Podcast: Guideline for homeless and vulnerably housed populations
Transcript
Andreas Laupacis: Hello everybody, I'm Andreas Laupacis, the editor in chief of the Canadian Medical Association Journal. And today I'm speaking with doctors Kevin Pottie and Gary Bloch, and Dawnmarie Harriott, who have all been involved in a clinical practice guideline for homeless and vulnerably housed people and people with lived homelessness experience. The guideline is published in the Canadian Medical Association Journal. So welcome to all three of you.
Gary Bloch: Thanks.
Kevin Pottie: Hi there.
Dawnmarie Harriott: Hi there.
Andreas Laupacis: I just like to start a bit about how you got involved in this guideline and your experience with homelessness or caring for people with homelessness, and maybe Dawnmarie, can we start with you?
Dawnmarie Harriott: Sure. So I do consider myself a personal lived experience or community partner on this project. And I've experienced homelessness from fleeing abuse, and, you know, entering into the shelter system and falling into poverty. So I currently, now I coordinate a speaker's bureau where people have lived experience and sharing the barriers that they face trying to get out of homelessness, addictions and various other forms of marginalization. So I support people in the community that are currently going through that. And I'm a big supporter of peer support, where people can use that knowledge of their experiences and support other people going through similar situations. And so I was asked to be a part of this project on that capacity.
Andreas Laupacis: And Kevin?
Kevin Pottie: Well, I'm always keen to get involved with guidelines for minority and marginalized populations. My background particulars come with the doing the refugee health guidelines. And when this opportunity arose, I saw some similar benefits, things that we could really make an impact in the field. So I think there was funding from Inner City Health in Toronto and I think this is an incredibly important possibility. So that, you know, the call for proposals doesn't happen that often in these fields. So I was really happy to be part of that. I see that the guideline development is a dynamic social networking process. And this is incredibly important for us because though we have certain practitioners that are currently specialists in small numbers that are doing this, I'm really interested to bring not only physicians, but it could even be civil society, it could be peer support workers. So I feel like when you develop a guideline, this is not a, you know, not for a simple recommendation. But it was an actual process. Because we need, you know, more people to be working in this field. And for me, that's my primary motivation.
Andreas Laupacis: And in your clinical practice, do you care for a number of people who are experiencing homelessness?
Kevin Pottie: Yes, I was originally praticing in Toronto and at that time, with more homeless people. In Ottawa, I have a mix. What's interesting is a lot of my refugee patients are either vulnerably housed, and some of them are homeless. There's domestic violence, even a month ago was one of my mother's with three kids who ended up on the street. So, and then I have also a number of people that were homeless and have been housed, but remain people with lived experience. And, you know, it's quite a pleasure to look after them. And I think that they have lots of good stories, and I don't really find it that difficult providing their care.
Andreas Laupacis: And Gary?
Gary Bloch: Yeah, so I'm a family physician in downtown Toronto with St. Michael's Hospital. I have always had a focus on homelessness in my career. In fact, the very first job I had in the medical world was at my first year of medicine, helping out with PhD research at Seaton House shelter, and really never stopped working with people experiencing homelessness, both in my regular family practice as well as in shelters. And I was actually involved in establishing the Inner City Health Associates, which is this large group of physicians working with the homeless in Toronto. And, you know, my academic work has sort of veered into thinking about what frontline primary care clinicians can do about social issues like homelessness. So the idea of a guidelines is a very natural fit with that.
Andreas Laupacis: And maybe while you have the microphone, what are you hoping that this guideline is going to achieve? And who are the main target audiences for the guideline?
Gary Bloch: So to me, there are really two main targets, right, and I think different people probably have different answers to this question. The first target is just sort of the general practicing field of clinicians, right, and just sort of medical practitioners, health practitioners in general. I think it is really important for the health world to understand that people who experience homelessness have a different set of health needs, or probably even better put, we need to kind of approach those needs through a different lens. And I think that to me is what this guideline starts to do for the general health provider public. I see the other really important audience for this is people who do a lot of clinical work with people experiencing homelessness, in the sense that I think those of us who've been embedded in the field know that this is a very specialized area of practice. But we've yet to really, kind of, start to define what that specialization is in ways that we can articulate it clearly. And I think this guideline also helps us move towards understanding what that looks like.
