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September 30, 2024

Foot care in Ontario

Like many seniors, my cousin, aged 77, needs help cutting her toenails, so she went to a foot care clinic north of Toronto. The clinician noticed a blister on her baby toe and, without any discussion, promptly cut it open, causing much pain and bleeding. Then she remarked that there was the beginning of an ingrown toenail on the big toe and, again with no discussion, plunged a sharp instrument deep into the toe, causing severe pain and heavy bleeding. After a few days at home, barely able to walk and unable even to put shoes on, my cousin went to her family doctor. The baby toe was infected and would require bathing in warm water and Epsom salts five times a day. Blisters should not be cut open. The injury to the big toe would take about six weeks to heal. My cousin was stuck at home for weeks. How can someone with apparently no understanding of foot care, wound care or even basic first aid have the authority to slice up people’s feet?

Aging is pretty hard on our feet. They support the weight of our bodies and undergo a lot of wear and tear. Some of the most common foot problems in seniors include bunions, corns, calluses, hammertoes, ingrown, thickened or discolored nails, diabetic foot conditions, poor circulation, flat feet and heel pain. Restricted mobility often means we can’t cut our own toenails. So many of us need foot care services. And those services are everywhere: community health centres, family health teams, foot care clinics, long term care, home care, hospitals. How do you choose the care that’s right for you?

Here's where things get murky. This field is just teeming with people with vastly different levels of skill and training, all offering foot care. And they all want our business, so as far as I could tell, none of them wants to help you figure out who can do what. But it matters who you see; anything beyond toenail cutting is a form of health care. You’d think that for the sake of patient protection, somebody would have laid all this out for us, but since I couldn’t find anything, I’ve tried to pull it together myself. Look at all these players:

  • Podiatrists. To practice as a podiatrist in Ontario, one must hold a Doctor of Podiatric Medicine degree from one of the nine Colleges of Podiatric Medicine in the United States, or from the podiatry program offered by the Université du Québec à Trois-Rivières. They’re trained in an accredited program and licensed. They can diagnose and treat all manner of foot disorders, order radiographs, prescribe medications, and perform surgery on the bones of the foot. Of all the foot care providers, they are the only group whose services get covered by OHIP, but it’s only partial coverage. You can’t train to be a podiatrist in Ontario, so there aren’t very many of them in the province. You can look for one here.
  • Chiropodists can do almost everything podiatrists can do, minus bone surgery and some kinds of prescribing. In Ontario, they’re trained in a comprehensive three-year full-time program at Toronto’s Michener Institute of Education. They’re trained in an accredited program and licensed. You can find a chiropodist here.
  • Pedorthists can prepare custom-made orthotics and modify footwear. Pedorthists are not regulated by any college and are not part of the Regulated Health Professions Act. Chiropodists and podiatrists are the only regulated health professionals in Ontario whose legislated scope of practice includes the provision of orthotics. However, pedorthists may join the Pedorthic Association of Canada and voluntarily follow a code of conduct as a requirement of membership. Pedorthists train by taking Western University’s Diploma Course in Pedorthics, with eight online courses and two practicums. You can find a pedorthist here.
  • Diabetes educators. Specially trained diabetes educators provide foot care services for individuals living with diabetes. They aim to reduce foot complications associated with diabetes through early intervention, regular monitoring and proper treatment of foot related concerns. To become certified, they must already be registered, licensed health professionals – for example, nurses or chiropodists – whose scope of practice permits them to provide diabetes education, and must have a minimum of 800 hours of practice in diabetes within three years, in order to qualify to write the certification exam. You can find a certified diabetes educator here.
  • Foot care nurses. These are professional RNs or RPNs who have taken additional training in foot care. But, as the Canadian Association of Foot Care Nurses cautions on their website, at this time there is no certification process for nursing foot care in Canada that is recognized by provincial regulatory bodies. So the training is all over the map. There are courses available at some of Ontario’s public colleges. Others are offered through private career colleges. Some are run by private businesses. Sometimes foot care nurses running their own clinics create and offer training as part of their business. The clinician who butchered my cousin’s foot got her training in one of those nurse-designed private courses. The programs range in duration from a couple of days to a few months. In other words, it’s the wild west: a bonanza for nurse entrepreneurs and a minefield for foot care patients.
  • Personal support workers. Various continuing education courses are available to them, from both public and private programs. The courses vary greatly in scope and depth. The Ontario Personal Support Workers Association has issued a foot care standard of practice document.

