My name is James Orbinsky. I'm the principal here at Massey College, and welcome to Health Science and the Democratic Trust. This is a conversation that speaks directly to the moment that we are living through. Let me just first acknowledge that we are on the treaty lands of the Mississaugas of the Credit First Nation and the traditional territory of many nations, including the Anishinaabe, the Chippewa, the Haudenosaunee, and the Wendat peoples. And that this land is also home to many other Indigenous people, First Nations, Inuit, and Métis from across the country, or what many, especially our Indigenous brothers and sisters, refer to as Turtle Island. We're very grateful for the opportunity to work on this land, and we very much recognize that it's our collective duty to share and care for this land.
And with that, again, let me welcome you to our Massey dialogue on health science and the democratic trust. This is a conversation, as I said a moment ago, that really speaks to some of the core currents of our time, core political currents of our time across Canada and around the world. Trust in institutions, be they scientific, medical, democratic, or of any formal public institutional nature. This trust is being tested, and how we respond to these challenges will shape not only our health systems but also the vitality of our civic life itself. Now, this event has been organized by junior fellows Katherine Stratton and Ferdinand Revic, which I hope I got right. Is that pretty good? Okay. Excellent.
And their leadership really does exemplify what makes Massey College so special. Our junior fellows are not only outstanding scholars, they are also conveners of dialogue, builders of community, and leaders in thinking about the public good. Katherine's work on rare disease registries and patient engagement, and Rey's research in biomedical engineering and stem cell modeling remind us that the future of medicine depends as much on collaboration and commitment to the public good as it does on technical innovation. Now, please join me in thanking them, as you already have done, but let's do it again, for bringing this conversation to Massey.
Here at the college, we convene conversations that help our community and our country understand itself in a changing world. We try to bring scholars, practitioners, and students together to wrestle with some of the difficult questions of our time and to do so with clarity and with purpose. And this afternoon's discussion continues that commitment. We have some wonderful panelists who've joined us. First, to my far left is Timothy Snyder, who is a senior fellow here at Massey College and is professor and chair in modern European history, and that chair is supported by the Thierry Endowment for Ukrainian Studies. He's also at the Munk School of Global Affairs and Public Policy, one of the world's leading thinkers on democracy, and I would argue one of the 21st century's most prominent public intellectuals globally. He's one of the world's leading thinkers on democracy, on authoritarianism, and on freedom, and his books, including On Tyranny, and one of his not-so-well-known books but very important books, Our Malady. His books remind us that access to health care is not simply a technical question but a democratic one. We're also pleased to welcome Mamabat here in the middle. Oh, sorry, at the far, far left, right, far right. There you go. I always have to do that, even at this age, which is my left, which is my right, anyway.
Either one. Right. You see, this is why we are so grateful to have Tim with us. Such wisdom, it just drips from him. Please take a bow.
Mamata Bat is a hepatologist and a clinician scientist at the University Health Network, and she's also associate professor of medicine at the University of Toronto. Her work uses artificial intelligence and precision medicine to improve outcomes in liver transplantation. And while her leadership, excuse me, in clinician scientist training and AI in medicine speaks to the future of healthcare innovation in the country. And then finally, somewhere in the middle, we have Dominique Nowak, who's a family physician and department head of family and community medicine at Women's College Hospital. He's also former president of the Ontario Medical Association, and Dr. Nowak has been a leading voice in strengthening Canada's health system and rebuilding trust across institutions that Canada depends on. So together, our panelists will explore how access to care, technological innovation, health policy, and democratic values, how do these intersect, and how trust or a lack thereof can be strengthened or weakened in this, what I would call, a dialogic process between those four kind of core elements. Our panelists will help us consider Canada's role in positioning health and science not only as a national priority but as a central activity of contemporary liberal democracy. Thank you all for being here. I'm very much looking forward to the discussion, and please join me in welcoming our speakers to Massey College. Over to you.
Okay. Welcome again, and thank you all for being here. I'm so excited to dive into the discussion. To start us off, we'd like to ask each of you about your work or your field. Where do you see democratic norms or trust in science most tested? Now, I'd like to start with Dr. Snyder, especially given your work on democracy and fascism, especially in the Eastern European context.
