U of T Medicine — Spring 2014

Shedding new light on dementia, cancer and arthritis: The Genetic Puzzle of Age-related Diseases

Discussing physician-assisted suicide can be uncomfortable: Dying for a Conversation

How innovations are addressing complex chronic health conditions: If It’s Not One Thing ...

How do attitudes affect the care of older patients?

Are You Ageist?

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SPRING 2014

How U of T is helping seniors stay healthier, longer — 8

“When one of the most amazing people in your life forgets your name, it really affects you.”

Paul McKeever PhD in Laboratory Medicine and Pathobiology, 2016

His research passion was inspired by his grandmother’s battle with Alzheimer’s disease. His ability to pursue that passion was made possible with donor support, which helped this former stonemason become a grad student. Paul is an example of the impact you can have when you give to the campaign for the Faculty of Medicine. You’ll be helping future scientists like Paul develop their boundless potential to provide hope.

Donate or find out more at: donate.utoronto.ca/medicine or 416-946-3111 boundless.utoronto.ca/medicine

MESSAGE FROM THE DEAN

HE DID NOT PRACTISE MEDICINE or do research, but Teddy Roosevelt was a keen observer of human nature.

He once said: “Old age is like everything else. To make a success of it, you’ve got to start young.” Today, medical research agrees with him.

It’s increasingly clear from the data that social determinants of health, activity levels, diet and a host of exposures in our youth have a tremendous impact on not only the duration of our lives but also the quality of our lives as we age.

The factthat Canada’s population is increasingly composed of an aging population is an important public health policy challenge.

Recently, the baby-boom cohort reached its 65th birthday — and the number of seniors in Canada is growing faster than ever. According to Statistics Canada, the population of seniors increases at an average annual rate of 4.2 per cent — up from 2.8 per cent five years ago. Chances are if you are not in this cohort yourself, you are close to someone who is.

In this issue of our U of T Medicine magazine, you will read about the advances in improving the health and quality of life of our seniors — but you will also read about some of the challenges facing seniors and their families — including tough decisions that need to be made at the end of life.

You will read about the complex disorders affecting seniors, and how integrated models of care and collaborative methods of research are helping to unlock potential treatments for conditions like Alzheimer’s and related dementias.

You will also find suggestions from our own faculty members on how to age well while you are still young.

Aging with Grace and in Good Health As we near the middle of the second decade of the 21st century, issues of end-of-life and palliative care, and the management of complex diseases will loom larger and challenge our current health policies. According to the recently published Ontario’s Seniors Strategy led by Dr. Samir Sinha: “We know that older adults in general — and those with complex issues in particular — drive health care costs as they tend to use more expensive and intensive types of services, particularly in acute care settings.

Indeed, while accounting for only 14.6 per cent of our current population, nearly half of our health care spending occurs on their behalf.”

Treating our patients with the grace and dignity they deserve is one way we can make a real, positive impact as caregivers. Addressing the health challenges of aging through innovation in research and education is our social responsibility.

“Treating our patients with the grace and dignity they deserve is one way we can make a real, positive impact as caregivers.”

Catharine Whiteside BSc ’72, MD ’75, PhD ’84 Dean, Faculty of Medicine Vice-Provost, Relations with Health Care Institutions

SPRING 2014 — 1

INSIDE THIS ISSUE

Contents

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34 4 Snapshots 6 News 8 Riding the Grey Wave Helping Ontario prepare for an older population with complex health needs.

14 Dying for a Conversation Discussing physician-assisted suicide can be uncomfortable.

Is that enough of a reason to stay silent?

18 Say What?

Physicians and researchers at U of T give their tips on how to age gracefully.

2 — U of T Medicine

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20 The Genetic Puzzle of Aging-related Diseases

30 Are You Ageist?

U of T Medicine scientists are shedding new light on dementia, cancer and arthritis.

24 If It’s Not One Thing …

How innovations in patient care, research and prevention are addressing complex chronic health conditions.

29 Setting a New Course for Geriatric Medicine

How do attitudes affect the care of older patients?

32 A Nutritious Start A gift from the Lawson family will improve childhood nutrition.

34 Q&A Dr. Judith Friedland: A Trailblazer in Occupational Therapy.

36 On the Bookshelf 37 Old School

Retired Teachers of Ontario establish a $3-million chair in geriatric medicine.

COVER PHOTO: JACKLYN ATLAS. COSTUME DESIGN, HAIR AND MAKEUP: JAMES BOLTON

SUPER SENIORS

Inside this digital issue There is more to U of T Medicine than what you hold in your hands. The online version of our magazine has bonus stories, videos and photos. For this issue, you’ll find …

Rethinking Dementia The cognitive decline associated with aging can be heartbreaking.

Researchers at U of T Medicine are exploring how genes and molecules could deliver new solutions. Writer Angela Pirisi talks to Sandra Black, Executive Director of the Toronto Dementia Research Alliance (TDRA), Lili-Naz Hazrati, a neuropathologist and researcher at the Tanz Centre for Research in Neurodegenerative Diseases and Gary Naglie, Chief of Medicine at Baycrest.

Speaking Truth Danielle Martin is using her new fame to help improve the system she defended in front of the U.S. Senate. Writer Heidi Singer profiles Martin, who is an Assistant Professor in the Department of Community and Family Medicine and the Institute of Health Policy, Management and Evaluation and Vice-President of Medical Affairs and Health System Solutions at Women’s College Hospital.

Are You Ageist?

Lynn McDonald, Professor in the Faculty of Social Work and Director of the Institute for Life Course and Aging wants to know: are you biased towards the elderly? You can go online to see a video of McDonald who talks to videographer Erin Howe about ageism in the medical community.

Look for these icons to get bonus photos, videos and stories. You’ll find us at uoft.me/medmag.

PUBLISHER Lloyd Rang EDITOR-IN-CHIEF Liam Mitchell ART DIRECTION + DESIGN Raj Grainger CONTRIBUTORS Sharon Aschaiek, Roberta Brown, Veronika Bryskiewicz, Sheldon Gordon, Erin Howe, Suniya Kukaswadia, Julie Lafford, David McLaughlin, Monifa Miller, Angela Parisi, Meera Rai, Heidi Singer, Morgan Tilley, Pippa Wysong ACADEMIC LEAD Sarita Verma — PUBLISHED BY University of Toronto Faculty of Medicine 6 Queen’s Park Crescent West Suite 306, Toronto, ON M5S 3H2 Phone: 416-978-7752 Fax: 416-978-6999 Facebook: U of T Medicine Twitter: @UofTMedicine Instagram: @UofTMedicine YouTube: UofTMed Email: medicine.communications@utoronto.ca The University of Toronto respects your privacy.

We do not rent, trade or sell our mailing lists. If you do not wish to receive U of T Medicine magazine, please contact us.

U of T Medicine Unveils New Digital Look After months of hard work, the Office of Strategy, Communications and External Relations launched the Faculty’s new website earlier this year. The revamped site features a user-friendly modern design with lots of great visuals. Visit our redesigned digital home at medicine.utoronto.ca.

SPRING 2014 — 3

FACULTY OF MEDICINE IN PHOTOS

Snapshots

01 U of T’s Movember team, led by Medicine alumnus and orthopedic surgery resident Jesse Wolfstadt (MD ’11), got an out-of-thisworld prize for raising the most money in support of prostate cancer: a free lecture from former Canadian astronaut Chris Hadfield. He addressed a packed Convocation Hall, which gave Hadfield a standing ovation 02 The sun shone brightly as U of T Medicine celebrated spring convocation on June 3.

03 A sculpture of U of T Medicine alumnus Norman Bethune (BSc in Medicine ’16 ) was unveiled May 31, next to the Medical Sciences Building. On hand were artist David Pelletier, former Governor General of Canada, the Right Honourable Adrienne Clarkson (BA ’60, MA ’62), the sculpture’s donors Mr. Zhang Bin and Mr. Niu Gensheng as well as U of T Chancellor Michael Wilson (B.Comm ’59), U of T President Meric Gertler and Dean of Medicine Catharine Whiteside (BSc ’72, MD ’75, PhD ’84).