Andreas Laupacis: And maybe before we get to the four recommendations, maybe one of you can talk a bit about the I guess, the epidemiology of homelessness, and maybe actually talk about homelessness and vulnerably housed, the difference. My sense reading the guideline is that you folks who have worked in this area, are observing that the kinds of people who are homeless in Canada have changed fairly dramatically over the last little while.
Dawnmarie Harriott: To answer your question and about the demographics that's changing, I'm finding that older women are more using shelters now. I'm finding that single working people are using shelters. Since well before but 2016, rents have just been rising and rising. And I myself, I'm paying 50% of my paycheck, my monthly income to rent. That's vulnerably housed. I think I'm secure enough right now but that's cutting it close. And I think that's what people are finding, and landlords are just jacking up the rents. So I'm finding that I'm supporting people in the community, where the landlords are saying they want, you know, to move into their units and ask people to vacate and then jack up the rent. So I'm finding yes, younger people, older women especially, and just single working people have to find housing together. I'm finding people sharing a one bedroom unit with strangers, because they just can't afford a unit on their own.
Kevin Pottie: We had a lot of discussion about our use of the term vulnerably housed, I think it went, you know, back and forth. And I believe that it's important for the practicing, let's say even family doctors, that don't always realize that a patient that's in front of them could be homeless the next day. And I think this is one of the kinds of awareness we want to raise. I mean, I just I've had a patient in recently, who, because he was in low income housing, his landlord decided to renovate and basically take the ceiling down while he was sleeping in his bed. And he actually just had to leave, and he basically didn't have the support and ended up on the streets. Something happened very fast. And I think this is what Dawnmarie is kind of suggesting that it's a different world of how fast things can change. And I guess we're hoping with our guidelines that family doctors will be watching for this and may be able to do something to prevent the homelessness.
Andreas Laupacis: So a naive question about why things changed recently. Why is this happening more frequently now?
Gary Bloch: I mean, it's a really good question Andreas. I don't think there's an easy answer to that question. I think we've, that things have been shifting actually, for many decades, right. And we've been living through probably 40 years of dramatically rising inequality, socioeconomic inequality in our society. And this is just one of the consequences of that, right. And as much as we have talked about, sort of, you know, our robust social programs and supporting those who are most vulnerable in our society. The fact is that on the ground, Canada's social programs have not improved in most cases. And in fact, in many cases have worsened, which has meant that people have been allowed to slide into deeper poverty. And I think, especially as we get a population that is aging, there's more pressures on social programs, more pressures on health programs, and we just really can't keep up. And when you look specifically at the issue of housing and the housing stock, it's very clear that Canada is way behind in terms of its ability to provide an adequate amount of housing for our citizens, and especially affordable housing for people who can't even come close to paying rapidly rising average market rents. So there are a lot big social forces at play here. I think what's important for us as clinicians is that we really see how those social forces play out on the frontlines of care. And we see that every day, right. And I think Dawnmarie's point is, what she's seeing in her sphere of work, and I certainly see it on the frontlines of Family Medicine, and it's scary, and it's disturbing. So I guess there's no question that we need to recognize this and deal with this at the frontlines. Also, to sort of reinforce Kevin's point that we need to always see this as a big social issue first, and a sort of frontline health issues second.
Andreas Laupacis: To risk of asking something excessively philosophical here, why do we in Canada consider healthcare a right, but housing, not a right?
Gary Bloch: I really, I'm not sure I have an easy answer for you on that Andreas. Other than to just sort of, look again at historical forces, right, and there are societies that do not see access to healthcare as a right. We have chosen to latch ourselves on to healthcare as a signature national program, we could certainly do that with housing. And I would hope that, as people become more and more aware of the true crisis of homelessness. I mean us, it's in our faces every day, right. I mean, the number of people living on the streets in Toronto has doubled over the last decade. That we realize more and more that this needs to be as much of a core right, a core social right in our society, as access to healthcare is.
Dawnmarie Harriott: I can just add, you know, there was no new social housing built since you know, the late 80s, early 90s. And I was talking about peer support, so I've been visiting some of the city shelters to be training peer supporters to work in the shelters, and there's more and more new shelters or shelters being constructed to have more space. So we're creating Band Aid solutions, instead of creating what people need, and that's housing. Stable housing.