Okay, I'm very happy to try to set the stage. So I should make clear, as I think James has made clear, that I'm not here as a physician or a medical researcher. My only qualification in this sort of conversation is to have been a patient, essentially. But I will say that that's actually a useful point of view, and it's where I'll be coming from. But professionally, I'm a historian, and it's a good question because if you take a big enough loop, the things that trouble me in my professional life do connect with the things that troubled me as a patient. So, as a historian of Eastern Europe, naturally I am a historian of propaganda, disinformation. I wrote a couple of big books about totalitarianism, in which one of the most important elements is the way that coherent narratives can replace the small facts. So that one way of going through life is for things to make sense to you, even if the things that are making sense to you do not actually correspond to any kind of external reality. In other words, it's a basic finding of the history of the 20th century that it's possible to live your life in what we call now alternative realities. You can live a life that's coherent and makes sense to you without a lot of the things that you believe to be true having much of a corresponding external reality. So in my world, then, as we move in towards the present, that's relevant to things that I care about, like the Russo-Ukrainian war, where Russia in the early parts of the second decade of this century was very far ahead of others in operationalizing or weaponizing certain kinds of vulnerabilities. The Russians were very quick out of the gate to understand that the way social media worked was to hover around the things that we want to believe or hover around the things that inspire us to stay online, and to use that vulnerability or to use that set of temptations to get people to think certain things about a war. And so their accomplishment in 2014, when they invaded Ukraine, was essentially to do so without people calling it invading Ukraine. If you can remember back 12 years ago, a country was invaded without anyone ever really quite saying that a country was invaded.
And so that got me thinking about a process which began in Russia and was spreading through Europe and in North America, into my country, and was associated with Brexit and with the election of Donald Trump, I think, which is this broad shift, which is sadly aided by what we call technology, away from a kind of fact-based or at least tenuously fact-based experience of life towards a more coherence-based experience of life, where your own personal coherence is aided or is goaded, is that you're seduced into the kind of coherence that seems best for you, but which may in fact leave you vulnerable. It may leave you mistaken on major issues of life. And so, without saying much more, you can see how that connects to the question of health. I mean, there's an obvious direct connection, which is that the Russian Federation does in fact engage in Canada and the United States in quite considerable disinformation operations having to do with vaccination and other health issues. That's the kind of easy connection to make. But the broader connection to make is that as we move into this world in which there's a kind of manufacture of personal coherence for everybody, we are, by way of what we call technology, we are drawn away often from what is evidently good for our bodies, and indeed drawn away from thinking of our bodies as an essential part of ourselves, where our personal coherences are essentially psychological. They're essentially mental, and they take place between us and a screen. And so we're led away from thinking about our bodies at all. Just one little footnote before I stop, which is that I've been trying to remind myself to say what we call technology, because I think that word is often abused. And I'm just going to give my little definition of it so you know what I mean. I think it's only technology if it's enabling. If it's disabling, it's not technology. And so a lot of things that we call technology, I think when we use the word technology for them, we're actually just repeating the propaganda of the people who make profit from them. So I think that thinking of technology as only being what is enabling can be a good start, maybe, in this sort of discussion.
Thank you so much, Dr. Snyder.
Dominique Nowak. I'm a family doctor. And who here has a family doctor? So the majority of this room? That's good to hear. And it's not representative of the majority of it, it is representative of most of Canada, but too many people can't find one. Right. And what I'll say as a family doctor is I care for people from newborn babies all the way to, you know, some of my patients are in their 90s and thriving, all the way to, up until recently, I was still doing home visits. So caring for people in their last few months or weeks or days of life. And it's really special to be a family doctor. In my leadership hats, I'm also an optimist. And for me, optimism means realism and hope. And if I were going to ask you, just be real for a moment around where Canadian healthcare is, what's one word that you describe as the vibe check of Canadian healthcare right now? Just throw out some words.
Crisis. Who said crisis? Raise your hand. Yeah. Crisis. What else? Give me a few.
Necessary. That's a good one. Love it. One in the back.
Fractured. Let's get one or two more.
A blessing. Yeah. Beautiful. Another optimist over here.
Needs improvement. And overwhelmingly, when you ask people about our healthcare system, and we get these words like crisis, catastrophe, strained from health professionals, you know, moral despair because people, their patients can't get through the waits, can't get the care that they need. Something like one in four people can't find a family doctor. Last year, emergency departments closed, I think more than ever, the emergency department closures because of physician shortages and nursing shortages. And we have a workforce that's under pressure, right? So that's the reality of our healthcare system. And when you think about people reaching out to public institutions, healthcare is a main one. People experience how government delivers, how our country delivers, based on how they interact with the healthcare system. On the other hand, optimism also means hope. And Canadian healthcare, if you look at Canada, we have world-class doctors, world-class hospitals. We have world-class science as well, world-class outcomes. At Women's College, which is my site, we're expanding access to primary care. We're launching an AI living lab to look at how AI can actually be productive and help our workforce rather than hinder our workforce, and how technology supports the care rather than hinders it. And then also we're looking at what do teams in healthcare look like and how do we spread good teamwork across the healthcare system. So healthcare is such a beautiful example of a public institution that we can nourish, cherish, and support to restore and build trust in generally Canada and a better Canada for the future. And that's our premise, I think, for this conversation today.