04 The Medical Sciences Building got more than a light dusting of snow this winter.

05 A delegation led by Professor Cynthia Whitehead (MSc ’08, PhD ’11), the Acting Chair of U of T’s Department of Family and Community Medicine, travelled to China where an important agreement with Fudan University was signed. The two institutions will develop activities to build education capacity in primary health care and public health.

4 — U of T Medicine

06 A student-led drive to raise awareness of Ontario’s organ and tissue donation registry became the province’s most successful campaign ever when more than 5,000 people added their names to the Trillium Gift of Life Network (TGLN). U of T President Meric Gertler (centre) and TGLN President Ronnie Gavsie (right) congratulated the team, which was led by Medical Society President Kim Blakely (left; PhD ’12).

07 CAMH President Catherine Zahn moderated a discussion with international thought leaders Victor Dzau from Duke University (and incoming President of the Institute of Medicine), Dermot Kelleher from Imperial College London and Tom Robertson from the University Health Consortium in Chicago. The panel talk was part of Fulfilling Our Potential, a day-long retreat that marked the halfway point of the Faculty’s strategic plan.

08 U of T Medicine hosted Brainstorm, which brought together colleagues, community members and alumni in London, England, to discuss the Faculty’s contributions to brain health and the global economy. Attendees included former Toronto Maple Leafs captain and Faculty supporter Mats Sundin, Chief Executive Officer of the UK’s Royal Mail Group Moya Greene, U of T Chancellor Michael Wilson (B.Comm ’59) and Dean of Medicine Catharine Whiteside (BSc ’72, MD ’75, PhD ’84).

Follow @UofTMedicine on Twitter, Facebook and Instagram to see our alumni, faculty and students in action. #UOFTMED

SUPER SENIORS

PHOTOS: JON HORVATIN (1); RAJ GRAINGER (2); ERIN HOWE (3,6,7); LIAM MITCHELL (4); COURTESY OF DFCM (5); STEVEN SHIPMAN (8)

SPRING 2014 — 5

FACULTY OF MEDICINE NEWS

News U of T Medicine Alum Slides into Gold OCCUPATIONAL THERAPY alumna and professional bobsledder Heather Moyse (MSc OT ’07) made U of T Medicine proud by bringing home a gold medal for Team Canada during the Sochi 2014 Winter Olympics.

Moyse and Kaillie Humphries had a close match against their U.S. rivals, winning by only a tenth of a second.

The duo also placed first in bobsleigh during the 2010 games in Vancouver.

Trevor Young Appointed Next Dean of Medicine Former Chair of Psychiatry Begins New Duties in 2015 Professor Trevor Young (MSc ’89, PhD ’95), Chair of U of T’s Department of Psychiatry, has been named the next Dean of the Faculty of Medicine. Young will also serve as the University’s ViceProvost, Relations with Health Care Institutions for a concurrent term. He succeeds Professor Catharine Whiteside (BSc ’72, MD ’75, PhD ’84) who has led the Faculty since 2005.

“We are delighted that Professor Young will be leading the University’s internationally renowned Faculty of Medicine,” said President Meric Gertler. “Professor Young’s outstanding record of contributions in clinical practice, research and administration make him ideally suited to this role, and I look forward to working with him.”

Young is a clinician-scientist who looks at the molecular basis of mood disorders and their treatment, and how to apply these findings to a clinical setting. The former Cameron Wilson Chair in Depression Studies at the University of Toronto is also a Professor in the Department of Pharmacology and Toxicology and Senior Scientist at the Centre for Addiction and Mental Health (CAMH). He is a Fellow of the Canadian Academy of Health Sciences, a Senior Fellow of Massey College and a Distinguished Fellow of the American Psychiatric Association. Young’s five-year appointment begins 1 January, 2015. We will reflect on the career of Dean Whiteside in the next issue of U of T Medicine.

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PHOTOS (FROM LEFT): RACHEL PETERS; JACKLYN ATLAS

SUPER SENIORS

DFCM Professor Schools U.S. Senate about the Canadian Health Care System

SANOFI PASTEUR TURNS 100 From a single-person operation run out of a stable to an international powerhouse employing 13,000 people, leading vaccine developer Sanofi Pasteur has come a long way since Dr. John G. FitzGerald helped launch the company in 1914. The vaccine developer — now in its 100th year — is known for a number of immunization innovations including responding to a shortage of tetanus antitoxin during the First World War and introducing the Salk polio vaccine. Sanofi Pasteur also played a role in eradicating smallpox and produced the first supply of insulin for clinical trial.

The Department of Family and Community Medicine’s Professor Danielle Martin is proud of Canada’s health care system — and she’s not afraid to show it. Martin — who is also Vice-President Medical Affairs and Health System Solutions at Women’s College Hospital — participated in a U.S. Senate panel on March 11 about single-payer health care models where she addressed critics with her quick wit and intelligent responses.

When asked by Republican Senator Richard Burr how many Canadian patients died on waiting lists, Martin replied: “I don’t, sir, but I know that there are 45,000 in America who die waiting because they don’t have insurance at all.”

BONUS: VIDEO & STORY uoft.me/medmag

Krembil Discovery Tower Welcomes Leading Researchers The much anticipated Krembil Discovery Tower opened its doors last fall. The state-of-the-art facility houses Canada’s largest concentration of neurologists, neurosurgeons, neuroradiologists and neuroscientists, including researchers from the Tanz Centre for Research in Neurodegenerative Diseases.

Facts: 01 Houses 150 researchers, including neurologists, neurosurgeons, neuroradiologists and neuroscientists 02 Has 30,193.5 square metres and is 56.5 m tall 03 Is expected to use about 25 per cent less energy than a similar building, with its use of occupancy sensors and heat recovery system, and 60 per cent less water, by using rainwater and low-flow fixtures PHOTOS (CLOCKWISE): SANOFI PASTEUR CANADA (CONNAUGHT CAMPUS) ARCHIVES; ERIN HOWE; ROBERTA BROWN

SPRING 2014 — 7

AGING POPULATION

How U of T Medicine is helping Ontario prepare for an aging population with complex health needs.

8 — U of T Medicine

PHOTO: JACKLYN ATLAS

SUPER SENIORS

RIDING THE GREY WAVE

BY PIPPA WYSONG

PHOTO: JACKLYN ATLAS

SPRING 2014 — 9

AGING POPULATION

Ontarians are getting older, faster.

By 2016, for the first time, there will be more seniors in Ontario than children.

By 2036, the number of seniors in the province will have more than doubled from 2 million in 2012 to almost 4.2 million.

Canada’s biggest province isn’t alone. In many industrialized countries, an aging and growing population is putting strain on economies, pension plans and public health programs.

Health care professionals are doing their part to ensure that elderly people have what they need to live long, healthy lives, but it’s a tremendous challenge — one that faculties of medicine, including ours at the University of Toronto are working hard to address.

10 — U of T Medicine

AS WE AGE, MANY OF US will develop complex conditions. For instance, we may find ourselves facing diabetes, mobility issues due from arthritis and heart disease at the same time. Complex diseases require more complex care, so people struggling with a variety of conditions need care from a variety of services — ranging from treatments from specialist physicians to rehabilitation specialists to nurses. They may also need help at home, and transportation around town.

Making sure that people get this kind of integrated care is one of the goals of Building Bridges to Integrate Care (BRIDGES) established and co-led by the Departments of Medicine and Family and Community Medicine with support from the Ontario Ministry of Health and Long Term Care. The series of evaluative projects are

seeking new ways to help integrate existing programs and services to give people seamless access to health care and provide the evidence to support these new directions. They’re conducting nine different multidisciplinary and multi-agency studies addressing different aspects of care and services for people with complex diseases.

“All the various health and community services that people need have evolved independently to address specific needs and work under separate organizations and institutions. Services are fragmented making them inefficient and more costly overall than they need to be,” says Onil Bhattacharyya (PhD ’07), Associate Professor in the Department of Family and Community Medicine and co-Principal Implementer of BRIDGES. PHOTO: JACKLYN ATLAS

SUPER SENIORS

“The best estimates we have say that Ontario could save between $4 and $6 billion a year by eliminating redundant services, improving coordination and providing more appropriate services.”