Kevin Pottie: And I think in our recommendations, which are coming from, I think, eight different systematic reviews, that there is actually something that can be done. So I do - the housing is an incredibly complex topic, but that does not mean that there isn't opportunities now, and that we can't advocate for more of these, you know, life saving and health saving approaches. And so housing, as we're probably going to talk about in a second, is just the start of our recommendations.
Andreas Laupacis: So why don't you actually continue there and tell listeners, what your main recommendations are?
Kevin Pottie: I think it's really important that we've created trustworthy recommendations. These are explainable from the different stakeholders, from people with lived experience to the clinicians and I think even stakeholders. We spend a lot of time engaging, I think into the 200 range, over 200 people, to make sure we're listening to them about their needs and we're listening to them about whether or not the guidelines can work. We've done implementation studies to look at the feasibility, the acceptability, the equity. This isn't always talked about as much with a regular guideline set but we spent a lot of effort on this. Because if we're going to put something on the table in this challenging field, we need to make sure that for the clinicians, that this is going to work, and for the patients that they're going to accept it, or they're going to at least believe that this is a good direction. And I think that this is kind of the prelude that led up to the recommendations. This is really a special situation and we wanted, we want this to really work, it must work. And so I think we spent the extra effort. I'm going to stop there and let maybe someone else talk about the recommendations.
Gary Bloch: I guess to again, to understand these guidelines, I wanted to understand that we first went through a very careful selection process in terms of topics through a kind of long, carefully done, drawn out Delphi selection process. And interestingly, the topics we chose to hone in on were not necessarily those that I would have thought when I - as a frontline clinician, I would have said: "Oh, well, we need a guideline on something like foot care or hepatitis C care." And what rose the top were actually, sort of, these much bigger overarching interventions like make a lot of sense, right. So looking first of all at simply finding access to housing and what we can do as frontline clinicians to help people access housing, right. Second of all, helping people access income, recognizing that there really is no homelessness without poverty, and that in order to be housed, you always need some sort of access to income. Then looking, sort of, towards the kind of incredibly over represented conditions amongst people who are homeless, so a more medical lens, specifically around mental illness, and understand that there are hugely disproportionate number of people with severe mental illness who experience homelessness, and trying to understand whether or not case management, different types of case management, have appropriate evidence behind them to recommend as an intervention for people experiencing homelessness. And then the final set of recommendations really look at substance use, right. So again, recognize that there's a huge proportion of people experiencing homelessness who use substances. And we look specifically at the evidence around opioid agonist and substitution therapy, and harm reduction interventions, like supervised consumption sites. So these are really the kind of five core areas that the guidelines looked at.
Andreas Laupacis: So could you give us a little detail on the first recommendation?
Kevin Pottie: I think that when you bring a non traditional, say social, more of a social recommendation into the family practice, we have to be a little bit more sophisticated in terms of helping that practitioner have the resources of how are they going to do something around the housing. So we definitely spend time, and there is actually a certain amount of networks and support phone numbers that are present and are developing, and that we believe that when the physician has access, or that someone in the physician's office, that this could be something, that is something actionable. So that as a physician, we're not trying to say, you know, "buy somebody a home". We're trying to say "this person needs linkage to a program for permanent supportive housing". And this is much more sophisticated because there's a support person, there's a lot of things that have to be organized to make this housing work, and that's what the programs recognize. Working on this project I've become very aware, and I've already had three people that I've been able to action on this item, because I am watching for it now. So, I've become aware and I'm figuring out how actually, I can make sure that these people find housing. So I think it's a very, it was a very positive feeling for the physician to be able to make this intervention. And I think like Gary said, this is like one of the things that will change a lot of the other, you know, medical and health care that you're going to deliver.
Andreas Laupacis: So I have to be honest, when I read the recommendation - which was to link my patients up with someone or a group that's experienced and knowledgeable about doing the best job possible to find my patient stable housing - I was trying to reconcile that with what Dawnmarie and the rest of you said, is that there is no housing. One of the reasons there's more homelessness is because there's less housing there was. So help me close that circle, if you will.
Dawnmarie Harriott: There are connections in terms of certain organizations or shelters that have connections to units with priority housing, and that's the thing about networking and finding out where there are places. But what I wanted to add really, from living in a shelter and finding affordable units, is when they are found, one of the issues and I think this can go with what Kevin was saying, is that then they're seen as housed and they don't have the support to maintain that housing. A lot of people may not have the skills to do grocery shopping, laundry, you know, maintain their lives with the life skills. So having that connection for people that support - maybe for several months, even up to a year - even if you're a peer worker, some shelters have a community liaison. Those are the ones that we can keep people housed. But in terms of answering your question, there are places its housing is at a low vacancy rate now, but there are some places that people are connecting to.