Hello, everyone. So my name is Mamata Bat, and I'm a clinician scientist and transplant hepatologist at Toronto General Hospital. So we have the largest transplant program in Canada, and, you know, as a practitioner who evaluates, takes care of patients along their journey towards a transplant. So I take care of patients. I evaluate patients with end-stage liver disease, liver cancer for liver transplantation. I take care of them during the process of the surgery, surgical admission, and then post-transplant. And in a way, I end up being the family doctor for these patients during their second life, you know, so it's a great opportunity and really wonderful to see the transformative effect that transplantation has on our patients. And in fact, I look after patients for several years post-transplant, optimizing their health post-transplant so they can lead successful lives thereafter. So as a clinician scientist, I spend 25% of my time, technically 25% of my time doing clinical work and 75% of my time doing research. And I lead a highly interdisciplinary research team of 14 full-time research team members, of whom 11 are computer science postdoctoral fellows or graduate students, and I also have clinical research fellows and bioinformatics expertise on my team. So my research background was a PhD in medical biophysics at the University of Toronto. Prior to that, I'd completed all of my medical training at McGill and then at Mayo Clinic in Minnesota. But then I did my research training here. And so that, I think, was a highly interdisciplinary background that then enabled me to lead such a highly interdisciplinary research team, wherein all of us, you know, who speak different languages, can mean skill sets, can come together to generate and create new knowledge that can serve our patients, to our, you know, so to provide really personalized care. So the focus of my research program is to both develop and deploy AI tools across our clinical setting to optimize and personalize the care of liver transplant recipients. The inspiration for that was because in transplant, you know, it's a constantly dynamic field. So we take care of very, we evaluate very complex patients for transplant. But the reality is that whoever was eligible for transplant 10 years ago may, you know, will still be eligible, but perhaps there are new indications or new types of patients who are now considered eligible because of the dynamics in medical care. So, for example, cancer was an absolute contraindication to transplant until, you know, five years ago. If someone had a history of HCC, you know, we would say, well, being a transplant recipient, you're on immunosuppression, we will increase your risk of recurrence and very aggressive disease. So the reality, just to summarize, is basically that our patient population is so complex. There are so many different patterns in the clinical features as well as the laboratory tests that we're examining, and it's very difficult to then determine what is the best treatment or what is the best approach to caring for that individual patient in front of you, because that individual patient in front of you represents the confluence of different factors. So our human brain can basically account for seven variables at a time or seven characteristics at a time. But the reality is that there's so much historical data. There's also a number of variables that you're considering when you see that given patient in front of you that, you know, AI as a co-pilot could potentially help you do a much better job by having trained on a very large amount of data to then help you, you know, fine-tune that individual patient's care. So that's really the sort of inspiration for my research.
And some of the other inspirations are, one is witnessing disparities on the liver transplant waiting list. So the reality is that we take care of a very heterogeneous patient population. And so it's very difficult to rank patients based on their risk of death or dropping off the wait list because there's so much heterogeneity. So we have been developing, we have developed an AI tool that considers all of those multiple characteristics and historical changes to better rank patients on the wait list. And that we anticipate would remove disparities that currently women as well as those with certain subtypes of liver disease experience on the wait list. Another interesting tool we have developed is to remove subjectivity and make the process of candidate transplant decision-making much more objective, and I'm happy to talk about that. But overall, all of this to say that we work very closely with patient partners as well to build their trust in such research and such tools and inspire that research. So I think overall, you know, in terms of trust and science, I think it's very important to work with patient partners and other key stakeholders in the healthcare community to then, you know, build trust in science, because really it's the inspiration that comes from our clinical interactions with our patients that then will inspire the work that we do and finally help us build trust in science.
Thank you so much for those answers, just to understand your work. So I think, you know, we've taken from this initial discussion the role of technology, right, and the role that that plays in a democracy, something that can enable, right. We've talked about our healthcare system and there's areas to improve, but hopefully approaching it from a place of optimism. And we've talked about increasing complexity, and so how can we combat that with technology, but also while building trust. So given those wonderful introductions, I think we have to sort of pivot now and think about where healthcare plays into this discussion. So freedom of expression is obviously a very important tenet of democracy, people would argue. But misinformation, though, has played a very substantial role in a deleterious effect in the health of the public. So for instance, we know that last year Canada lost its measles elimination status. During the COVID pandemic, there were, you know, public health introduced restrictions, and a lot of people criticized those as infringing on rights, but at the same time they had to be justified because they were protecting the public or coming from that perspective. So how do we balance, right, scientific guidance as something that the public has a right to, while also remembering the ideals of freedom of expression and the fact that we exist in a public that will have very diverse values and priorities? And Dr. Nowak, I'd like to start with you.