There are gaps in the system as well as overlap.

For example, some people may cycle between inpatient and outpatient care as well as support from community services.

BRIDGES helps correct these problems by integrating services, which reduces costs in the health care system and makes the system work better for patients and providers alike.

“The best estimates we have say that Ontario could save between $4 and $6 billion a year by eliminating redundant services, improving coordination and providing more appropriate services,” says Bhattacharyya.

“Our goal is to develop and test different models of care to help these higher-risk patients so we can reduce their need for hospitalization and improve their overall quality of care,” he said.

Once the evidence shows PHOTO: JACKLYN ATLAS

which models work best, they can be scaled-up and rolled-out across the province. This is where Samir Sinha, an Assistant Professor of Medicine and Director of Geriatrics at Mount Sinai Hospital, comes in.

Sinha has been testing alternative ways of integrating services and care in different communities as part of an overall Acute Care for Elders (ACE) strategy at Mount Sinai. One new approach he is leading is the 24-bed ACE Unit, which opened its doors in 2011.

Through ACE, patients are treated for their medical problems in the hospital where a team of specialists and caregivers work together to determine their social and functional needs — and ensure they get the right supports and services when they are discharged. Hospital staff work closely with

community partners such It’s part of Ontario’s Action as the Community Care Plan for Health Care, which Access Centre, House Calls outlines a new direction for and other agencies revamping the health care to deliver the care patients system. need.

Sinha’s recommendations “The approach is working,” — developed after broad says Sinha. “By linking all consultation — address these systems together financial security, finding with technology and better primary care physicians communication, we are and ensuring that seeing better outcomes for community support our patients.” agencies and family doctors The approach also saves can communicate better. money. In 2012–2013, ACE The report suggests saved the hospital $6.4 developing more assisted million by supporting living and supportive shorter hospital stays housing units so that and reducing repeat people with needs can live admissions — all while independently for longer serving even more and diversifying the scope patients than before. of care that can be provided The success of these by paramedics — especially projects led to Sinha in rural communities. The becoming the Provincial report also recommends Lead of Ontario’s Seniors allowing long-term care Strategy. He authored the facilities to offer out-patient “Living Longer, Living Well” care to people in the report, which is being used community. by the Ministry to integrate Finally, the report says services and care that geriatrics needs to be throughout the province. a core part of training SPRING 2014 — 11

AGING POPULATION

2036 2012

Age Pyramid of Ontario’s Population 2012 and 2036 Males Sources: Statistics Canada, 2012, and Ontario Ministry of Finance projections.

programs for all health professionals.

“Canada has a shortage of geriatricians, and part of that is because people are not exposed to working with older people in their training,” Sinha says.

So far, the province has already taken action on two-thirds of the recommendations.

“As a result of the programs enhanced by that investment, there was a 26 per cent drop in people aged 75 and over being placed into long-term care facilities,” Sinha says.

Waiting lists for long-term care facilities are shorter than they were just three years ago.

REDUCING ELDERLY people’s need for health care services is also an important part of the solution.

Geoff Fernie and Alex Mihailidis (B.AS ’96, MASc ’98) from the iDAPT 12 — U of T Medicine

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(Intelligent Design for Adaptation, Participation and Technology) Centre at the University Health Network, Toronto Rehabilitation Institute (TRI) are working on doing just that. Researchers at the centre are creating innovative technologies to help people with daily tasks, mobility issues and communication.

Hidden away on University Avenue, iDAPT is a series of labs, workshops and offices located two-and-a-half stories above ground and five storeys underground.

The facility has a series of rooms that allow researchers to model everything from someone’s apartment to a hospital room to an outdoor environment. The rooms and equipment allow researchers to mimic everyday environmental challenges faced by older people.

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“For the aging person, we are working on three fronts,” says Fernie, who is a Professor in the Department of Surgery and the Institute of Biomaterials and Biomedical Engineering and Vice-President Research at TRI. “Prevention, rehabilitation and independent living.”

One example of prevention is a new method researchers have developed to rate the safety of footwear on ice. After testing various boots and shoes on an icy surface in one of their labs, they discovered the key to staying upright in winter is the material used for a shoe’s sole, not the tread.

The team is now inviting shoe manufacturers to send shoes for testing so they can offer labels with ratings of how well the shoes grip ice.

This ensures consumers can look for shoes that are safer on ice — and prevent falls, says Fernie. He notes

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that falls account for huge surges of emergency room visits in the winter.

Falls on household stairs are another big source of injuries. Fernie’s team discovered that the standard length of each step is too short and can lead to an increased risk for falls. The Canadian building code will be changed as a result, which should result in three times fewer falls.

Alex Mihailidis is leading a project that will use a small ceiling-mounted device combining a motion sensor, communications system and a computer vision. The system can detect if you fall, and will ask if you need assistance.

If you say yes or don’t respond at all), it will call or text family members or neighbours to help — or call 911 directly.

“Together these projects will make the smart home of the future.

SUPER SENIORS

Boundless Promise The Boundless campaign is more than a fundraising initiative — it is a key commitment of the Faculty of Medicine to support excellence in health research and education.

Over the last year, the Faculty has made great progress in reaching our $500 million goal. With landmark and sustaining gifts from our community of alumni, donors, faculty, staff and friends, we’ve raised $358 million as of April 30, 2014. This achievement reflects the confidence our supporters have in the Faculty’s ability to transform health in the 21st century. Here are some interesting campaign facts.

“Together these projects will make the smart home of the future.

The technology can be fitted into anyone’s home, will be affordable and will help older people live independently for much longer.”

The technology can be fitted into anyone’s home, will be affordable and will help older people live independently for much longer,” says Mihailidis.

Policy makers worry that the oncoming grey wave — the rapid growth of the number of seniors in the coming years — has the potential to swamp the health care system.

Clinicians and researchers at U of T Medicine are doing their part to ensure Ontario can ride that wave by improving the delivery of care — and ensuring care is needed less frequently.

These lessons are not only having an impact in Ontario but are also informing responses in other parts of the world.

Sinha’s report has been downloaded over 25,000 times from countries around the globe and has been reviewed across Canada as well as in New Zealand and Singapore.

“Last December, I was invited to present the strategy to the World Health Organization.

I’m honoured that they’ve taken such an interest in the report and its principles,” says Sinha.

In Toronto, Sinha and others at U of T continue to influence policy and solve serious problems related to aging.

Since the beginning of the campaign, U of T Medicine alumni: ××

Have made 3,653 donations

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Have given an average amount of $2,285

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Have donated just over $51 million

Now’s the Time — Make a Gift Today!

Our challenge is to keep up the momentum and reach our $500 million goal. We can’t do this without your continued support. To learn more about the Faculty’s campaign and the many ways you can contribute, please visit donate.utoronto.ca/medicine Your contribution will help educate our future health care leaders and advance groundbreaking research that will help improve clinical care for generations to come.

BONUS: VIDEO uoft.me/medmag SPRING 2014 — 13

DOCTOR-ASSISTED DEATH

Kerry Bowman and James Downar in the DeGasperis Conservatory at Toronto General Hospital.

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SUPER SENIORS

Discussing physicianassisted suicide can be uncomfortable.

Is that enough of a reason to stay silent?

BY DAVID MCLAUGHLIN

PHOTO: JACKLYN ATLAS

SPRING 2014 — 15

DOCTOR-ASSISTED DEATH

He is everything you would want to see in a doctor: confident, kind, experienced, knowledgeable.

SPEAKING IN A COMFORTABLE ROOM AT HOME, HIS WARMTH and ease seem at odds with the difficult and controversial subject of his eight-minute YouTube video.

He is clearly in poor health; it’s been only months since a diagnosis of brain cancer, which has no treatment.

He tells the camera he will soon die. His disease will eventually take away his ability to see, hear, speak and swallow. This is not how he wants it to end. He’d like to choose the moment, be able to say goodbye to loved ones.