Andreas Laupacis: And can I just ask you about people that are in rural Canada? Because you do say, or at least I read your to say, that there's an increase in homelessness and vulnerably housed people in rural Canada. What I wasn't sure of was, did those people tend to migrate to the bigger cities or do they stay in their rural communities? And if they do, are there supports for them?
Kevin Pottie: We receive this feedback from a lot of our investigators from outside of cities. We had, we were a little bit more urban focused at the beginning. And I think what really is going on here that people are, you know, falling homeless in an area that has virtually no resources, like an urban area may have some programs, some resources. So what's happening is people living in rural areas, that find themselves in this scenario, is they just don't have that development to handle the situation. So yes, there are homeless people but the big difference is, no, there's not really, you know, the programs are not yet developed.
Gary Bloch: I'll just echo that. I mean, homelessness in rural areas is different but it's also not different to what happens in urban areas, right. There are people who are living, who are living outside, who are living on the streets of small towns, who are couchsurfing or squatting on land, or moving between places. You know, I mean, we have to remember again, that, you know, people living on the streets or in shelters is only the tip of the iceberg when it comes to homelessness. So most homelessness is happening, actually within sheltered spaces, but people who are just very unstable and insecurely housed. And we see that full spectrum within rural areas as well. And I will agree with Kevin, that the infrastructure and resources are far less available in rural areas than they are in urban areas. They're certainly inadequate in urban areas, which, you know, leads us to question what's going on in rural areas and what's available, and there's very little. So this is absolutely a huge issue. And I think we try to walk the line in the guidelines of allowing space for that reality, right. Recognizing that there are healthcare spaces that have better or worse access to resources around things like housing and income supports in case management. But we also try to point to, you know, what I think we see is a minimum necessary access to resources and a minimum availability of resources. And those are both direct support resources for people experiencing homelessness and for clinicians working with them, as well as to the bigger social resource such as the housing stock, right, which comes back to what you pointed to as well Andreas, around your question of closing the circle. I mean, my thought there is, we cannot close the circle on housing without having access to housing. And again, this is a huge conceptual piece that we had to grapple with needing figuring out how to represent these recommendations. And I think we are very aware of the fact that, you know, we are putting forward recommendations that in some, in many cases, speak to an ideal that is not realizable, without significant social policy change.
Andreas Laupacis: And you're hoping that this guideline might be an impetus to push us as a society into that change?
Gary Bloch: Yeah, I would hope that this helps push towards that. I mean, again, these are not social policy guidelines, per se, right. I think they would have a different set of recommendations if they were. But I think it doesn't take much scratching below the surface to reach the social policy recommendations that lie behind these guidelines. And absolutely, number one under those is access to adequate housing.
Kevin Pottie: I just want to emphasize that, I agree exactly, but there's also a certain skill that is not always in existence in rural areas, or in certain cities. We did an implementation survey across the country and asked people about the key barriers to implementing the guidelines, and there's quite a variation. We like to think that together, the guidelines can bring the different groups, some new ways of practicing, and hopefully the government will support them. But one of the things that I saw, and don't want to necessarily mentioned the site, after working in Ottawa with the Inner City Health program, they have peer support workers doing almost everything, it's actually quite, to me, it's quite amazing and there's really good things happening, you seem to feel like this is the way it should be. But then you go to another like, say city or a place, and you find that people have never even heard of that, and that the workers don't really necessarily understand what they're doing with their job, you know, they're paid, but... So, it's quite - we have a lot of room for improvement across the country. And I think practitioners or clinicians and other people could potentially, you know, speak up and say: "Well, we need to kind of move this a little bit more in this direction."