Yeah, I think I'll be brief because I'm curious what my co-panelists want to say on this. What I did notice during the COVID pandemic, we saw a number of different studies that showed that people trusted advice from their primary care professional, whoever that was, usually a family doctor. And I think of the number of times I heard someone say to me that, you know, I tried to get a family doctor, I tried to get in to that visit, and I couldn't. And that's why I went online. That's why I went on, you know, TikTok. That's why I went on Reddit. That's why I went to some other health professional that may not have the credibility or the training to speak in a way that's science-based on vaccines. And those were some of the root causes behind disinformation, misinformation, and people having incorrect information about not just vaccines, but then other health-related topics. So I'd say that that foundation of having a trusted partner in health, that is a family practice or a primary care professional, is so important to then building up credibility and trust in the rest of the healthcare system, and then since we're here, by extension, in other public institutions.
Thank you, Dr. Bat. Does that resonate as well as a physician, but in a different setting than primary care, perhaps?
Yeah. Yeah. So I would agree with Dr. Nowak. Certainly during the COVID pandemic, our transplant recipients would, you know, very, they were quite anxious and scared, obviously, early in the pandemic, being immunosuppressed. So being on anti-rejection medications, they were at much higher risk of infection. So particularly before the vaccines came out, there was a lot of, and any successful antiviral medications to treat COVID, we did have, unfortunately, several people pass away due to COVID-related illness. And in that very high-stress, high-tension environment, I mean, our transplant recipients would often contact us. I mean, we have transplant coordinators. So our transplant coordinators are really their first point of contact with our transplant program, and they would be, you know, relying on our program for their care and as sources of information. I did also want to comment potentially on, you know, the differences in public healthcare and private healthcare in terms of trust. So I, you know, I did my fellowship at Mayo Clinic in Minnesota, and, you know, obviously world-class physicians like my mentors were there, were amazing. Now, certainly they had, you know, excellent relationships with their patients, and, you know, so highly trusted. But I think overall, in the public healthcare environment, there is perhaps, you know, a bit of caution in terms of our testing, but also, like we will discuss, with our patients, different options, and they know that, you know, we're not going to be swayed by certain, you know, costs or certain other considerations like insurance, etc. You know, so like when I order a test, I'm not thinking, oh, will this person's insurance cover it, or, you know, so there is a greater deal of trust, I think, that we're fortunate to have from our patients because they know that we're not, we're trying to make a decision along with them that is in their best interest, considering their unique circumstances. So I think, you know, even when it comes to very difficult discussions, which we often have in transplant, you know, there is a greater sense of trust, I think, overall, that we're working together to make the decision that is in that patient's best interest, and that really follows the criteria that we have in our jurisdiction around, you know, whether it be transplant candidacy or transplant care. So I just wanted to make that comment, like I think, you know, trust between a patient and physician is very important, and I think also the longer-term sort of relationship that you build, or say myself and my transplant, or my colleagues in my transplant clinical practice build, are quite important. But even beyond that, there is this additional level of trust that I think comes from the type of practices we have in this public healthcare environment.
Can I top up? So I think it's important to name the areas of healthcare where we do see an enormous amount of misinformation, disinformation. I'd be curious to know why these areas have that amount there. I think of when people are at their most vulnerable, the patients that you care for during the most difficult times of life, in cancer care, we see a lot of misinformation there. Women's health, huge amount of, I think in many ways, possibly corporate-influenced misinformation or not. There are these streams of misinformation. I'd be curious to know why those are some of the patterns that we're seeing.