Donald Low, a renowned public health physician and researcher, became widely known for his calm leadership during the SARS crisis. He later became known for speaking with grace and clarity about his own imminent death and why he believed it is time for Canadians to begin talking about the possibility of physician-assisted dying.

It is an option that was not available to him. But still exhibiting the values that characterized a lifetime of advocacy, Low argued that other terminally ill patients should someday be given a choice.

“Why make people suffer for no reason when there’s an alternative? I just don’t understand it,” said Low. In Canada, the issue of assisted suicide recedes from the front pages, at times, but never seems fully settled either.

In 1993, the Supreme Court ruled against physicianassisted death, by a narrow 5–4 margin, in a case involving British Columbian Sue Rodriguez. In 2010, the House of Commons voted on legalizing assisted dying, which was defeated by a wide margin. At their most recent policy convention, federal Liberals voted in favour of a proposal to legalize assisted dying, though it has not been included in any platform document. One legislature in Canada — Quebec — came within a third-reading vote of legalizing assisted dying, a bill stranded by a surprise election call.

The Supreme Court of Canada says it will hear an appeal by the B.C. Civil Liberties Association that could grant terminally ill Canadians the right to assisted suicide.

While ethicists, lawyers, philosophers, politicians and the public weigh and debate the issue, the medical profession has not been among the voices calling for a wider discussion. The Canadian Medical Association, at their 2013 annual meeting in Calgary, defeated a resolution urging the government to conduct a large-scale public consultation regarding medical aid in dying at the end of life.

Kerry Bowman (MSW ’87, PhD ’97) is an Assistant Professor in the Department of Family and Community Medicine at the University of Toronto, and a bioethicist at the University of Toronto Joint Centre for Bioethics.

16 — U of T Medicine

He sees a rapid change in attitudes around assisted dying and thinks physicians need to be more engaged in the discussion.

“Health workers have been too silent for too long,” says Bowman. “It is not necessary to have a position, but we have perspective and experience that is valuable to this debate.”

For example, he explains that when physicians receive a request for assisted dying, it can act as a starting point for a deeper conversation about the patient’s suffering.

“It is an illegal act and a request that cannot be granted.

But by asking the patient why they want it, it leads to questions about symptoms, whether it is depression, pain or others. The stigma of illegality, however, can prevent such a conversation from happening.”

Bowman himself believes that physician-assisted death should be allowed in very limited circumstances. “I believe there is a very small percentage of terminal patients, who are capable, but with symptoms that cannot be treated, and pain that cannot be managed, where, if a request is made, it should be considered,” he says. “I’ve come a long way; I did not use to believe that.”

As an ethicist, he is acutely aware of the moral hazard associated with physician-assisted dying.

“There is a concern there would be an implied social pressure on the elderly and disabled — the feeling that they are a burden.”

It is sometimes argued that until high-quality palliative care is available to everyone in Canada, physician-assisted suicide should not even be considered. Bowman agrees that a discussion of legalizing physician-assisted dying should be part of a broader — and overdue — conversation on gaps in palliative care.

“I’ve seen surveys of health workers in palliative care where quality is often rated as poor. If that were a cardiac program, we would not accept such low grades,” says Bowman.

A 2010 Senate Report, “Raising the Bar,” written by Senator Sharon Carstairs, highlights that 70 per cent of Canadians do not have access to palliative care.

“We are a death-denying society who refuses to accept that we are all going to die, and cling to the hope that our own death will be quick and painless. Yet, that will not be the reality for 90 per cent of us,” she writes.

The quality of palliative care is one of the factors that takes the discussion of physician-assisted dying towards that most feared of places: the slippery slope. Many physicians, and others, worry that instead of investing in better care for the dying, physician-assisted death would be used as a “shortcut,” thus reducing demand for palliative services.

The concept of a slippery slope is why legislators proceed with caution, and consult widely on nearly any change

SUPER SENIORS Donald Low

in law. When it comes to the most irreversible of all consequences — death — Canadian legislatures, except for Quebec, have chosen not to proceed at all.

James Downar (MSc ’10) is an easygoing physician, but when engaged by a topic, he speaks with a knowledge and eloquence reflecting a mind that doesn’t arrive lightly at conclusions. He sees a fundamental problem with the slippery slope argument: it has no place in medical science.

“In Oregon, in 2011, after more than a decade of legalization, only 0.2 per cent of all deaths were due to assisted dying. In Holland and Belgium, the numbers have actually fallen since legalization, and remain in the 2 to 3 per cent range” “In medicine, we look at the evidence. Where physicianassisted dying has been legalized for terminal patients near the end of life, it is only used by a small percentage of patients,” says Downar, who is Assistant Professor, Divisions of Critical Care and Palliative Care, University of Toronto.

“In Oregon, in 2011, after more than a decade of legalization, only 0.2 per cent of all deaths were due to assisted dying. In Holland and Belgium, the numbers have actually fallen since legalization, and remain in the 2 to 3 per cent range,” says Downar.

Downar also points to evidence that echoes Bowman’s assertion that legalization of assisted dying can increase overall communication and understanding around end-of-life care.

“Legalization of assisted dying has actually been associated with a growth in palliative care hospice services in the Netherlands and Belgium, and Oregon now has some of the highest rates of hospice referral, opioid prescription and end-of-life communication in the U.S.” Downar, who acts as a medical advisor to the advocacy group Dying with Dignity, is reassured by evidence from U.S. examples that the moral hazards could be overcome and that the vulnerable can be protected.

“Patients who receive assisted dying are overwhelmingly educated, non-elderly and insured, and they are almost always motivated by personal concerns about control and quality of life, rather than concerns about the effects of their illness on their family,” he says.

A frequent debater, Downar goes out of his way to express respect for physicians and others who oppose assisted death. However, he does see a moral inconsistency in how society and the medical profession view controlled death.

“We have crossed this line already. Physicians honour a patient’s request to withdraw life support or discontinue feeding and hydration, which hasten death. Compared to those circumstances, which are legal, what moral advantage is achieved waiting for a terminally ill patient’s horrendous complication to arise and end their life?”

As an advocate for giving terminally patients a choice, Downar makes a somewhat surprising admission: “Even if it became legal to assist terminal patients with symptoms that cannot be fully managed, I am not sure I would do it.”

In fact, most doctors are reluctant. A Canadian Medical Association poll last year found that only one in five doctors would be willing to help a patient end his or her life if euthanasia were legalized.

Both Downar and Bowman emphasize that the conscientious objections of physicians must be honoured.

Bowman imagines that legalized assisted dying would only ever be carried out by a few specialists, trained in navigating both medical and ethical considerations.

While it is up to society to ultimately decide, he does not see the issue diminishing. Rather, he sees the opposite.

“At one time, physician-assisted dying would not even be discussed at the medical conferences focused on end-oflife care. Now, you see presentations on the subject.

Throughout health care, we see patients wanting to exercise greater control and to have more choice.”

Donald Low died on September 18, 2014, eight days after filming his online appeal. James Downer is among the more than 80,000 who have watched the video. He knew Low by more than reputation. Downer worked in Low’s lab earlier in his career and co-wrote papers with him.

“He was a sweet, kind man,” says Downar.

While he had made up his mind already, watching Low’s video boosted his confidence in sharing his opinions more widely.

“I began my career believing that there was no rational need for physician-assisted death, because palliative care could manage all symptoms and, therefore, physicians could assist patients in living out their lives until they died naturally,” says Downar. “Over time, I have found there is a very small percentage of patients where that does not hold true. But the dying have had no voice, no political capital.”

Low, because of his notable career, had such capital.

And he spent what remained on an enduring appeal to fellow physicians to consider his experience as a terminally ill patient: “… there’s a lot of clinicians in opposition to dying with dignity. I wish they could live in my body for 24 hours and I think they would change that opinion.”

SPRING 2014 — 17

SAY WHAT?

Want to grow old gracefully?

Stay active!

We asked physicians and researchers at U of T to give their tips on how to age gracefully. This is what they told us.

