As Family physicians, we have privileged access to our patients’ lives (CanMED-FM, 2017). During your residency, you will learn one of the most powerful tools of our profession: the patient-centred interview method. You will learn to explore your patients’ social context and discover how this impacts their health. We are best positioned to recognize the determinants of health that contribute to and undermine our patients’ health and well-being as well as the health and well-being of their communities. Collectively, we have a social responsibility to be Health Advocates at the patient level, the community level, and then systems level.
Curriculum Overview
By the beginning of residency:
You are likely already familiar with the “determinant of health” as described by the .
During the first 12 months of training, you will start to actively apply these concepts to your patients.
Specifically, you should:
- Identify the determinants of health that are compromised in the patients you see in clinic and in the hospital.
- Learn the preventive health screening and promotion guidelines for adults and children.
Make sure to recognize when the screening guidelines for average risk patients do not apply.
- Link to Priority Topic “Preventive Health Exam" in the resident study guide
- Link to Priority Topic “In Children” in the resident study guide
- Take opportunities to incorporate health promotion in all clinic visits, as appropriate.
- Apply the Zigby Advocacy toolto your patients to determine who are particularly vulnerable, and whose health would benefit from the intervention of a third party. You will also need to learn the delicate balance between advocacy and patient empowerment.
- On your homecare visits, we encourage you to use the home assessment tool developed by Cherine Zaim and David Kaiser.
By your second year:
You should be starting to:
- Regularly mobilize the patient resources available within your Family Medicine Unit setting.
- Become more knowledgeable with the community supports and resources outside your FM-unit setting
Advocacy Mentors
Motivated to do advocacy at the community and/or system level?
Some of you may choose to start to become agents of change at the community and system level. Feel free to speak with your Academic advisor or your site director for people within our department who might be able to support your vision.
Advocacy mentors in our Department (non-exhaustive list)
– president of CAPE (Canadian Association of Physicians for the environment
– co-founder of La Maison Bleue
– President, Médecins québécois pour le régime public
Dr. David Kaiser – Graduate of our Department and Program Director of Public Health. Particular interests: Housing and health; public health surveillance (Extreme heat & heat vulnerability; noise; green spaces)
Global Health initiatives, Department of Family Medicine
Elective Opportunities
All rotations are 4-weeks, unless specified.
Social pediatrics and Perinatatogy |
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Social Pediatrics, MUHC, GLEN Site |
A wide spectrum of socially disadvantaged patients are seen during this rotation: children of poverty, abused and neglected children, children in foster care, homeless and chemically dependent youth, children with special needs, child refugees, First Nations children, transgendered youth, incarcerated youth and children with psychiatric disorders |
socialpediatrics.med [at] mcgill.ca (Dr. Geoffrey Dougherty) |
Social Perinatology (Maison Bleue) |
La Maison Bleue is an interdisciplinary clinic that helps families awaiting a child and that are in need of support due to living in a context of vulnerability: poverty, a situation of abuse, violence, neglect, addiction, precarious immigration status, mental health problems, teen pregnancy etc. |
3735 Plamondon, Montréal (Québec) H3S 1L8 coordo.cdn [at] maisonbleue.info (Carmen Gabriel-Chouinard), Coordinator 7867 Querbes, Montréal (Québec), H3N 2B9 |
Refugee and Asylum seekers |
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CLSC ôٱ-- |
Physicians, nurses and social workers work together to help serve asylum seekers from across the world. Residents will be exposed to manifestations of post-traumatic stress conditions, tropical diseases, and the challenges of providing care to these marginalized populations. |
Supervisor: Anne-Katrin Richter |
Gender Identify |
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ƻԺ Sexual Identity Centre |
MUHC, MGH Site |
/cosum/information-healthcare-professionals (514) 934.1934 ext 43585 |
Montreal Children Hospital Child Development Program, Gender Variance |
2300 Tupper St. |
Supervisor: Contact: 514-412-4314 (office) |
Mental Health and Addictions |
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Eating Disorders, Adolescent |
MUHC, GLEN Site |
suzanne.macdonald [at] muhc.mcgill.ca (Dr. Suzanna McDonald) |
Griffith Edwards Centre, Addictions Unit |
Griffith Edwards Centre |
Tel: (514) 934-8311 |
Methadone Clinic |
Jewish General Hospital |
514-340-8222 ext. 28273 |
Patients with Genetic and Developmental syndromes |
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Genetic Clinic One half day/per week |
CLSC ôٱ-- Clinical exposure to patients with various syndromes including Down syndrome, Neurofibromatosis, autism Turner syndrome, various other chromosomal abnormalities. |
Teresa.rudkin [at] mcgill.ca (Dr. Teresa Rudkin) |
Patients from a marginalized community |
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Hasidism |
The Montreal Center for Health and Care |
psteinmetz1 [at] gmail.com (Dr. Peter Steinmetz) |
4-week course |
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The Role of Physician in Society |
Lectures and self-directed learning activities. Main topics would be: Health System organization, Policy, Physician role, Social contract, Interprofessionalism and Accountability. Residents are expected to produce a briefing note on chosen topic at the end, with a blog and a presentation during the rotation |
isabelle.leblanc [at] mcgill.ca (Dr. Isabelle Leblanc) |
Appendices
Zigby Advocacy Tool
Home Care Environement Guide
Unlike the clinical encounters with your patients in clinic, the home visit enables you to immerse yourself in your patient’s daily environment and pinpoint possible causes of recurrent or intractable health problems. This is one of the multiple reasons an environmental assessment should be at the forefront of your first home visit with a patient.
