‘In Dialogue’ Episode 9: Dr. Jonathan Wong
In episode nine of “In Dialogue,” CPSO Senior Communications Advisor Mark Sampson speaks to Dr. Jonathan Wong, a family physician with Inner City Health Associates and program lead for the Street Clinical Outreach for Unsheltered Torontonians (SCOUT) about providing health care to unhoused and precariously housed populations, building trust within the community, and the system issues revealed during the pandemic.
This is part one of our two-part conversation with Dr. Wong, a.k.a. Dr. Johnny as he’s known amongst his colleagues and clients. He’s dedicated his career to working with people experiencing homelessness in the Greater Toronto Area, working almost exclusively with Inner City Health Associates since completing his residency. He works at a drop-in shelter, performs street medicine and works closely with the Seeds of Hope, CPSO’s chosen charity for three years, providing health care to folks using their services. He emphasizes the criticalness of trust and relationship building with this particular population, as well as ensuring the care they receive is dignified and allows them to maintain autonomy.
Stay tuned for part two of our conversation with Dr. Johnny in 2023.
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CPSO presents “In Dialogue,” a podcast series where we speak to health system experts on issues related to medical regulation, the delivery of quality care, physician wellness, and initiatives to address bias and discrimination in health care.
Mark Sampson (MS):
Welcome to part one of our two-part conversation with Dr. Jonathan Wong.
My name is Mark Sampson and I’m a senior communications advisor here at CPSO. It’s my privilege to present this discussion on a very important issue that affects many in our society. For thousands of Ontarians who are either experiencing absolute homelessness or are precariously housed, access to health care can be a tremendous struggle. It was a huge issue prior to the pandemic and the fallout from COVID-19 has only exacerbated their plight. There are many health professionals who are dedicated to helping these populations: emergency department physicians, street doctors who treat and advocate for people experiencing homelessness, hospital leaders who work to embed system improvements for these patients when they come in the door, and scholars who are building an evidence-based body of research to assist with these systemic changes.
One such incredible physician is here with us today to talk about his experience in helping vulnerable people in the GTA and his work with CPSO’s chosen charity for the next three years, the Seeds of Hope Foundation. We are very excited to be joined by Toronto-based family physician, Dr. Jonathan Wong, a.k.a. Dr. Johnny as he’s known to all the staff, volunteers and the people that he helps there at Seeds of Hope.
Welcome Dr. Johnny and thank you for being here. We were wondering if you could maybe start by telling us a little bit about yourself, your background and the work you do helping people experiencing homelessness here in Toronto.
Dr. Jonathan Wong (JW):
Thank you so much for having me. It’s an absolute delight and privilege to be here. A bit about myself. I did medical school in the U.S. I couldn’t get into med school here in Canada, so went to good ol’ Wayne State. It was a great experience. I fell in love working with people experiencing homelessness there and that sort of led me to the work that I’m doing today. I was fortunate enough to come back to Toronto for residency at U of T and specifically at St. Michael’s Hospital. And since finishing residency, I’ve worked pretty much exclusively with Inner City Health Associates. So, we’re an organization that serves people who are homeless or precariously housed. I specifically work at a drop-in shelter. I have a family practice out of a family health team where I will see people longitudinally. And also, my favourite work is the street medicine piece where I’m physically going out to see people where they live in their tent encampments, under bridges, by ravines, on heating grates. So that’s with a team called SCOUTS, which stands for Street Clinical Outreach for Unsheltered Torontonians.
MS: Thanks so much for sharing that. It’s just incredible to be able to talk to you about some of the experiences that you’ve had working with these populations here in the GTA. People experiencing homelessness have suffered some of the most harrowing traumas imaginable, including physical abuse, emotional and sexual violence, mental health issues and substance abuse. How do you and your team approach treating these patients’ health concerns, while also recognizing the complexities of their lives and their circumstances?