BONUS: VIDEO uoft.me/medmag 18 — U of T Medicine

PHOTO: VITALY KAZAKOV

SUPER SENIORS

“As a specialist in geriatric medicine and a health services researcher in the area of aging, I find that most people see aging as a subject of interest only to people who are old. In order to age gracefully, my view is that Canadians need to think of aging as a process that is lifelong and begins when a person is born.

Investing in health from an early age with regular physical activity and engagement with life will have long-term benefits for people as they age. The key is to start now.”

PAULA ROCHON MD, MPH, FRCPC Professor of Medicine; Vice-President, Research, Women’s College Hospital

“As a neuroscientist, it would be great if I could point to the ultimate brain-training platform to help you age well, but it seems that key is exercise. It’s probably *the* most reliable predictor of good brain health. It doesn’t take much, but it helps not just in terms of fitness, but also to clear your head.

I always have a new perspective on a problem after a run or yoga routine.”

RANDY MCINTOSH PhD Professor of Psychology; Vice-President Research, Baycrest and Director of the Rotman Research Institute

“Love and be loved. Social capital matters.”

CAMILLA WONG BSc ’99, MD ’03 Assistant Professor, University of Toronto; Geriatrician, St. Michael’s Hospital

“I always advise all patients to make sure as they grow old to never get sick and to be fabulously wealthy.

Many ignore my sage advice, and to them I recommend that they have a strong support network as they grow older.”

BARRY J. GOLDLIST MD ’74, FRCPC, FACP, AGSF Professor of Medicine; Head, Geriatric Services, University Health Network and Toronto Rehabilitation

“Stay in the game, whatever that might be. If you play a sport or do an activity in your 60s then you should be able to do it in your 80s. If you can’t, then let your doctor know so you can hopefully get back into it. Don’t attribute anything to aging alone.”

ROBERT LAM

MD, MS, CCFP, FCFP (CARE OF THE ELDERLY) Assistant Professor of Family & Community Medicine; Attending Physician, Geriatric Rehabilitation Program, Toronto Rehab

01 Exercise daily, (i.e. walk for 20 min., stretch for 10 min.)

02 Listen to music for at least 30 min 03 Meet with people at least twice a week 04 Eat small amounts of food and avoid eating after 7 pm 05 Keep your medical problems under control 06 Do all the preventative tests: mammogram, BMD, colonoscopy, thyroid, diabetes

“While there is still much to learn, what is most consistently clear from the evidence to date is regular physical activity, maintaining a strong social network, and properly managing any chronic health conditions are key protective factors. Staying mentally engaged throughout life and being financially stable don’t hurt either.”

SHABBIR M.H. ALIBHAI

M.H., MD ’93, MSc ’01 Associate Professor of Medicine; Staff Physician, University Health Network and Mount Sinai Hospital

07 Volunteer MARICA VARGA MD FRCPC Professor, Department of Medicine; Chief of Geriatric Services, St. Joseph’s Health Centre

“Don’t ever change your routine; if you were always socially, physically and mentally active, continue this forever. That way you never get old.”

DAN LIBERMAN MD, MScCH, FRCPC Medical Lecturer; Medical Lead, Geriatric Rehabilitation Program, Toronto Rehabilitation Institute

“The first tip is to choose the right parents and biogenetic makeup.

After that, manage what’s in your control — keep physically and mentally active; develop and encourage robust social networks; volunteer if you have an opportunity to do so; and, find ways to see the humorous side of life and the world.”

MICHAEL GORDON MD, MSc ’01, FRCPC, Professor of Medicine; Medical Program Director Palliative Care, Baycrest SPRING 2014 — 19

GENETICS

THE GENETIC PUZZLE OF AGINGRELATED DISEASES Genetic discoveries by researchers at U of T Medicine are shedding new light on dementia, cancer and arthritis.

BY SHARON ASCHAIEK

20 — U of T Medicine

SUPER SENIORS

ILLUSTRATION: LUKE PAUW

SPRING 2014 — 21

GENETICS

“Sometimes, it feels like a thousand ants are eating my bones.

Other times, it feels like somebody’s putting nails into me with a hammer, or using an electric saw to slice my joints.

You never know when the pain is coming, when it’s going, and which joints will be affected.”

AFTER 14 YEARS OF LIVING WITH rheumatoid arthritis (RA), 51-year-old Alla Diatko is intimately familiar with the nuances of her body’s aches and pains. She can also concisely summarize the hardships RA, an autoimmune disease with genetic links that causes pain, inflammation and swelling in the joints and organs, has visited on her life: an office job she had to leave after she couldn’t even hold a pen; crippling fatigue that makes it difficult to cook or clean, even walk; days when it has been too painful to get out of bed; and years of unemployment, which has forced her to rely on financial support from her 30-year-old son.

“This disease is a really nasty one — it steals your life,” Diatko says.

Diatko is one of 300,000 adults in Canada with RA. And they are among the millions of Canadians suffering from age-related diseases such as cancer, dementia, heart disease, osteoporosis and diabetes. Key to tackling these illnesses is understanding their genetic 22 — U of T Medicine

underpinnings, and some of the most important research in this area is taking place in the labs of University of Toronto medical researchers. By studying the genes involved in these diseases, they are helping to advance current treatments, and laying the groundwork for medicines tailored to our individual genetics.

Kathy Siminovitch (MD ’76) is one such researcher. A clinician, geneticist and Professor in the Department of Medicine at the University of Toronto with cross appointment in the Departments of Immunology and Molecular Genetics, she studies RA and other debilitating autoimmune conditions. Siminovitch, who holds the Canada Research Chair in the Mechanisms Regulating Immunologic Disease and leads a research team at Mount Sinai Hospital LunenfeldTanenbaum Research Institute, has identified some of the approximately 100 gene variants associated with the risks for RA. Recently, she discovered a second gene involved in the risk for RA in the chromosome six region, which was historically thought to have only one risk-associated gene.

RA usually strikes after age 40, but its impact on sufferers and how they age differs from person to person, Siminovitch says. It is an autoimmune disease, meaning it is activated by an environmental element, usually an infection. So while gene variations may be present, when or even whether it manifests depends on a triggering event. Once it develops, the frequency and severity of RA symptoms vary for

each person, and it’s not clear why.

What’s better understood, Siminovitch says, is that the sooner you treat RA, the better.

“In rheumatoid arthritis, and it’s probably true for any autoimmune disease, we know that the earlier you catch the disease and treat it, the way better outcomes you will have,” Siminovitch says.

To better understand the cause and progression of RA, Siminovitch is undertaking a massive, years-long project involving genetic screening of several thousand people with RA. She hopes the results will promote personalized medicines that treat RA patients according to their specific genetic risk factors.

“I think [this knowledge] is really going to drive the way we treat people, and the development of new therapies in the future. There’s a lot to be optimistic about,” she says.

Such optimism can be found too at U of T’s Tanz Centre for Research in Neurodegenerative Diseases, where a genetic focus is taken to tackle diseases like Alzheimer’s, Parkinson’s and dementia.

Tanz Centre Director and University Professor Peter St George-Hyslop in the Department of Medicine, is investigating the molecular mechanisms causing neurodegeneration in conditions such as Alzheimer’s disease. St GeorgeHyslop and his team have played a primary or partial role in discovering the approximately 20 genes associated with this most common form of dementia that affects 750,000

SUPER SENIORS

“The kind of research we are doing, going deep to understand how the disease works, what causes it, what are the sequential steps that occur, is going to make a difference on a therapeutic level.”

Canadians, most age 65 or older.

They have also had success with identifying and determining the functions of the amyloids —or harmful proteins — that generate the neurotoxic compound central to the disease.

“We learned that one gene encouraged protein accumulation in the brain that was near toxic.

A mutation in this gene led to a mutant protein that killed neurons.

This is a central component of understanding neurodegenerative diseases, as the vast majority appear to be due to this process,” St GeorgeHyslop says.

What the Tanz researchers have also learned is that different genes associated with Alzheimer’s have different effects on how one ages with the disease. For example, he says, one irregular gene poses a 98 per cent chance that its carrier will get the disease between ages 40 and 55, and die within 10 years. Lower-risk gene variants, however, carry only a 5 per cent to 10 per cent risk, and the condition may not manifest until age 65 or older.