Gary Bloch: Can I just - I'm worried that we are presenting a slightly over pessimistic view of what these guidelines mean in practice. So, I just want to, kind of, take a step back from that for a moment, in the sense that these guidelines are actually structured to be empowering to clinicians. Despite you know, the social policy environment we work in, I mean, that social policy environment exists for many health issues we deal with, right. It's not just this one, although this one kind of rises to the fore quite quickly. But, you know, in every review that we did, the sort of first recommendation focuses simply on asking clinicians to identify the issue that we're talking about, right. So identify homelessness, identify income security, identify a history of severe mental illness, identify a substance use, or certainly an opioid use disorder. And, you know, while that's may sound trite, in some ways, it's not. This type of screening for these kind of underlying social issues, or severe medical issues associated with homelessness, first of all, it's it's not done in many cases, it's not necessarily routine part of practice to ask about housing or income. Second of all, just starting to understand what our patients stories are, what their social situations are, what their lives are actually like, is an incredibly empowering step towards being able to provide adequate care. And it's empowering for clinicians but it's absolutely empowering for our patients, in the sense that, you know, and I know this from reviewing literature for this guideline, as well as much more deeply around income security, that people appreciate their clinicians knowing about the conditions, the social conditions in which they're living, about understanding who they are, and what their life conditions are. And I think people know, intuitively, and often very explicitly, that until we understand their social conditions, we'll have a very hard time actually dealing with their health conditions in a very real way. And so to me, in many ways, just having that as a fundamental recommendation for each section of this guidelines, is a very easy to implement, but in some ways, you know, in a small way, a kind of revolutionary step towards starting to really incorporate an understanding of what it means to live in a vulnerably housed or homeless situation. The kind of second stage recommendation on each of the parts of the guideline certainly does push us deeper into these issues, right, helping us access housing, access income security supports, access case management. And that's where you get into the specifics of what's available in your area, what connections can you set up, you know, with other organizations in your community, or build into your team, you know, and obviously, that's a more intensive and more resource intensive piece of it. It is doable from different levels and I don't think anyone - there's no example actually in the country of perfection on this and any health team that I know of. But, it's sort of, that's where it gives us something to really strive towards in terms of building real and tangible supports to help people deal with their pressing health situation around homelessness. But hopefully, there will be a sense from these guidelines that there are pieces here that every clinician can take on, that these are eminently doable and realizable, and that our ability to deal with these issues will grow over time. And you know, I don't think any of us expect that there will be a radical shift in homelessness because of these guidelines but hopefully, there will start to be a shift in the mindset understanding and focus of clinicians on the front lines of this crisis.
Andreas Laupacis: Thanks for that Gary. Maybe, can I just ask Dawnmarie, I don't know whether you feel comfortable talking about whether, in your experiences, your family physician or clinician did ask you the kind of questions that Gary talked about or not?
Dawnmarie Harriott: So I, a lot of my experience after fleeing abuse was spent in survival mode. So I never really connected with a family doctor for quite a while, and then I needed a female doctor, and then I experienced some addictions, and then I experienced stigma from some medical centers. So I kind of stayed away until I finally met a doctor that understood and was asking those questions through an initiative. So the guideline is definitely a great tool, but there are also other initiatives that are happening with physicians to combat these issues. And so yes, I was able to find a doctor that I felt very comfortable with. And having, as Gary mentioned, having the doctor, having that knowledge of harm reduction, for example, and how they can support me instead of just saying, you know: "Stay clean", which is not very helpful all the time. And so that definitely helps and I also, as a person with lived experience, I love working with family physicians and physicians and researchers in terms of, I feel they have a lot of power in terms of creating social justice and creating change. And when we're working together, then we're talking about the barriers that we both face when we're trying to navigate these systems. So I think it's very empowering for myself to have definitely a doctor that knows about resources, that cares, that is willing to listen, that is willing to look at me not just taking notes and not, you know - I understand that there's limited time when I'm seeing my doctor, but just certain mannerisms make makes a very big difference.
Kevin Pottie: I want just to acknowledge that there is a whole section on our guidelines about approach, and learning to work more effectively and deliver some of these, this care more effectively. For example, using techniques such as trauma informed care. So I think this is something that we also did reviews on. And we are, you know, bringing forward, maybe not in the five recommendations, that comes out in another section of approaches because we, I think Dawnmarie said it very nicely, that we want the clinicians and the patients to have a reasonable experience. And sometimes, the doctor doesn't know what happened, why that didn't go well, so maybe it's, you know, the patient. So we're trying to also bring that onto the table as well. So it's really just a skill development. I just wanted to mention briefly, because I see that what we're doing is we're like reframing, and we're focusing. And I think that this is research, and so there's always going to be more research to follow. So we've got a grant from the Law Foundation of Ontario for what we call the L-Consult. L-Consult will be the legal consult, which you will be able to use as almost like an email from your medical record, it's going to follow the same system as the E-Consult, which is in nine provinces in the country where a family doctor can ask, get a rapid answer from any specialist now. So, we get this opportunity to develop this resource for people with lived experience in the same way. So until we brought our guidelines out, I don't think people will be using the E-Consult or the L-Consult very effectively, because they haven't really seen the problem clearly. So they don't know the quick question to ask. But I believe this can come and we've got, you know, ongoing research and practical work to do.