So what sort of foot care should you choose? If you’re living in long term care, or are housebound and dependent on home care, then you have to take what’s on offer. But if you live in the community and are mobile, then you can make some choices. Seniors often have more than one foot problem, and the problems are often complicated by systemic disorders like arthritis or diabetes. If all you need is nail-cutting, it doesn’t really matter who you see. But as my cousin learned, a simple cosmetic procedure can quickly cross the line into health care, and then who you see matters very much. If you choose a nurse, you might get a professional registered nurse who has taken several months of training at an accredited college. Or you might get someone who trained in a private facility, spent a few hours in a classroom, watched some videos, and thinks that the best way to treat blisters is to cut them open. So I think the safest bet is to choose a chiropodist. In Toronto, community health centres with foot care clinics staff them with chiropodists. OHIP doesn’t cover most foot care services, but if you have private insurance, you might get reimbursed. Foot care clinics in some community health centres are covered by OHIP. So take your time choosing. Finding good quality foot care should not be a matter of luck.

August 30, 2024

Literary quotes about aging

Here is what some well-known authors say about getting old:

Carolyn Heilbrun:

As we age, many of us who are privileged . . . those with some assured place and pattern in their lives, with some financial security---are in danger of choosing to stay right where we are, to undertake each day's routine, and to listen to our arteries hardening. . . . Instead, we should make use of our security, our seniority, to take risks, to make noise, to be courageous, to become unpopular.

Oscar Wilde:

With age comes wisdom, but sometimes age comes alone.

Charles Dickens:

Father Time is not always a hard parent and though he tarries for none of his children, often lays his hand lightly upon those who have used him well; making them old men and women inexorably enough, but leaving their hearts and spirits young and in full vigor. With such people the gray head is but the impression of the old fellow's hand in giving them his blessing, and every wrinkle but a notch in the quiet calendar of a well-spent life.

Virginia Woolf:

The older one grows, the more one likes indecency.

Margaret Atwood:

The world is being run by people my age, men my age, with falling-out hair and health worries, and it frightens me. When the leaders were older than me I could believe in their wisdom, I could believe they had transcended rage and malice and the need to be loved. Now I know better. I look at the faces in newspapers, in magazines, and wonder: what greeds, what furies drive them on?

Michel de Montaigne:

Age imprints more wrinkles on the mind than it does on the face.

Mark Twain:

If I had been helping the Almighty when he created man, I would have had him begin at the other end, and start human beings with old age. How much better to start old and have all the bitterness and blindness of age in the beginning!

Jonathan Swift:

No wise man ever wished to be younger.

Simone de Beauvoir:

There is only one solution if old age is not to be an absurd parody of our former life, and that is to go on pursuing ends that give our existence a meaning — devotion to individuals, to groups or to causes, social, political, intellectual or creative work… In old age we should wish still to have passions strong enough to prevent us turning in on ourselves. One’s life has value so long as one attributes value to the life of others, by means of love, friendship, indignation, compassion.

Ursula Le Guin:

Getting old can be worth the trouble if it gives you time to do some soul making.

July 30, 2024

Home care in Ontario

As we become older and need more support, most of us hope that we can age in place. That probably means that we are likely to need home care. It’s what most of us want, and it helps ease the pressure on hospitals and long term care. But years of underfunding and political tinkering have left home care in tatters. Denial of service, missed home visits, insufficient staff, poorly paid staff, service reductions and cancellations, lack of transparency about who qualifies for what service and for how long, unequal availability of and access to services from one region to another, lack of public reporting about quality of care, care outcomes and system performance – the list goes on and on. Bill 135, the Convenient Care at Home Act, which went into force on June 28, 2024, is the Ontario government’s latest effort to restructure home care. Will it fix this ailing service?