Dr. Snyder, do you have some thoughts on that? Being a historian,
I do, but I'm going to just, I'm going to play by the rules and answer the question that was asked first. No, because it actually flows very nicely from the remarks about trust. So the question was about the tension between freedom of expression, i.e., not wearing a mask, and wearing a mask, i.e., public health. And as I see it, a lot of these, usually these apparent tensions between freedom and the public good break down if you actually take the idea of freedom seriously, because usually the idea of freedom that's put on one side is a very narrow idea of freedom. But if you think more broadly about freedom, then the tension releases and the opposition goes away. So what do I mean? I mean that, first of all, we're only free in our bodies, right? We can't be free any other way. There's no, we don't exist any other way. We only exist in our bodies. We're only free in our bodies. And a lot of the way we talk about freedom misses that. And insofar as we've built societies where people can be free, it doesn't have to do just with the government leaving you alone, which is the common, you know, liberal or at least American way of talking about freedom. Insofar as people actually have freedom in their lives, it's because their bodies have been taken care of in some way, because there is prenatal care, because there's natal care, because there are vaccinations, because there's access to family doctors. All of those things, when they are built in, have created the lived reality of freedom that we have. I mean, and so as a historian, it's not hard for me to formulate this because I have a sense of what it was like before all of this happened. And people were unfree up until, you know, the 20th century, essentially. Not so, not only, and not even chiefly because government did bad things to them, but chiefly because they were constantly getting, I'm not, I'm going to list all the terrible ways that people regularly died, right? Like the basic status quo was just so fundamentally different before the onset of vaccination and public hygiene, right? The things that we now take for granted. And what I would do is I would say is I would merge those things into our, into freedom. I think freedom actually, I mean, I wrote a whole book about this, but I think freedom actually, like freedom actually has to start that way rather than starting from I'm momentarily irritated because there's something that I don't want to do or the government is telling me to do something. And I think if we frame it that way, that these societies that we have in which we can be free have to do with knowledge about the body and particular kinds of health practices, then the discussion about masking looks a bit different because, yeah, sure, I have a freedom of, I have freedom of expression, but other people also have this bodily-based freedom not to be afraid of death, which I would argue is, you know, not even so much a contrast. It's just like, yeah, if we're talking about freedom, let's consider both of those kinds of freedom and see where we end up.
Yeah, thank you so much, everyone, for those thoughts. Thinking a little bit more about the physician shortage crisis that we are facing. So if democratic legitimacy does depend on citizens actually being able to access those services or essential services, then how should we understand the primary care physician or just physician more broadly shortage crisis in Ontario? Dr. Nowak, do you believe that delay in care is a democratic trade-off that is fair for universality, or is it possible that that could undermine trust just as deeply as exclusion due to cost or financial reasons that we more normally associate with, let's say, an American privatized system could?
Yeah. Look, so the question is around, is it okay if we have a universal system, in some ways a universal system that people wait to get access? And I think of, you know, what I shared earlier around our Canadian healthcare system, we have world-class doctors and nurses and health professionals, world-class hospitals, world-class outcomes if you can get through the wait. If you can get through the wait and actually... The wait is heartbreaking for many people. It's, you know, probably many of us in this room have experiences like this. Let me tell you what the wait looks like, right? In Windsor, I was meeting with a teacher who needed a hip surgery and they were in pain, in agony, off work. Weeks turned into months. Now, they've been on a wait list for two years just trying to get through the system. That's what a wait looks like. In Rainy River, I was meeting with a family that was taking their grandfather to the emergency room with signs of a stroke and they got there. It was the winter and the emergency room had a sign on the door that said ER closed and the next one was two hours away during great weather. This was the winter. They weren't getting there that day. That's what a wait looks like. In southwestern Ontario, we had a family practice open a few months ago. So it was sometime towards the end of last winter. And as early as two thirty in the morning, there were already a thousand people lined up just to try to get access to a family doctor because their waits were so long otherwise. So that's what a wait looks like. It's not just an academic exercise of universality versus waits. This is actually hurting people and harming by making them wait. So it actually does hurt trust when we do make people wait because it hurts health. People are reaching out to the healthcare system and not getting what they need. And in large part, that's not because we don't have a world-class healthcare system here in Canada. It's because we make people wait. So there's no separating the conversation on wait times, access from the conversation on trust and people getting exactly what they need from the healthcare system.
I wondered if you could speak a little bit more, just as a follow-up to the comment that you made about outcome, that we still have very good outcomes at a population level, and so someone might say, despite the wait, we seem to be still faring relatively well. Could we be doing even better if the waiting issue was maybe addressed, or do you think that is then something that, you know, should be overlooked or maybe is exaggerated? It's frustrating, as you said, it causes harm in the sense that it's very agonizing to wait, but are they maybe not zooming out and looking at the bigger picture because at the end of the day the outcomes are good, or is that still not quite pinpointing the issue?