Andreas Laupacis: I think one of you mentioned that you care for people who have been recent immigrants or refugees and then also indigenous people have, or, many Indigenous people experience homelessness as well.
Kevin Pottie: Maybe I'll let Gary answer that one and especially around Indigenous populations, because that's a really important focus question.
Gary Bloch: Absolutely. So there is a really powerful reconceptualization of what homelessness means for indigenous peoples in Canada that's been going on. This work has really been led by the brilliant York University scholar, Jesse Thistle, who created an Indigenous definition of homelessness that came out a couple years ago, which looks at homelessness not just as, you know, our sort of a links to be understanding, you don't have an adequate home, therefore you're homeless. But sort of radically shifts what the definition looks like to include a disconnection from land, but also disconnection from culture, from family from relationships, really looking at the kind of deep impacts of you know, a centuries old colonial process that has affected indigenous peoples in Canada. He developed this definition through extensive consultation and academic work. It's a strongly evidence based and academically grounded definition. What this then means for frontline clinicians in terms of recommendations is a whole different cup of tea. And there's actually parallel to the guidelines' development process, the guidelines we're talking about today. There was another process also funded by Inner City Health Associates and run by Jesse Thistle and Janet Smylie, another brilliant family physician and Métis Indigenous health researcher, to lay out a set of guidelines specifically for Indigenous people experiencing homelessness. And I'm not going to take away the fire on those other than to say that there are, they've taken an extremely different approach to creating recommendations, one that is very community grounded, grounded in Indigenous research and community based techniques. Specifically, and they will be publishing at least an initial commentary on those guidelines, imminently. And I think we should all be looking as clinicians with some sense of excitement to what that commentary reveals in terms of what the outcomes of that process was. Because I think there really will be ground shifting in terms of how we deal with Indigenous people who experience homelessness. The other piece, I'll say, as just as a bit of a coda to that, is that Janet Smylie's work has shown that there are far more Indigenous people who experience homelessness, across the country and in urban and rural areas, then we have acknowledged, and then official counts have showed over time that Indigenous people are hugely over represented amongst the homeless population in Canada. And, you know, this is an issue we really need to be putting another focus on as a healthcare community very specifically. So I'm very excited to see how Janet and Jesse's work plays out within the healthcare community over the next year or two.
Andreas Laupacis: And just to let listeners know, Jesse Thistle and Janet Smylie have written a commentary that's appearing in the same edition of the CMAJ as your guideline, so that they will be able to read that. Kevin, did you want to comment on refugees?
Kevin Pottie: You know that the terminology here is important, because since the United States has changed its policy, we've seen a number of what we would call undocumented migrants that have come across the border into Canada. Of course, we also receive refugees through our asylum and refugee program. And then, of course, there's immigrants. But this I think, especially in certain provinces, I know Ontario, we've had quite a change. And in terms of a lot more people, when you don't have any, you know, legal rights, such as undocumented person, they are much more vulnerable and they're much higher chance that they're going to end up homeless. And we did a systematic review on this, on this topic, and the experiences of this migrant group. And certainly, there are major challenges with, you know, culture, food, understanding the system. So these, you know, the homeless shelters are not traditionally made for newcomers or for settlement. And so we have a real disconnect going on there. So this is being addressed by certain groups, which is great. But I think it's just important for the again, clinicians, we have to realize that there's young people that could be homeless, a lot of youth, there's a lot of women and mothers, there could be the different migrant populations. So it's something as family doctors, we have to be thinking a lot more about.
Andreas Laupacis: Maybe I'll just ask each of you whether there's anything that we haven't talked about that you think is important?
Kevin Pottie: Well, I mean, I guess I have to say, I like the fact that Gary keeps bringing up - there's a lot of positive energy. And I believe there's a lot of opportunity. And I really believe we have, you know, with their guidelines for refugees, it totally transformed the confidence of family doctors. And all of a sudden, we have an incredible number of family doctors looking after refugees, where 10 years ago, we never had that. So that's what I'm looking forward to, is my colleagues to feel more empowered and comfortable and also want to engage, because I think we need extra people here for sure.