JW: Yes, thank you for this great question. I neglected to mention, I also work at a family health team that serves people experiencing homelessness as well. Generally, all care should be trauma-informed and harm-reduction focused. We want people to feel really dignified and autonomous in their own lives. Consistency for us, in our street medicine practice, is crucial. You can’t just see someone once and expect them to take you seriously. They need to know that us going out to them and sort of meeting them where they are, on their turf, isn’t some sort of charity, but that you’re in it with them. I think that that holds a lot of weight for people. And in terms of being patient with folks and going at their own pace; I mentioned meeting people where they are — we would do this for anything in medicine, right? Whether it’s chronic disease management, mental health or substance use, we’re always assessing and reassessing people’s willingness to make change in their lives, and to not shame or blame or judge them for any choices that are being made. And I think with the consistency and patience, of course, it does lead to trust building and relationship building, which is so, so critical. I don’t need to tell anyone who might be listening to this that trust is key and working with anyone, not even just people experiencing homelessness.
And then we also really work, certainly in the first visit and ongoing visits, figuring out what people’s goals are and allowing them to lead. Giving them agency, I think, can be very powerful and I think not necessarily something that people are always used to. A lot of people talk about paternalism, basically, and fear of judgment. I literally just had someone yesterday comment to me, at the moment that she mentions that she uses crack, it’s like she can feel the judgment on her skin. And it’s just wow, you know, people aren’t stupid. They’ll know when I’m not taking them seriously or aren’t really giving them the time of day or think that their cause is hopeless. And so, I think it’s our job to sort of bring hope and restore hope, and partner with people so that they can be agents of their own lives.
So, I learn a lot from the people that we serve, and your question about recognizing the complexities of their lives and circumstances… When I meet someone for the first time, it’s like, “How can I build trust with this person? How can I ensure that you don’t think I’m some sort of narc?” And that you’re not lost follow-up, because that is a very common thing to happen that we lose people to follow-up. You can have the best laid plan for someone or work with someone to sort of figure out a best plan, but being able to follow-up is crucial. I rarely ask anyone for identifying information right off the bat, just sort of go with what they might offer me by way of name, or alias after I introduce myself. And so, it’s not uncommon for people living on the street to use aliases, because they fear for their own safety; they might be fearful whatever they report to me might somehow be circled back to the system, it might somehow be circled back to the justice system. So, just letting them lead is very, very crucial.
I get that for listeners on this podcast, it’s different given your context, if you’re working in a clinic, for instance, and your receptionist is taking names, taking the OHIP card and creating a chart. But I think if you do get someone who is marginalized or precariously housed or experiencing homelessness, just maybe coaching receptionists to be trauma-informed and not make a big fuss over those types of things, I think is key. I think there’s a lot of barriers to care already and just simply dealing with or working with and communicating with your receptionist should not be what causes someone to leave the clinic immediately. And from there, it’s really just going with the flow, getting to know them better, and getting to understand what their goals are and how we can potentially support. I do like asking about people’s daily routines — and more in the context of street medicine — but how our street med team sort of fit naturally into a patient’s daily routine. And it also gives me a good lens that life can be really a hustle, like accessing drop-ins for food, panning. And sometimes, if someone is a substance user, panning to get enough money to purchase drugs to ward off any cravings, or really overt withdrawal symptoms. It’s all very time consuming, and they’re doing this all while ensuring that they don’t get their stuff stolen, warding off harassment from just about everyone in society, like security guards, other members of the public — it’s a real grind. So, losing people to follow-up because like, where are you staying? Are you housed? Are you living in a shelter or hotel shelter? Are you living outside? So, that we can hopefully find them.
And in terms of income support — OW [Ontario Works] or ODSP [Ontario Disability Support Program] — oftentimes, for folks who are not getting the income that they might need, and they’re clearly meeting the definition of the Ontario Disability Support Program. I love being able to support people with income. We know that poverty is most definitely a social determinant of health. So, getting someone on Ontario Works or ODSP is a very low hanging fruit for us, and certainly does help to build trust and show that “Hey, we’re in it with you and we want to support.”
Of course, we’ll ask about phone numbers. Unfortunately, most people don’t have one. So, our team is pretty low barrier, like our nurses have phones themselves, work phones, and we give those numbers out to everyone and anyone, and they can text us or call us more or less any time and just having that infrastructure to be low barrier in that way. And also to be accepting of emails from patients, because oftentimes people won’t have phones, they won’t have minutes and maybe if they have a phone, it’s a text-now phone and they can only text. So just enabling lines of communication to remain open. And we also ask about trusted contacts — would you consent to us to pass messages through folks, if we wanted to try and reconnect with you, or try to set up a follow-up date if we’ve had a misconnection.