St George-Hyslop and his collaborators have built on their knowledge to develop an Alzheimer’s vaccine that, in pre-clinical trials, blocked the accumulation of amyloid protein in the brain and prevented cognitive failure. The vaccine has been tested in clinical trials by pharmaceutical companies such as Eli Lilly and Elan, and more such trials are still underway.

“The kind of research we are doing, going deep to understand how the disease works, what causes it, what are the sequential steps that occur, is going to make a difference on a therapeutic level,” St GeorgeHyslop says.

Much of what we know about the genetics of breast and ovarian cancer come courtesy of Steven Narod, a Professor in U of T’s Department of Medicine and Dalla Lana School of Public Health. He has made a significant impact on current knowledge of how to assess the risk for these cancers, and reduce mortality among carriers of mutated BRCA1 and BRCA2, the primary genes involved in the hereditary form of these cancers.

A Tier 1 Canada Research Chair in Breast Cancer who directs the Familial Breast Cancer Research Unit at Women’s College Research Institute, Narod has extensively researched current cancer screening and treatment methods, including mammography, chemotherapy, and prophylactic surgeries — primarily mastectomies and oophorectomies (removal of ovaries).

Narod’s most recent research found that among BRCA1 or BRCA2 carriers preventive oophorectomies were associated with an 80 per cent reduction in the risk of ovarian, fallopian tube, or peritoneal cancer, and a 77 per cent reduction in all-cause mortality. In another study, he found women with BRCA mutations treated for stage I or II breast cancer with a bilateral

mastectomy were less likely to die from breast cancer than those treated with a unilateral mastectomy.

About 23,800 new diagnoses of breast cancer occur in Canada each year, usually in women ages 50 to 70.

For ovarian cancer, there are about 2,600 new cases each year, typically occurring in women over age 50.

Mutated BRCA1 and BRCA2 genes account for about 5 per cent of all breast cancers and up to 11 per cent of all ovarian cancers. Women with an abnormal BRCA1 or BRCA2 gene have a 40 to 85 per cent chance of developing breast cancer, and a 15 to 65 per cent risk of developing ovarian cancer. Other genes are also involved in these cancers, and scientists are still exploring the role of all of them in how these cancers progress.

Narod says he isn’t sure how or even whether personalized medicine may emerge for breast and ovarian cancer.

But given what research like his and that of others show about the efficacy of prophylactic surgeries, he says the medical system should conduct more screening of women for harmful BRCA genes and promote prophylactic surgeries.

“I think we would be much better spending all of our energy and time on getting widespread genetic testing for BRCA1 and BRCA2 … and that everybody with a mutation be recommended to have chemotherapy, bilateral mastectomy and oophorectomy,” Narod says. “I think it should be the standard of care as of tomorrow.”

SPRING 2014 — 23

COMPLEX DISEASE

If It’s Not One Thing …

How innovations in patient care, research and prevention are addressing complex chronic health conditions.

BY SHELDON GORDON

24 — U of T Medicine

SUPER SENIORS

Mary, 65, was admitted to hospital with a stroke that left her with double vision. In the past three years, she has also had coronary bypass surgery and a mastectomy. Her diabetes and blood pressure are poorly controlled; she suffers chronic pain and is depressed.

She sees a family doctor, a cancer specialist and an endocrinologist, but not a cardiologist or a psychiatrist. She is separated, lives alone and, although functioning independently, is socially isolated.

“Mary” is typical of a patient group posing a huge challenge to our health care system: a growing population of seniors with complex chronic health conditions and multiple care providers.

Ontario alone has 170,000 such patients, costing the provincial health care system $9 billion annually.

The numbers are rising as the population ages and life-extending treatments flourish.

Through improved patient care, innovative research and greater prevention, U of T Medicine is addressing this challenge.

SPRING 2014 — 25

COMPLEX DISEASE

Patient Care

BRIDGEPOINT HEALTH, AN INTEGRATED network of health facilities and services that is Ontario’s largest complex care rehabilitation centre, is one of the institutions wrestling with the complex chronic health challenge.

Renée Lyons is Professor at U of T’s Dalla Lana School of Public Health and Institute of Health Policy, Management and Evaluation, Bridgepoint Health’s Chair in Complex Chronic Disease Research and the TD Scientific Director at the Bridgepoint Collaboratory for Research and Innovation.

Over the past five years, Lyons has built a research program on health systems re-engineering for patients with complex chronic care needs.

Her studies accompany Bridgepoint’s shift in its model of care — away from isolated treatments by multiple clinicians, and towards a collaborative approach that treats the patient’s overall physical and psychosocial health.

Bridgepoint, which previously had a long-term care population, now averages a patient stay of only 90 days.

26 — U of T Medicine

“We provide much more intensive rehab or restorative care,” says Lyons.

“The bulk of patients end up going home. We look at how we can transition people to being as independent as possible back in the community.”

In order to develop high-quality care, though, “you have to know who your clients are,” says Lyons. So her unit initiated a study of Bridgepoint’s patients — who they are, how they got there, and their multiple health conditions. “We found that our data systems needed improvement even on such things as why certain medications were prescribed.”

Also, although Bridgepoint is a leader in restoring patients’ physical functions, her research team found resources lacking for mental health issues. One-half of patients display a risk for clinical depression. A more advanced patient assessment tool was developed that focused on mental health and social factors, and mental health professionals were hired. Bridgepoint embedded specific mental health goals and indicators in its quality and safety plan.

“The bulk of patients end up going home.

We look at how we can transition people to being as independent as possible back in the community.”

— Renée Lyons

In May, Bridgepoint announced its intentions to merge with Mount Sinai Hospital by the end of 2014 to allow for better integrated patient care. The newly established Sinai Health System will join the clinical care, research and education activities of the two organizations into one effort, though both Mount Sinai and Bridgepoint will keep their brands and locations.

“As we come together, we will meet and strengthen our commitment to patients and families, by creating an opportunity to offer a more comprehensive, highly coordinated care experience,” Marian Walsh, Bridgepoint’s president and CEO, said in a release.

PHOTO: JACKLYN ATLAS

SUPER SENIORS

Research PAULA ROCHON IS LEADING STUDIES on drug therapy management of chronic disease among the 1.8 million Ontarians aged 65 and older.

Rochon, a geriatrician, is a Professor at U of T’s Department of Medicine and a senior scientist at the Institute for Clinical Evaluative Sciences (ICES).

She is also Vice-President of Research at Women’s College Hospital.

Her multidisciplinary team, comprising physicians and statisticians, analyzes Ontario-wide databases (available from ICES) on medical services and medications provided to the 65+ age group.

“The evidence for how you prescribe drugs comes from clinical trials, which focus on people who are younger and healthier,” says Rochon.

“But the drug therapies tend to be

PHOTO: JACKLYN ATLAS

used on patients who are often older, are predominantly women and have multiple chronic conditions. We’re looking at what happens when these drugs are used in the ‘real world.’”

Clinical trials study adverse drug effects in terms of specific outcomes, for example a hip fracture or impairment of cognitive functions.

Rochon’s research instead considers the side effects not in isolation but collectively.

“It’s one thing to know the risk of suffering a single event,” she says, “but it’s important to understand the risk of developing any of these events, including some you may not currently recognize.”

They found side effects that did not initially appear to be linked to the drug actually were.

“It extends our understanding of how a drug will impact a group in much greater detail. You can use this information to modify the way a drug is prescribed,” she says. “There’s room for intervention here to improve our prescribing practices.”

“Drug therapies tend to be used on patients who are often older, are predominantly women and have multiple chronic conditions. We’re looking at what happens when these drugs are used in the ‘real world.’”

— Paula Rochon

SPRING 2014 — 27

COMPLEX DISEASE

Prevention RESEARCH ON TOBACCO USE MAY help reduce the strain that chronic diseases among the elderly place on the health care system. Smoking is responsible for 13,000 deaths a year in Ontario, and $6 billion in direct health care costs. It is the primary cause of lung cancer and chronic obstructive pulmonary disease (COPD), and is associated with other forms of cancer and diabetes.

