From Antipathy to Medicine, to a Lifetime of Healthcare
A remarkable journey. Eva carried her lived experience in an immigrant family through a medical career in clinical epidemiology, exploring Chinese medicine, cancer care, multifaceted health promotion, and now helping a new wave of Canadian immigrants.
Dr. Eva Grunfeld completed medical school at McMaster University, a doctorate in epidemiology at Oxford University, and a diploma in acupuncture through the Nanjing University of Chinese Medicine. A professor in the Department of Family and Community Medicine at the University of Toronto. Her research focused on the role of family physicians in the care of cancer patients. She led two major research programs: CanIMPACT, to improve the coordination of cancer care; and the BETTER Program, which has developed and tested an approach to improve the prevention of and screening for cancer and other chronic diseases in family practice.
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“I have to forewarn you that I had a very negative attitude to medicine. It certainly wasn’t that I dreamed of being a doctor…that left me with very strong feelings of antipathy, to use a gentle word – although I might have used different words at that time – towards the health care system.”
Let me take you back to your childhood because that’s such an interesting place to start, how did your interest in medicine begin?
Eva Grunfeld: Well, I have to forewarn you that I had a very negative attitude to medicine. It certainly wasn’t that I dreamed of being a doctor. I grew up in Montreal where my family were new immigrants from Czechoslovakia. My parents didn’t speak English so it was really when the kids started to go to school that English was brought into the household.
I was in a pretty severe car accident when I was 11 when I was hit by a pizza delivery truck and sustained serious injuries which involved six months in hospital, including two months in a body cast – essentially, six months of not moving. And then complications followed: these were primarily iatrogenic resulting from the medical treatment. So, for ten years – from 11 to 21 – I was in and out of hospital for various surgeries.
During that time my family experienced everything one hears about in terms of an immigrant family in a complex system they don’t understand. This was before there was Medicare available in Canada, so there was the financial toll. But, primarily, it was a completely disjointed experience. We would see one specialist and there was no communication. There was no family doctor. It was a very difficult period as an adolescent. Going through that left me with very strong feelings of antipathy, to use a gentle word – although I might have used different words at that time – towards the health care system.
DMacA: Well, your career certainly took a U-turn. And, after medical school, at McMaster, what did you do then?
EG: My original academic background and my first degree was in comparative literature and it was only afterwards that I studied the sciences. So, I have both a BA and a BSc, followed by an MSc. I was studying nutrition, did a master’s in nutritional biochemistry, and was working as a nutritionist. And that’s where my interest in medicine really started. When I went to McMaster, I’d already come from a research background through my Master’s degree, so I did have a research orientation. And then I had one of those incredibly fortunate things in life in that David Sackett and Gordon Guyatt were there and I did several electives with David Sackett in Clinical Epidemiology.
When I started medicine, I was interested in a clinical career but I was also interested in being a clinician scientist, but how to achieve that was complicated. I did family medicine in Ottawa and then, after working for a few years clinically, I went back and did a DPhil in Oxford in cancer epidemiology where my advisor was the Professor of Public Health, Martin Vessey. I spent three years in Oxford, did my DPhil, and then came back to Canada where an unbelievably lucky thing happened: I was awarded a clinician scientist award through the Ontario provincial program. And that was what started my progress as a clinician scientist.
DMacA: Lets take a step back, what brought you to Oxford?
EG: I had a very specific idea of what I wanted to do – I wanted to go somewhere where I could do that piece of research. I did explore going to University of Toronto and to McGill, the two local institutions but then my husband and I were on a canal trip in the south of France after which we went to England. I had sent a letter to Martin asking to meet, expecting just to have a conversation, and at the end he said, “Well, if you want to come, I’ll be your supervisor.” So, in some ways it was happenstance, and I did decide to go to Oxford.
I was looking for a program, such as the DPhil, which is a research-based degree not a course-based degree. I’d already done a lot of science courses and statistics courses so I wanted somewhere where I could do the piece of research that I was interested in.
There was a fellowship program for Ontario physicians to study acupuncture at the Nanjing College of Traditional Chinese Medicine (https://english.njucm.edu.cn).. So, that’s what I did. And I trained as an acupuncturist and even passed my exam using the Chinese names for the acupuncture points.
DMacA: Before we move on to your career as an epidemiologist, you have another qualification which intrigues me. You have a qualification in acupuncture!