Taking an Environmental History
Several ways of structuring the environmental history have been proposed (the acronym CH2OPD2 is the one shown here)
* Community : neighbourhood sources of hazard; industries; noise sources; criminality
* Home : year of construction, renovations; materials used in construction and decoration; moulds; garden and house plants; use of cleaning products, pesticides, herbicides; air quality; insalubrity
* Hobbies and leisure : exposure to chemicals, heavy metals, dusts or micro-organisms
* Occupation : current/previous occupations of household members
* Personal habits : hygiene products; smoking
* Diet : sources of food and water; cooking methods; cultural habits
*Drugs : prescription and non-prescriptions; alternative medications and health practices
What are Inadequate Housing Conditions?
Talking about the environmental history brings to mind possible issues that could be uncovered during the first visit to a patient’s home. Table 1 presents a non-exhaustive list of housing-related issues you may encounter in your home visits as a clinician. Pictures are presented on page 3. Frost’s Visual Clutter Rating is presented on page 4.
Table 1 : Housing-related issues most commonly encountered
Clutter | Clutter (measured as per Frost’s Visual Clutter Rating, page 4) |
Signs or Risks Factors for Excessive Humidity | Visible mould |
Mould odours (musty, earthy smell) | |
Unrepaired water damage or recurrent water infiltrations on history | |
Signs of water infiltration (water rings, spots, paint blisters) | |
High level of relative humidity (if measured > 50%, dew/ice on windows, bloom on walls, permanent need for dehumidifier) | |
Basement apartment | |
Signs of Vermin Infestation | Silverfish or woodlouse |
Bedbugs (or signs of infestation : excrements, black spots on linens) | |
Cockroaches | |
Rats | |
Mice | |
Excrements on floor or other indirect signs of infestation | |
Signs or Risk Factors for Potential Lead Exposure | Crumbling paint on walls |
Known presence of lead pipes | |
Ongoing renovations in a building built before 1980 | |
Risk Factors for Extreme Heat Exposure | Absence of air conditioning |
Top floor apartments | |
Inability to open windows |
Why Pay Attention to Housing Conditions in Home Care Settings?
On average, people spend 15-16 hours a day in their home– more so in the case of home care patients who are more often than not home-bound. Inadequate housing conditions are prevalent throughout the province.
According to a survey conducted by the Department of Public Health in Montreal in 2014, 28% of households report a sanitation problem in their dwelling. Renter households are the most affected: except for rodent infestation, renters report significantly more cockroach/bed bugs infestations, more humidity issues and more interior mould issues than owners.
Often, the most vulnerable people are the ones more affected by this issue. For example, amongst survey respondents, 40% of couples with children reported an insalubrity issue versus only 18% of single people. Fortunately, environmental health problems generally disappear when exposure ceases. However, some patterns may become chronic.
Extent, duration of exposure, and intrinsic factors may influence prognosis. That is why it is important to use the opportunity to use the home visit as a tool to assess environmental issues present in your patient’s home. A careful and complete assessment will not only help you provide optimized care to your home care patient; it can also be the first step to equip your patient with tools and resources to improve their living conditions.
One of your biggest allies as a clinician facing inadequate housing conditions is the neighbourhood’s Comité Logement. These organizations have the mandate of both helping renters uphold their individual rights, providing them with information and help, as well as advocating for their population’s right to decent and affordable housing. Contact information for Comités Logement based in most of ƻԺ Family Medicine Units’ neighbourhoods can be found on page 6 of this document, as well as on the website of the .
What to Do in Case of Inadequate Housing?
For tenants
The landlord is responsible for dealing with problems in rental units such as insect pest, vermin, water damage, mould growth.
- Inform the tenant that he must notify the landlord verbally of the problem
- If no process is undertaken after a verbal acknowledgement of the situation, the tenant must notify the landlord by registered mail. The letter must detail the problem and provide a reasonable timeline for resolving it.
- If the situation is not dealt with in an adequate timeframe, the tenant can lodge a complaint to the borough (call 311 in Montréal) or municipality
- The tenant can also lodge a complaint with the Régie du Logement du Québec.
For owners
It is much more difficult to intervene in a situation involving a dwelling owned by the affected occupant. According to the Law on Health Services and Social Services, one cannot force a person considered fit to receive services or to leave his/her home. However, if the current situation poses risks to others, the issue can be brought to court. As a clinician, you can however continue clinical management of relevant medical conditions, as well as provide medical or psychosocial follow-up as needed.
For clinicians
As a clinician, you should:
Refer to appropriate resources in the community (such as Comité Logement or the public health unit in the appropriate CIUSSS) or to a social worker
Treat relevant symptoms and medical conditions as per standard clinical management
Provide medical or psychosocial follow-up as needed
Assess for other environmental hazards (as previously described in Guide – heat vulnerability, lead exposure, neighbourhood safety, etc.)
You should also be prepared for home visits (see Home Care Environment Checklist) in order to protect yourself and decrease the risk of propagating possible infestations to other buildings. After assessing the situation, you should also reflect with your Home Care supervisor on the possibility of taking arrangements to give necessary care elsewhere if the current setting is not amenable to safe care for the resident.
In all cases, consider calling Montreal Public Health if :
- you are particularly concerned about potential health impacts, for example, in the case of vulnerable patients (dementia, functional impairment, etc.)
- there are persistent or recurrent problems
- the problem is affecting multiple dwellings
- you need advice/expertise on the situations
Ressources according to regions and UMF territories
Region | Bed Bugs | Moulds | General Insalubrity |
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Montreal | santemontreal.qc.ca/punaises-de-lit | santemontreal.qc.ca/moisissures | |
QEHC | |||
ôٱ-- | |||
Ville-Marie | |||
Parc-Extension | |||
Gatineau | |||
Val d'Or | |||
Chateauguay | |||
All | lespunaisesdelit.info | rclalq.qc.ca |