Yeah, you know, I'll say in Canada, we have a tale of two cities for a healthcare system. We have people who have access to strong primary care and a family doctor and people who don't. And if you do have a family doctor, you end up using the emergency department less often. You save hospitals for the folks who need them. You get cancer screening. You get preventive care. Studies show that you actually live longer if you have consistent relationship with primary care, family doctor, and at a lower cost to the healthcare system. So that makes our health system more sustainable for years to come. At the same time, for people who don't or people who lose their family doctor, there's, I don't know if anyone saw this, but there was a study recently on what happens when you lose your family doctor and what happens to people who are unattached where they share it. They saw enormously worsened health outcomes for people who don't have a family doctor or who had lost one recently, especially for people who had multiple different health conditions going on. So we have a tale of two cities. We have people getting excellent care for those folks who do have access to primary care and yet people who don't are being left behind. And that's why this is one of the most fundamental things that we can do is getting everyone connected to primary care in some way, maybe through a team, maybe through a family doctor's office, and restoring that sense of everyone should at least expect that level of care from their healthcare system.
Thank you so much. Dr. Nowak, I want to turn the conversation to talk more about technology. So I know Dr. Bat, you do a lot of work with AI, and so AI is often presented as a way to improve efficiency, reduce delays, and help to optimize processes. And so these technologies are advancing at a faster rate than the public can keep up, right? And so how should democratic societies manage the gap between this technological speed and social trust from the public?
Yeah, that's an excellent question. Do you mind just using... Sorry. Yeah. Yeah. No worries. Okay. Yeah, that's an excellent question. So I should also mention that I'm partnerships lead with TARM, which is the Temerty Center for AI Research and Education in Medicine. So this is a national network of healthcare AI institutions based at the University of Toronto, and we certainly, you know, have various activities, seminars, educational opportunities for both trainees as well as the academic community overall. So in terms of AI technologies in healthcare, I would say that the actual implementation of AI in hospitals is quite variable from one institution to another, let alone one province to another. So if you look at the University of Toronto-affiliated hospitals themselves, it depends on whether the hospital has decided to make an investment into AI because they are relying on foundation money, like philanthropic donations, etc., to actually provide the AI compute and that, you know, ability to implement. Ideally, we would be able to implement AI to such a degree, say I work at Toronto General, as I mentioned, so to optimize efficiencies around scheduling visits, around writing notes. You know, we often spend time, as we say, pajama time, you know, writing notes. So at Toronto General, so far, we don't yet have an AI scribe, which we should, but we don't. I mean, the plan is to have it by the end of the year. But the reality is something different. So yes, ideally, AI tools would be used to operate, like improve operations, improve efficiency. Operations as in like resource utilization, not wasting. You know, there's a lot of waste in hospitals, right? In inpatient care, like we would try to kind of manage stocks of, you know, instruments, gloves, this and that, you know, medications based really on predictions that are AI-forecasted. You know, so there is a lot of opportunity for improving efficiencies in health.
care with AI, but I think the level to which we are able to implement those tools has been somewhat limited. And say at St. Mike's Hospital, where they did have a very active AI deployment program that was all foundation supported, it was not resourced by the provincial government. And you know, so I think it has required hospitals to make decisions as to where they will invest so that then they can reap the economic benefits and, you know, healthcare resource optimization. But it takes time to actually see the benefits of that, even, you know. So I think it does require hospitals to make those decisions that then will result in healthcare efficiencies. Now, in terms of, I think the question was, sorry, can you come back to the question? What was it around?
So the question was about the speed of technological advancement with AI and, like, the public trust in...
Yeah, so that's, I think the speed of implementation has been limited, especially in provinces like Quebec, the Maritime provinces, but we are seeing greater speed of implementation in Ontario, Alberta, and British Columbia. So, for example, like I do research, I have this CIHR grant, okay, a Canadian Institutes of Health Research grant. So I hold a few grants that are national in scope, and we have all seven transplant programs on that grant, but the ability to which people can participate in Quebec and the Maritimes is limited because they don't have AI deployment capacity, they don't have the ability to extract data in an automated way. Their charts are still written, handwritten. So, you know, how can you actually involve them in research that is national in scope, especially if we are so dependent on data and we're ultimately dependent on, you know, all of that infrastructure for deployment, right? Whereas Alberta and BC and Ontario are much more able to do this. So I think within Canada itself you see inequities in terms of being able to deploy. In the US there are some of these private hospitals that have been able to invest a lot into AI implementation. So Mayo Clinic, Cleveland Clinic, Kaiser Permanente, these are all, you know, hospital systems that have been able to implement and they do report having efficiencies. So I think ultimately it depends on some resource investment decisions.