EG: How did you find that out? I’m impressed. Not many people know that. Yes, I am a Chinese trained acupuncturist. So how did that come about? Like, all good questions or motivations, it’s stemmed from clinical experience. At this time I was doing my residency in family medicine and my mother-in-law developed facial shingles which left a partial facial paralysis, which she was very distraught about. She was a lovely person, conventional and conservative in every way you can imagine and I adored her. She was not the kind of person you would expect to explore alternative medicines yet she was desperate for a solution. She started to see an acupuncturist and I was really struck by, first of all, how much hope and faith she had put into that treatment and also, how much she spent on it. Obviously, having been nurtured in clinical epidemiology, I was asking myself about the evidence and
I felt I wanted to learn and understand more. There was a fellowship program for Ontario physicians to study acupuncture at the Nanjing College of Traditional Chinese Medicine (https://english.njucm.edu.cn).. So, that’s what I did. And I trained as an acupuncturist and even passed my exam using the Chinese names for the acupuncture points.
DMacA: I am really intrigued how you combined your scientific basis of epidemiology and alternative medicine?
EG: I don’t know how much you know about the debate about alternative medicines. But there’s a strong principle within alternative medicines, or there was at that time, that traditional Chinese medicine is not amenable to scientific investigation. Scientific investigation is too reductionistic – that’s the terminology that people used. Traditional Chinese medicine treatments are multifaceted and individualized and therefore, a clinical trial is really not feasible.
Given my Clinical Epidemiology training, and I’ve published and given some lectures about this, I felt that you should be able to study an outcome. There are many areas of medicine where we studied an outcome before we understood the pathway, before we understood the underlying mechanism. For example, if we think about the early vitamin studies, the relationship between niacin and pellagra, the relationship between scurvy and vitamin C, those were all approaches that looked at the outcome before there was even an idea of what a vitamin really is. I think that that can be translated to alternative medicine because most people, in my experience – and certainly even in my experience in China – went there with a specific complaint. The Nanjing College of Traditional Chinese Medicine is one of the most ancient colleges and prides itself on offering both Western medicine and traditional Chinese medicine so many of the patients came to the acupuncture clinic with a Western diagnosis, for example, high blood pressure or Bell’s palsy, which was very common. To my mind, particularly in a Western context, if people have a specific concern, such as smoking cessation, it can be measured objectively. Even if the treatment is individualized, I don’t think that precludes being able to study it. It might preclude being able to deconstruct or dissect which aspect of the treatment worked but it doesn’t preclude studying this package of alternative Chinese medicine, with the flow of QI and the balance of Yin and Yang, and whichever acupuncture points are prescribed, whatever that treatment is. Even if the treatment varies from person to person, you can still study the outcome in a rigorous, controlled way.
I did do a trial of the P6 acupressure point which was commonly used. You hear about bands that people use for seasickness – that’s the P 6 point – and, a lot of people use it in the clinic for mild chemotherapy-related nausea and vomiting. I got the company to make bands without the pressure point to use as a placebo, and we did a randomized trial to see whether or not it improved mild chemotherapy-related nausea and vomiting. It was a negative trial.
… often at that point, if there was a question of palliative care, we would be searching for the family doctor because the patient had been so focused on breast cancer follow up and coming to the breast cancer clinic, that they had often had lost contact with their family doctor.
Lifetime Achievement in Family Medicine Research Award
These awards honour individuals who are trailblazers and leaders in family medicine research, and who have made a significant career contribution to family medicine research during their active career years. These awards give public recognition to both their work and to the discipline of family medicine.
DMacA: So let’s bring you back to your career as a clinician and epidemiologist. And, you’re interest in cancer…
EG: In my first year after residency, which was in family medicine, I was looking for that perfect 9 to 5 job where I could recover from all those years. I worked as physician in the Ottawa Regional Cancer Center, primarily in breast cancer clinics. This was in the late 1980s and one of the things that struck me was that, on any given day, the clinics were overflowing. Specifically, I was involved in the breast cancer clinic and the breast cancer clinics were overflowing. The vast majority of people were there for routine follow up. The clinical skills that I needed in order to provide that care – I had them as I walked in the door. By that I mean that my training as a family physician afforded me all the clinical skills and knowledge specifically about routine follow up for breast cancer patients that I needed to provide care. The other thing that struck me, and disturbed me, was that the demand was so huge, the clinics were so full, the time was so short, the amount of time per patient was so limited that, when there was a patient who had a problem or concern about recurrence or was perhaps in need of palliative or symptom control, there was no time to deal with them. And often at that point, if there was a question of palliative care, we would be searching for the family doctor because the patient had been so focused on breast cancer follow up and coming to the breast cancer clinic, that they had often had lost contact with their family doctor.
So, I had two things in my head. One, I’m a family doctor, and know how to do this. And the other is, why has this patient had no contact with their family doctor in all these years when there are other medical conditions that they need to be thinking about? Those were experiences that made me question whether or not routine follow up could be provided by the family doctor as safely and effectively. I’m giving you my hypotheses! And that was a pretty radical idea at the time.