Andreas Laupacis: And that guideline for refugees was published about how long ago?
Kevin Pottie: That was published in CMAJ in 2011. And that guideline went on to produce guidelines in the US, Australia and in Europe. So we were able to kind of leverage that. And we even were involved in all these other guidelines in other countries. And I really am quite sure we're going to be doing the same thing with this guideline, because no other countries have this guideline yet.
Andreas Laupacis: Gary?
Gary Bloch: Yeah, I'll just say that, you know, to me these guidelines are really a starting point. I think we are entering into trying to get a handle on a very complex area of care in many ways. But also it sort of, in some ways, it's kind of genre shifting area of care. Right. And I think that our recommendations here really point to that, again, you know, that we're truly bringing a social lens, or in some ways adding on, a sort of social care module to the usual care that we provide. As with most guidelines, probably, these guidelines point to more holes in the research than hard answers, from the evidence that's out there. And there's certainly a call to the research community that's implicit here to say we got to start to plug some of these holes in really understanding what works. But they also point to vast areas of just, kind of, practice transformation that needs to happen. Starting with just a basic understanding of the health needs of people who are homeless, and again, starting to ask questions around that. But then thinking about everything from how we structure our clinical environments, the processes that, you know, we ask our clients to go through, and what sort of barriers those pose, or whether or not those are welcoming to people who experience social marginalization, to, you know, building up our own skills in things like knowing how to incorporate an experience of trauma into our frontline care assessments, to building up our ability to help people directly access resources around things like housing and income to, you know, working with people to understand how to combat impacts of broad social forces, like racism or histories of colonialism, right? And I sort of list these two to, again, make this point that we are just at the beginning of really putting in place what I think will be an exciting and hopefully a transformative shift in how we approach care for people who've experienced homelessness, but also people who experience social marginalization from a number of different angles. And that's where I get really excited about the potential of these guidelines to really push how we understand the provision of healthcare in this country.
Andreas Laupacis: Dawnmarie?
Dawnmarie Harriott: I guess the only thing I would add is, I really enjoyed working on this project. And I really enjoyed the collaboration and everything that I've learned, and it's just, it really strengthens the voice of the people that are being served. And I believe these guidelines will help remove stigma and some of the oppressive practices that are in healthcare. And just to be able to, it's fun to be working with physicians who are trying to create a equitable healthcare system. And I think it's very important and very empowering. And I think I'm really excited to see the turnout of these guidelines.
Gary Bloch: And Andreas, the only other piece that I will add is that there is a an article coming out in Canadian Family Physician, which is really geared towards an interpretation of these guidelines for frontline Family Medicine care. And I think it is coming out synonymously with the guidelines or within a month or two of the publication of the guidelines.
Andreas Laupacis: That's great. So encourage listeners to look for that. So listen, I've learned a lot. I've actually learned to be more hopeful than I was coming into this, giving me realistic hope. I think it's great that all three of you and all of your colleagues are devoting your time and energy and expertise to this and just thank you very, very much.
Kevin Pottie: Thanks Andreas.
Andreas Laupacis: I've been speaking with Dawnmarie Harriott and with Dr. Kevin Pottie and Dr. Gary Bloch. Dawnmarie Harriott is a Voices From The Street coordinator with the organization Working For Change in Toronto. Dr. Gary Bloch is a family physician at St. Michael's Hospital and Inner City Health Associates in Toronto, and Dr. Kevin Pottie is a family physician and clinical investigator at C.T. Lamont Primary Health Care Research Centre and at Bruyère Research Institute, and he is a professor of Family Medicine at the University of Ottawa. To read the clinical practice guideline for homeless and vulnerably housed people and people with lived homelessness experience, please visit cmaj.ca. There you can also read the commentary from Jessie Thistle and Dr. Janet Smylie. Both articles are also linked in this podcast description. If you haven't yet subscribed to CMAJ podcasts, we highly encourage you to do so on SoundCloud, Apple Podcasts or any podcast app. This way, you'll be notified every time we publish a new podcast episode. And let us know how we're doing with our podcasts by leaving a rating. I'm Dr. Andreas Laupacis, editor in chief of CMAJ and thanks for listening.