Robert Schwartz is Associate Professor at the Dalla Lana School of Public Health. He is also Executive Director of the Ontario Tobacco Research Unit, a Canadian leader in tobacco control monitoring and evaluation.

The unit’s latest Smoke-Free Ontario Strategy Monitoring Report

28 — U of T Medicine

found that the largest number of current smokers in Ontario are aged 50 to 54. While much of the emphasis in tobacco control is on prevention, this is a group that has been smoking for 35 years.

How can these smokers be encouraged to butt out? Schwartz cites policy measures that include dramatically increasing taxation on tobacco, banning smoking in more places and decreasing the availability of cigarettes.

“Taxation is by far the most effective,” he says. For every 10 per cent increase in price, tobacco use declines by 1.5 per cent. “We also know that if people have to travel greater distances for their cigarettes, it’s helpful in quitting.”

Psychosocial counselling and drug therapy can also make a difference, says Schwartz, but even with such support, the successful “quit rate” is only 15 to 20 per cent. He says family doctors should follow up with their patients who are trying to quit.

“It’s an addiction, not a lifestyle,” he says.

“Policy measures include dramatically increasing taxation on tobacco, banning smoking in more places and decreasing the availability of cigarettes.”

— Robert Schwartz

PHOTO: JACKLYN ATLAS

GERIATRIC MEDICINE

Setting a New Course for Geriatric Medicine Retired Teachers of Ontario Establish a $3-Million Chair in Geriatric Medicine

BY MONIFA MILLER

ILLUSTRATION: LUKE PAUW

THANKS TO A GIFT FROM THE RETIRED Teachers of Ontario/Les enseignantes et enseignants retraités de l’Ontario (RTO/ERO) through its foundation, the Faculty of Medicine will be able to offer improved education and research in care for our seniors through the new RTO/ERO Chair in Geriatric Medicine.

The Chair was made possible through a $2.5 million donation, the largest in RTO’s history. U of T’s Department of Medicine also made a $500,000 contribution for a total of $3 million.

The gift was made in response to a coming shortage of geriatric medicine specialists in Canada. According to the Canadian Medical Association, there were only 239 such specialists practising across the country in 2012.

Of those, more than one-third were over the age of 55, while 4 per cent were under the age of 35. There is a clear need to recruit and train the next generation of medical professionals to provide specialized care to the elderly.

In 2011, the RTO established a foundation with a mission to

“improve the quality of life of all seniors.” The foundation raised the funds needed through an inaugural campaign that engaged over 70,000 members across the country.

“Thanks to the efforts and generosity of our dedicated donors, the RTO/ERO Foundation successfully reached its goal to establish an Endowed Chair in Geriatrics. This was achieved through active fundraising, personal and bequest donations from RTO/ERO members from across the province,” says Valerie Mah (BA ’78, BEd ’80, MEd ’84), Chair of the RTO Foundation. “The RTO/ERO Foundation was able to create a legacy that will impact the lives of seniors now and in the future.”

U of T’s Faculty of Medicine graduates approximately 250 students per year, all of whom receive geriatrics training. The University’s Division of Geriatric Medicine is the largest specialty training program in Canada, researching a number of areas in geriatrics, including older women’s health, geriatric oncology and quality of life for chronically ill elderly.

“The new RTO/ERO Chair in Geriatric Medicine means that we now have sustainable funding for leadership to educate the next generation of health care professionals about how to provide the highest quality care for the elderly,” says Dr. Gary Naglie, the George, Margaret and Gary Hunt Family Chair in Geriatric Medicine at the University of Toronto and Chief of Medicine at Baycrest. “This opportunity provided by the RTO empowers the work we’ve been doing at the Division, enabling us to delve further into research and create new knowledge that will guide senior care for generations to come.”

SPRING 2014 — 29

AGEISM

Are you ageist?

How Do Attitudes Affect the Care of Older Patients?

BY ERIN HOWE

How you do view older people?

Do you think of them as weak and fragile?

Wise and sweet? Or able and vital?

BONUS: VIDEO uoft.me/medmag 30 — U of T Medicine

LYNN McDONALD, PROFESSOR IN THE Faculty of Social Work and Director of the Institute for Life Course and Aging in the Faculty of Medicine, says even in health care, ageism is rampant. She believes practitioners need to think about their own values and attitudes when providing care to the elderly.

“There will be instances where there is over-care, and there is under-care,” she says.

Over-care can manifest itself as well-intentioned help, such as doing tasks the older person is capable of managing on their own. According to McDonald, this can prompt older people to live down to the low expectations of their abilities and cause them to become less

independent over time.

On the other hand, seniors’ needs can sometimes be overlooked or ignored.

“Often, right out of the gate, older people are not getting the appropriate treatment because the people providing care to them don’t know how — or they’re not interested,” says McDonald.

McDonald is a member of an expert panel working with the Registered Nurses Association of Ontario to develop new best practice guidelines to recognize, manage and prevent abuse and neglect of older Canadians.

“We’re hoping that firstly, we’ll be changing attitudes, secondly that we’ll be making health practitioners

SUPER SENIORS

Lynn McDonald, Professor in the Faculty of Social Work and Director of the Institute for Life Course and Aging in the Faculty of Medicine

QUESTIONS FOR HEALTH CARE PRACTITIONERS How do I address older people?

Using pet names instead of proper names can be condescending and may have deleterious effects.

McDonald says, “They’re treated like they’re old, and basically deaf and senile. And oftentimes, that attitude is picked up by older patients themselves, and older people, and they start to act within that framework.”

What attributes do I associate with the elderly?

more aware that elder abuse is all around us and that they are the first line who can recognize it. And finally, that the whole health profession start to look at education on this particular matter.”

McDonald is also the Scientific Director with the National Institute for the Care of the Elderly and the Principal Investigator for the National Survey on the Mistreatment of Older Canadians.

She points out that Canada’s last — and only — previous national study on elder abuse was done in 1989, and only 16 such investigations have been done in other parts of the world.

The new national survey, which has been underway since 2012, includes

5,000 adults aged 55 and up living in their own homes. It is exploring the physical, psychological and financial abuse and neglect by informal caregivers. The study will provide an estimate of how big the problem is in Canada and who is at the greatest risk.

“This is groundbreaking research,” says McDonald. “When you know the type of abuse you’re dealing with, that’s where you’re going to put your dollars and your staff to look after the problem, and that’s where you will be setting your polices.”

According to McDonald, it’s important to be aware of one’s own perceptions of aging. “At the National Initiative for Care of the Elderly, we have a whole campaign here on rethinking aging, because the attitudes are out of date.

People are working into their 70s, no problem. They are contributing to society and the economy; they’re involved in volunteerism. So we need to rethink our views.” She recommends care providers look at their own attitudes to see if they have kept up with the times and shifting demographics.

Am I up to date on how to best meet the needs of my older patients?

Valuing older people also means knowing the latest trends and research in elder care. “There’s enormous development happening every day in the field. As a professional, you have to be willing to say to yourself, ‘I don’t know it all, it’s a moving target and I need to stay up to date,’” says McDonald.

SPRING 2014 — 31

CAMPAIGN UPDATE

“We urgently need to support initiatives that work to ensure that everyone has access to healthy, sustainable food.”

— Joannah Lawson

32 — U of T Medicine

PHOTO: HENRY FEATHER

SUPER SENIORS

A Nutritious Start Lawson Gift Improves Childhood Nutrition

BY MONIFA MILLER BRIAN AND JOANNAH LAWSON HAVE long been committed to nutrition and the health of children. To help realize their goal, they have made a $5 million donation to the Centre for Child Nutrition, Health and Development in the Faculty of Medicine.

The Lawsons’ gift will support the work of the Centre and will set the stage for the establishment of an Endowed Chair in Nutrition, advance research and education, create an expendable fund to advance the cause of good nutrition as a public policy priority and establish a term Chair in microbiome nutrition research (microbiomes are the community of micro-organisms that share the human body).