DMacA: And this brought you to this idea of survivorship plans…
EG: People were not talking about survivorship at all. At that time the terminology used was- routine follow up. But then, with the Institute of Medicine report, things began to broaden, realizing that 80 to 90% of people, if we talk about breast cancer and prostate cancer, 60% for colorectal cancer – the major adult cancers – that the majority of people will be long-term survivors. For those people there is a need to look at preventive measures related to other medical conditions as well as to be aware of other cancers they might be at risk of. So, the survivorship concept was moving from a unilateral focus on survival from the index cancer to a much broader holistic focus on the needs, the preventive care, and specifically the chronic care needs of the patient including psychosocial support and issues related to quality of life. So that’s where the survivorship concept came from. From my knowledge of the literature, I was only the second person to ever do a randomized trial. There had been one trial in Italy before that. Early in my career I did several major trials, so I was in the vanguard of moving the thinking from index cancer follow up to survivorship care.
DMacA: You mentioned other conditions in addition to cancer. And that brings me on to ask you about your other interest, which is in communicating preventive strategies.
EG: Well, it doesn’t take long, both from a family physician perspective and from a knowledge of the epidemiology, to realize that we’re in a crisis of chronic disease. The World Health Organization moved some years ago from being primarily focused on communicable diseases to recognizing that non-communicable diseases, which is W.H.O. speak for chronic diseases, are one of the most significant international concerns. And so, with the family doctor perspective, I felt that one of the errors that we make in thinking and talking about prevention is we are too narrowly focused. We have programs for breast cancer screening, programs for colorectal cancer screening, your family doctor will talk to you about diabetes, but we do it in a very siloed way. Nobody can think in broad terms. We need to be thinking about prevention, screening, and prevention for all chronic conditions at the same time because upstream factors are common to all of them. These are the lifestyle factors. We all know this. How can we integrate screening and prevention for all chronic conditions in a unified message for patients so they can understand the relationship between these conditions, and understand how an intervention for one of the upstream factors like exercise or weight control, will have an impact on all of the conditions, rather than thinking of it in a very narrow way. So that’s the insight that led me to the work I’ve been doing, under the rubric of what we call BETTER.
… I have great empathy for the plight of people who are new immigrants to Canada, having lived it. One of my policies in life is to say yes if someone is giving me an opportunity… led me to create a volunteer program, we call it HELP which stands for Health English Language Pro.
The HELP programme was written up in the national newspaper The Globe and Mail
DMacA: I’m going to bring you full circle and finish up with something you’re involved in at currently. You earlier described the language difficulties your family had when they arrived in Canada, but now you’re helping a new wave of immigrant families deal with language difficulties…
EG: This is my current project and I’m very excited about it. I have great empathy for the plight of people who are new immigrants to Canada, having lived it. One of my policies in life is to say yes if someone is giving me an opportunity. Reg Perkins, whom you know, is a very well-known family physician in Toronto. He and I met at a conference, and we were chatting about what we were respectively doing. He told me about a Syrian refugee family that his church had sponsored to come to Canada. The mother was an obstetrician gynaecologist but she realized she would never be able to practice medicine in Canada and had identified the possibility of becoming a midwife. There were four children. The refugee supplement offered by the Canadian government was coming to an end so it was important to earn a living as quickly as possible. Reg said the biggest problem she faced, while learning English as a second language, was to learn medical lingo- the medical terminology, acronyms, abbreviations – and the opportunity to practice talking about those things in a high stress situation. So, I offered to help her. We met once a week, at a coffee shop, and we brought our obstetrical instruments with us, which left other visitors to the coffee shop rather shocked. She did get into the midwifery program. She graduated. She’s now a midwife. Her kids are doing great. It was very rewarding. I described that experience in a short story. https://www.cmaj.ca/content/194/31/E1094
That experience led me to create a volunteer program, we call it HELP which stands for Health English Language Pro. HELP partners Canadian volunteer physicians with internationally trained physicians. The goal is to improve their fluency in using what I call the secret language of medicine, the medical terminology. There was an article in the national newspaper, the Globe and Mail, about it. https://www.theglobeandmail.com/canada/article-doctors-foreign-trained-mds-language-barrier-program/
We launched the program recently and I’ve already been contacted by about 20 physicians saying they would like to volunteer, so I am very excited. https://accesemployment.ca/programs/bridging-and-sector-specific-programs/help-program
DMacA: That’s another fabulous success story. Eva, thank you very much for sharing so much of your life and your contribution to Canadian medicine. It’s no surprise that you were given the Lifetime Achievement Award, and it’s absolutely no surprise that you are a recipient of Officer of the Order of Canada. It’s been an absolute pleasure talking to you. Thank you.