I think that's a really interesting comment because I think the general public perception is that AI is just innovating too quickly and that they're fearful of changes and maybe the loss of a human element of healthcare. Whereas, so it's interesting to hear from your perspective that the concern is actually about limited implementation and that being a source of inequity perhaps in healthcare implementation. So that's actually very interesting. Thank you. Yeah. And to follow up on, you were describing the different types of AI, like you talked about admin AI for scheduling and writing notes, but I want to ask you about AI that can be used as a predictive tool to make clinical decisions. Yes. Now you already mentioned that there is limited implementation for just the admin AI. Do you think that we will be able to see the use of predictive AI tools in the future? What would that look like? Yeah.
So, certainly we already have such solutions across the TASN system, the University of Toronto affiliated system. We have, for example, an AI tool to recognize patients who are at risk of deterioration. In my own practice, I mean, we are currently using, we developed and have deployed via Epic, which is our electronic medical record system, a tool to predict cardiovascular risk in our transplant recipients and so modifying their management accordingly. So in 52% of cases of patients who were reviewed with this tool, we were able to modify and optimize the management of their cardiovascular risk. So certainly we do have various clinical prediction tools that are in use. But, you know, these are kind of selected tools so far. So it's not like a broad institution-wide deployment of certain tools. So I would say also there is a lot of compute resource required. Depending on the complexity of the tool, it may be more or less difficult to implement via Epic. So for example, we had a very complex model. It's a type of model called a transformer model that we tried to deploy via Epic and it was generating hallucinatory predictions. And then we had to, like, you know, which was, you know, we had published that paper in a high-impact journal, so a few years ago in Lancet Digital Health, so in 2021. And then I tried, you know, then I said, okay, let's go on to this next step. Development is well and good, but we should actually try to use this to personalize care of patients. And then when we tried to implement this, we ran into this problem. So our data engineer was able to, you know, integrate the solution into Epic and everything, but the transformer model was so complex, like it was considering 167 variables and then historical changes. So it just became too much for Epic to manage or for a system to manage. So then we had to make it much less complex, considering a much smaller number of variables, and then it started working well. And now we are actually using it for cardiovascular risk prediction. So just to say that it's not straightforward. The whole implementation side of things related to AI is not straightforward. But I would say, you know, the patient partners who work with me are very keen on AI implementation because they see it as a co-pilot in their care, so that we can do much better at personalizing their care. And what we also do with the predictions is every time we have a certain, you know, cardiovascular risk prediction, okay, so this patient has a 30% five-year risk of cardiovascular event, you can then tell what it is in their clinical and laboratory characteristics that is the heaviest in weight in that prediction. Meaning, okay, very simply, you know, age, diabetes, perhaps they have a high immunosuppression level. So you can look at all of these parameters for that individual patient, and by doing that, we are also empowering patients in their care because they can look at that list and then say, oh, well, perhaps I need to work on this so that I can, you know, improve my cardiovascular risk. So I think by doing that, we can help patients gain trust also in these solutions by providing what's called interpretability to the AI clinical decision tools.
Thank you. Dr., I don't have expertise in democracy. So, you know, I'm sorry if I'm not, like, perfectly relating this to the democracy side of things, but...
No, I think it's a broader discussion.
Right, well for me, but very interesting.
Yeah, and just wanting to learn about the work that you're doing and, as you said, how you've had to think about the themes of trust and engagement, as you said, with patient partners and things like that. So that's excellent. Thank you so much. Dr. Snyder, so, you know, one of the more striking arguments that you have made in "Our Malady" but more broadly in some of your talks is that the American healthcare system is very predicated, if you can say, on fear. Fear of illness, fear of bankruptcy, fear of unemployment because your ability to access healthcare is so intimately linked to your employment. In recent years, some provinces in Canada have been taking steps to privatize elements of our healthcare system. And so I would like to know what you would maybe say to these officials and what do you think, you know, Canada ought to reflect on our form of healthcare historically and how it may have supported, if that's your view, democracy, particularly in the current moment that we're facing as a country.