Home care used to be coordinated by 14 organizations called Home and Community Care Support Services, formerly Community Care Access Centres, formerly Local Health Integration Networks. Under the new legislation, these have all been dissolved and replaced by a single corporation, a crown agency called Ontario Health atHome that is responsible for all home care services across the province. They will do this through new entities called Ontario Health Teams, 58 groups comprising for-profit and not-for-profit health care providers including hospitals, doctors, and home and community care agencies. The teams will be responsible for coordinating and providing home care services to people in their local communities. These teams are still being formed. Once they are all up and running, the role of Ontario Health atHome will focus on providing designated Ontario Health Teams and/or other client providers with back-office and care coordination supports, including by assigning care coordinators to work under the direction of client providers. Under this new structure, patients should be able to move seamlessly from one form of service to another, and from one region to another.

But dig around a little, and you start to spot some red flags. Ontario Health atHome is governed by a Board of Directors, all appointed by the Minister of Health. There are no provisions for public meetings of the Board, public notice, public access to Minutes and documents nor any other democratic provisions. There are provisions for audits and reporting to Ontario Health, but not to the public. There is no legally required process for the internal governance, oversight, operations and legal liabilities or other responsibilities of Ontario Health Teams. Bill 135 does not require any standards of transparency, oversight and public accountability for Ontario Health Teams, other than reporting to Ontario Health atHome which itself is also not subject to any such standards. The key functions of care coordination and patient placement, which have always been administered publicly, are now contracted out to the provider agencies. Bill 135 repeals significant clauses in existing legislation that protected clients’ and the public’s interests in home and community care, including the Bill of Rights and complaint processes. These have been replaced by a Patient, Family and Caregiver Declaration of Values for Ontario, an aspirational document with no force in law.

With so little accountability and oversight, the new system primarily creates an environment hospitable to for-profit companies. But here's the problem with privatization in home care: the need to generate profit creates a huge new expense. In a service sector like home care, there aren't many ways to generate that profit. It has to come from cutting back on service and keeping wages low. For-profit service providers will be tempted to cherry-pick patients with simple, short-term needs, and limit access to care for patients with more complex, longer-term problems. There is a conflict between the need of private companies to produce a profit, and the need for patients to receive appropriate, quality care.

So who benefits from this restructuring of home care? Here’s a hint: it’s not us.

June 29, 2024

Mediterranean diet

In cardiac rehab I learned that while exercise is key to improving heart health, it’s not the only tool. Diet is vital too, so vital that it was the topic of three of our sixteen sessions. There are lots of different diets and nutrition guidelines, but in terms of heart health, one stands out: the Mediterranean diet.

What is the Mediterranean diet? It’s not primarily a weight-loss diet; it’s really just an approach to healthy eating. If you want to learn about it in detail, there are many good sites, for example this one and this one, but here’s the short version: eat primarily plant foods, fruits, vegetables, nuts, seeds, legumes, fish, whole grains and low-fat dairy. Season with spices, onion and garlic, but not salt. Use extra virgin olive oil as your main source of fat. Limit your intake of sweets. In terms of proportions, imagine a dinner plate. One half is filled with vegetables, one quarter with whole grains, and one quarter with protein. You want to stay away from highly processed foods, so do your shopping around the outer edges of the grocery store, where the fresh whole foods are.

If you do decide to try the Mediterranean diet, what benefits can you expect? Plenty, as it happens. Of all the diets out there, the Mediterranean diet is the most thoroughly studied, and the results are impressive. The most striking evidence is for the primary and secondary prevention of cardiovascular disease. But the benefits extend to many other conditions as well, including cancer, cognitive decline, diabetes and obesity. Those are all conditions that particularly affect us seniors.

It’s hard to change the dietary habits of a lifetime; they’re all tied up with our culture and upbringing and personal tastes. But really, I find it to be no sacrifice. The food is tasty, digestible and easy to prepare. As we reach that time of life when health conditions and prescriptions start piling up, it’s nice to think that, at least to some extent, we can let food be our medicine.