Through their gift, the Lawsons are supporting U of T’s work in child nutrition and helping to advance the goals of the Centre.

“As a registered nutritionist working with clients, I see first-hand how life-changing good nutrition can be to physical and mental health,” Joannah Lawson says. “We urgently need to INSET PHOTO: HENRY CHAN/DIGNITAS INTERNATIONAL

support initiatives that work to ensure that everyone has access to healthy, sustainable food.”

“Nutrition is a nexus for many issues we care about deeply, such as the effectiveness and fiscal sustainability of our health care system, quality of life and our environment,” says Brian Lawson. “The U of T Faculty of Medicine is uniquely positioned through the excellence and scale of its activities to undertake cutting-edge research, deploy the results in the field and lead strong advocacy — all of which should lead to improved lives for families in Canada and globally.”

Joannah Lawson (Master of Industry Relations ’89) is a registered nutritionist in private practice specializing in nutrition curriculum design and delivery, environmental conservation and organic farming practices. Brian Lawson (BA ’82 Trinity) is a member of U of T’s Governing Council. He is senior managing partner and chief financial officer at Brookfield Asset Management Inc. and was named Canada’s CFO of the Year in 2013.

SPRING 2014 — 33

ALUMNI PROFILE

Q&A Dr. Judith Friedland A Trailblazer in Occupational Therapy 34 — U of T Medicine

PHOTO: NANCY FRIEDLAND

SUPER SENIORS

Dr. Judith Friedland (Dip. POT ’60, BA ’76, MA ’81, PhD ’89) is a former Chair of the Department of Occupational Therapy, and continues to lead through her scholarship and mentorship in her role as Professor Emerita.

VERONIKA BRYSKIEWICZ: What is your favourite memory from your time at the Faculty of Medicine?

JUDITH FRIEDLAND: A memory that is engraved in my mind and in my senses is the anatomy lab, which was then in the McMurrich Building.

To this day, when I go into the building — and I do go in there frequently for my research ethics work — I think I can smell the formaldehyde. Although I loved anatomy, the smell also brings back the memory of bell ringers, which were times of great anxiety — knowing you had to move on to identify the next specimen the instant the bell rang.

VB: What have you been involved in since graduating from the Faculty of Medicine?

JF: After graduating, I worked for a few years in psychiatric facilities as an occupational therapist. When I had my children, I stayed home but continued at school. I earned a BA at Woodsworth College, and later a Master’s and a PhD through OISE (Ontario Institute for Studies in Education).

I returned to work in the 1970s as a community occupational therapist.

I was invited to join the Division of Occupational Therapy in 1982, so I came back to the Faculty of Medicine to start my academic career. I’ve been here ever since. My teaching has been in the area of mental health, and my research has been primarily in the area of psychosocial adjustment to physical injury and illness.

I have done some historical research which also culminated in the publication of a book titled Restoring the Spirit: The Beginnings of Occupational Therapy in Canada, 1890–1930 in 2011. The book was an opportunity to recover our early history and to promote the ideas that had contributed to occupational therapy’s original vision of creating meaningful engagement for individuals with injuries or illness.

I’ve also been involved with research ethics at U of T, first as a reviewer on the Health Science Research Ethics Board, and later as its Chair. I am currently chairing the Ethics Review Board at Public Health Ontario.

VB: How has your career path been defined or influenced by your work at the Faculty of Medicine?

JF: Being in the Faculty of Medicine has enabled me to promote a broader definition of health that considers well-being even in the face of illness and injury. I’ve had the opportunity to advocate for the role of occupational therapy in achieving that definition of health.

There is something very challenging and stimulating about the atmosphere at U of T that keeps you moving and wanting to do and

accomplish more. It’s not competitiveness, but rather something that is invigorating.

Perhaps it’s because the university is so big — the bigness means there’s a lot coming in.

VB: In what ways do you think your work has inspired or affected others?

JF: I like to think that when I worked clinically, I was helping people to cope with illness and injury. When I began working academically, I worried at first that I wasn’t helping anymore.

But then I realized that I now had a chance at multiplying the effect through teaching and mentoring students who would go out and interact with even more people, and I could also have an effect through my research.

VB: What words of wisdom would you like to share with current and future students of the Faculty of Medicine?

JF: I would go back to my own experience and say that they should take advantage of all that U of T has to offer, because it is a great deal.

Learning is lifelong, whether you do it in a formal way or not. Although you can feel overwhelmed by the choices here, you are also blessed in having so many options.

The University of Toronto was the birthplace of Canadian occupational therapy in 1918, training ward aides to work with injured First World War soldiers.

In 1926, the first diploma program was established in the Department of Extension, and in 1950 physical therapy and occupational therapy were combined into one program (known as “POTs”) and brought into the Faculty of Medicine as part of the Department of Physical Medicine and Rehabilitation. In 1971, they separated again into individual divisions with their own degree programs.

Today, the Department of Occupational Therapy boasts 20 core faculty and over 300 clinical faculty who train 160 students every year.

SPRING 2014 — 35

ON THE BOOKSHELF

On the Bookshelf

By Meera Rai

The Alphabet of Galen: Pharmacy from Antiquity to the Middle Ages NICHOLAS EVERETT University of Toronto Press MOST OF THE WORLD’S INHABITANTS USE PLANTS TO treat illness and injury. Researchers devote intensive study to natural products, looking for new approaches to solve old health challenges. How have we come to rely on these products? How far back can we look to learn the origins of modern medication?

The Alphabet of Galen (AG) is a major resource for understanding the richness and diversity of medical history. Originating in Late Antiquity, this index describes the medicinal uses for nearly three hundred metals, aromatics, animal materials and herbs. Nicholas Everett (Associate Professor of History, University of Toronto) offers an English translation of the original Latin text and adds commentary on the extensive evidence the AG circulated over several centuries among medical 36 — U of T Medicine

authorities, including Hippocrates, Galen of Pergamum, Soranus, and Pseudo-Apuleius.

In researching the text, Everett quickly found that tracing the vast history of medical writing required additional preparation. In 2011 he registered for a Bachelor of Science program at U of T and has spent the past three years taking life science courses, learning alongside Faculty of Medicine students.

Many of the AG’s prescriptions for therapeutic use hold up remarkably well — opium to induce sleep, celery as a diuretic and ginger as a digestive aid. Other entries haven’t managed to withstand the test of time — thankfully, we no longer need to treat intestinal parasites by drinking an egg mixed with the shavings of a stag horn. It’s the staying power that Everett suggests may be most compelling about the text. It contains very little of the “potions” we might associate with ancient or medieval medicine, and far more cures that are derived from practise and experimentation, the benefits of which we continue to enjoy.

PHOTO: COURTESY OF UNIVERSITY OF TORONTO PRESS

OLD SCHOOL

Oronhyatekha

(10 August 1841–3 March 1907)

HE WAS BAPTIZED PETER MARTIN, BUT FOR MOST OF HIS LIFE HE WAS KNOWN AS Oronhyatekha, which means “Burning Sky” or “Burning Cloud” in the Mohawk language. Born on the Six Nations of the Grand River First Nation near Brantford, Ontario, he was the sixth son of Peter Martin and Lydia Loft, and one of 14 children.

After being selected to deliver a welcome address to the visiting Prince of Wales during a visit to Canada, it is said the Prince was so impressed, he arranged for Oronhyatekha to study at the University of Oxford. Upon his return to Canada, Oronhyatekha studied medicine at the University of Toronto, where he earned his MD in 1866 — becoming only the second Indigenous Canadian to become a practising doctor. In the years that followed, Oronhyatekha served as a solider in the Queen’s Own Rifles during the Fenian Raids, a member of Canada’s National Rifle Team, President of the Grand Council of Canadian Chiefs and led the Independent Order of Foresters — a fraternal order that has evolved into an international member-based insurance company. In addition, he practised medicine throughout southwestern Ontario and western New York state.

— LIAM MITCHELL

PHOTO: DESERONTO ARCHIVES (FLICKR)

SPRING 2014 — 37

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