So thanks for bringing up the topic of fear. There are actually a couple... I was, as we've been talking, I've been thinking about how these subjects come into my books, and they actually come into several books. And one of the books they come into is something that I wrote with my friend Tony Judt, the great historian, a book called "Thinking the Twentieth Century", which I talked to him. We talked it out together because he was dying of ALS. And this is what we did while he was dying of ALS was we wrote this book. And this notion of fear, I think, comes largely from him. He was a committed social democrat. But I think a social democrat from good historical arguments as well as from personal and moral conviction. And one of the things that Tony noticed was that the American political system seems to run a lot on fear, which is a good observation, and it's an observation that is more easily made from the outside. Tony was British and moved to the United States. And fear is so pervasive in the United States that we don't really notice it. I mean, I only notice it in the absence. I notice it when I go to other countries. So I notice it. We've lived a good deal in Austria. When we go to Austria, I notice that something has changed. Or when I fly into Pearson as opposed to flying into Kennedy, I notice that something is different right away. Like my human ability to pick up 168 variables at the same time allows me to notice that something has changed. So I appreciate this. I appreciate you raising fear because that's really, really important. Because if you're living in a society like this one, where so the second thing is fear is very intimately connected to the body, right? I mean, giving birth, and I won't say this as an observer, a multiple observer, is terrifying, and dying is terrifying, and disease is terrifying, and there are all these things along the way that are very frightening, even in the best of circumstances. And you can make these things more frightening, right? You can, by like not having natal care or by not having hospices or by not having access to family doctors. You can make all these things that are already frightening more frightening, or you can take them as an opportunity to build human relationships and effective practices which not only mitigate the health risks in a narrow sense but also give you a sense of political and social and cultural connection to other people. So what we have done in the US, and so it directly connects to the privatization question, because what we've done in the US is that we've essentially commercialized the fear, and we've taken the fear that's natural, that's human, that's inevitable given the kinds of creatures we are, and we've turned it into a source of profit. And so, I appreciate you starting with the fear because it's hard in Canada to articulate what it is that you have to lose, right? Because even when you're in the US, I know a lot of you spend a lot of time in the US, you always have this thing to come back to, right? And you, you know, there's always the Canadian health system you have to come back to. And it's hard for Americans to understand the fear that they're living in because for them, it's just the way the world is, right? So, you know, when we evacuate a sailor from Greenland to Denmark to use the Danish, you know, healthcare system, we really struggle to explain how that sailor could have access to that healthcare system because what is a healthcare system and like how can you pay for it and like well, how can this possibly be working, right? We just don't have mentally the notion that you can have a doctor or have a hospital. What we have is that this is one more process that you pay for. So when you go in even to the emergency room like with various kinds of, you know, ridiculously horrible things that can happen to you, the first thing you confront in the American system is the question of whether you have insurance and what kind of insurance. That's the first thing you confront, which reminds you in this moment where you might be afraid for your life that you are nevertheless right down to the last minute a commodity, right down to the last minute, right? That's the thing you're going to, if you die after that conversation, that's what you're going to be thinking about, and I almost did, which is why I have this example in mind. And so I appreciate you starting from fear for that reason, because there's an inherent terror which comes from being human, from knowing that you're going to die, you know, reproduction is very difficult, these things are inherent. And then I really think that good politics begins, this isn't just an element of something, it's not just an aspect of democracy, that good politics begins from recognizing that fear, that terror, and turning it around into something which can be positive and nurturing, right? Turning those fears around and creating from them a political community. And it's in that way precisely that the United States is not a political community. There's a lot of, because there's so much ambient fear. And it's not just that people are afraid individually. It's that those individual fears can then be mobilized. They can then be transformed. They can be turned against other things. The fears that you have that are natural and have been magnified by commercial medicine can then be turned politically against whatever, African Americans, immigrants, Canadians when we're on a having a really good day. You know, we, that, but the, but that fear then becomes, it's a permanently produced, regularly produced political resource. And it is, it is incon-, it's not just that it's a problem for democracy. I think it's fundamentally inconsistent with democracy because democracy isn't just about going and voting every so often. Democracy is about believing that you're part of a people. And if you're afraid so much and if you don't have a relationship with a doctor that brings, or a nurse or whatever, who bring, that brings you into a sense of a larger community, you don't in a fundamental sense believe that there is a larger community. So I mean, I, so I'm gonna, I'm gonna, you know, I'm going to answer the question in this kind of abstract way because I can't, you know, I don't know exactly what they're talking about in Alberta or whatever. I assume it's Alberta.
Sadly, some parts here as well in Ontario, but other places as well.
Wouldn't expect you to know the particulars, but more, yeah.
Yeah. Just so the thing that I would say is this, that when you, once you open the door to the body being a commodity, it's very hard to close that door again because precisely the fears, and this goes to the earlier question that Dominic had about why certain things become the targets of disinformation, precisely the things that are most frightening, like birth or cancer, but just health in general, those things can be very easily monetized. And once the temptation is there to make money from this stuff, it is a very short step to organizing hospitals around keeping people sick in the right way for the right period of time or something like that, which is what we do. That's how, I mean, sorry, but that's, that is what in fact what we do. That's the, that is, you could be the wrong kind of sick, you know, too bad. You could be the wrong, the right kind of sick but for the right, for the wrong period of time, too bad, right? And so, and then once you open that door, then a lot of money is made very quickly and that changes your politics. So about a sixth of our GDP is from so-called healthcare, right?