May 29, 2024

Cardiac fitness

I’ve been working out regularly for years. Every morning before breakfast, I followed a twenty-to-thirty minute aerobics video for seniors, doing a different one every day. And in the afternoon, I would do a twenty-minute walk. I thought I was meeting the standard guidelines: 150 minutes of at least moderate activity per week, or 30 minutes five times a week. So I was a bit surprised when I got diagnosed with a heart condition not long ago. I was even more surprised when the cardiologist reviewed my stress test results and told me my cardiac fitness was weak. He whisked me off to cardiac rehab, where I soon learned that my exercise routine was all wrong. Really, I was just being an idiot, it’s all there if you look for detailed guidelines and read them carefully. But hardly any of the seniors I know are getting it right either, so I’m going to lay it all out for you.

What kind of exercise builds heart strength and endurance? It’s an activity that boosts your heart rate above resting level and keeps it there the whole time you’re exercising. You can’t stop, slow down, or change to a different exercise. Activities you could choose include brisk walking, cycling, swimming, or using an exercise bike or elliptical. To do this, you could go to a gym, invest in some home equipment, or, like me, just do the bargain-basement version: brisk walking in small circuits in the house: living room, dining room, hall, a thousand times over. How long do you do it? Ideally, you work your way up to twenty minutes at a time, plus five minutes to warm up and five to cool down, at least five times a week. How hard should you work? On a perceived exertion scale of 1 to 20, you want to feel you’ve reached 12 to 13, a bit hard to somewhat hard; you’re breathing deeply and starting to sweat. But if you’re like me and find it easy to lie to yourself about how hard you’re working, you need a more objective measure. Calculate your maximum heart rate: 220 minus your age. Your target heart rate should be 50% - 80% of your maximum heart rate for a moderate intensity workout, or 70% - 85% for a vigorous intensity workout. Ranges vary by age, so you might want to check this chart. Then get an inexpensive activity tracker that captures your heart rate and wear it on your wrist while you exercise. Of course, if you have a heart condition, don’t figure out your target heart rate on your own; consult your doctor. And to round out your exercise routine, add in some resistance training two or three times a week.

So what about fitness videos? Most of them aren’t ideal for building endurance. They keep changing movements, so it’s hard to keep your heart rate in the target zone. I still do them, but I see them as serving a different purpose now. They help me get going in the morning. They warm me up, loosen my muscles and bones, and get my heart going a bit. That’s all fine, but don’t depend on fitness videos to strengthen your heart. Follow those guidelines. Your heart will thank you.

April 30, 2024

Medical escorts

Has this ever happened to you? You get scheduled for surgery, and then they tell you that when it’s time to go home, someone has to come right into the medical facility to get you, escort you home, and then go into your home with you to make sure you’re settled. You have to tell the medical facility the person’s name and contact information. If you can’t provide this, your surgery will be cancelled. But you live alone and don’t have anyone to pick you up. What are you supposed to do?

This requirement rules out the transportation services most of us use. You can’t call a taxi or book WheelTrans or any of the Toronto Ride affiliates, because their drivers have to wait for you outside. What other options are there?

Some community service agencies offer a program called Home at Last, which provides precisely this service. But there aren’t many of them, and some operate only within a specific catchment area. Examples of agencies offering Home at Last include CANES Community Care, Lumacare, Transcare Community Support Services and West Neighbourhood House. Red Cross Transportation Services will try to find a driver / escort for you if you give them a lot of notice, and they cover rides anywhere within Toronto city limits. Some service organizations, for example Woodgreen, provide medical escorts, but you must arrange your own transportation. There are also some companies you can hire for this service. I found a couple through Google, but don’t know anything about them and can’t vouch for them. Examples include C-Care Health Services and The Care Company.

If this service is so important that our surgery can be cancelled without it, then we shouldn’t be left scrambling. This is a broken link in our healthcare system.