic

The DICE-ICU pilot study used three different definitions of diarrhea to estimate the incidence in critical care patients, which ranged from 40% to 77% depending on the definition. It also identified the risk factors most strongly associated with diarrhea, which included the number of days a patient was prescribed antibiotics. And, importantly, the study suggested that Clostridium difficile, which has been thought to be major cause of diarrhea in critical care patients, is actually responsible for only a small proportion of cases.

Based on these pilot results, Dr. Dionne initiated a larger DICE-ICU study, which includes more than 1,000 patients at 12 centres in four countries – the largest study of its kind in the world. The results will provide foundational information on the cause and impact of diarrhea in the ICU and may influence treatments that increase risk of diarrhea, such as antibiotic prescribing and enteral feeding practices in ICU patients.

In 2019, Dr. Dionne received a PSI Research Trainee Award, a two-year award that provides support to protect 75% of her time for research and allowed her to further the DICE-ICU study.

“The funding I received from PSI has been the building blocks of a research program that otherwise may not have been funded,” she says. “And importantly, PSI is able to support you as you grow as an investigator. It supports junior and early career investigators and has different programs to support you over time. That longitudinal support is absolutely transformative.”

Dr. Dionne says that it was challenging to get the DICU-ICU study underway, in part because there hasn’t been much interest in studying diarrhea in critical care patients or recognition of its clinical importance. But mentorship from Dr. Cook and support from PSI encouraged her to continue pursuing this question. This support inspires her to give back to younger trainees now and in the future.

“It makes me want to give back to my province, to PSI which has been incredibly instrumental to my career, and to give those opportunities to the next generation of young investigators,” she says.

Despite the challenges young clinicians may face, especially when trying to undertake a new research program, she encourages them to persevere to examine important clinical questions that can change patient care.

“It’s a true honour to work with patients and serve my community and my province, but when you’re working at the bedside, there’s always a question you cannot answer. That curiosity always drives me back to research,” she says. “As a physician, I can do my best for my patients, but as a researcher I can help patients that I will never meet, and I think that’s pretty powerful.”

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