MS: It’s really interesting in terms of what you’re talking about around the autonomy of these patients and really having them tell you what you need. I know when we spoke before, in our interview for the Dialogue article, you had said, “I don’t try to go in there and tell these patients you need X.” It’s really about, as you say, building that trust, listening to them and figuring out from their circumstances what they need. But as someone who works so closely with these populations, how hard is it for you not to jump in with a potential solution? How difficult is it some days to just be able to turn that part of your brain off and just listen to these populations? Many of the people in them, people haven’t listened to them their whole lives and now you have an opportunity to do that for them. How difficult is that to shut off that part of your brain and just hear what they have to say?
JW: Yeah, so I mean, it’s not, but it’s partly due in part to the way our program is funded. I get that the system at large is not geared towards serving people who are vulnerable and marginalized and experiencing homelessness, impoverished. So just briefly on that, our team — at least the physician side — we get funded through an alternative payment plan. So, we’re paid hourly, which is wonderful, as there’s some recognition that working with this population can take a little more time and require some patience. And so, for someone working in a fee-for-service model, I get that it’s probably not feasible to spend extra time and get to know someone. But also, just a testament that, hey, we have this very efficient system that works, I guess, most of the time for most people. But in working with this population and speaking with folks living on the street, a lot of the cracks in the system are revealed. So, I mean, yes, in my head, I will tend to have, wouldn’t it be great if we can do X, Y and Z for this person. I’ll table it, if I’m able to. And it’s sort of just a pick and choose, what we can work on today in the here and now is really, I guess, what happens. Because I’ve been burned before. I mean, I wouldn’t say burned, but to your point about coming up with an elaborate plan. Yes, it’d be wonderful if you got all this blood work, imaging, I got these referrals for you so you can see the eye doctor or check out your foot or something like that. And it just all falls by the wayside, because at that particular time, it’s maybe not a priority or not something that, to my earlier point about the daily grind and hustle that people need to go through just to survive. It can be very difficult to make it somewhere for an appointment. So yeah, just working with people at their own pace is crucial.
MS: In addition to being a family physician at Inner City Health Associates and the program lead for the Street Clinical Outreach for Unsheltered Torontonians, a.k.a. SCOUT, you work pretty extensively with Seeds of Hope, which is, as I mentioned, CPSO’s charity for the next three years, and it’s an organization that serves unhoused and precariously housed populations throughout the GTA. Tell us a little bit about how this charity supports these clients and your role in helping them carry out their mandate.
JW: Seeds of Hope has a bunch of programming and does incredibly meaningful work. And maybe Kim Curry would say otherwise, their executive director, but I think their mandate is really just to serve people who are houseless and precariously housed, and really breaking that cycle of marginalization, and on and off the streets, and in and out of shelter, and empowering people and giving dignity and agency to people’s lives. I believe they run a safe bed program for women escaping precarious situations, like the sex trade or an abusive relationship. And they do event supportive housing units, which I believe is supported with some addiction supports. Those units are rent geared to income.
Our team, SCOUT, we primarily interact with their drop-in location. And the reason being is many people who are experiencing unsheltered homelessness, they need a place to grab a meal, to maybe get a shower, maybe get some clothes. And so, their drop-in is wonderful for this. A very, very strong reputation and place that is largely viewed as a safe, welcoming community by folks. And so, if they identify anyone who might be in need of any sort of medical care, they’ll refer them over to us. And then we’ll typically see them at their drop-in. The benefit of this is they’ve really built this unity, where people enjoy going to or they socialize, or they can use computers, do some learning, and just all the time spent with folks has garnered a lot of trust. And so, they do all the heavy lifting in terms of that trust and relationship building, and then they say, “Hey, here’s the SCOUT team, would you be interested in seeing them?” And so, it just makes our jobs a lot easier because they were the referrer and the person in question who we’re going to eventually see has consented and will trust anyone from Seeds of Hope who recommends anything.
MS: It’s so great to hear you talk about the interconnected relationship between the work that you do and Seeds of Hope, and that idea of building trust with these individuals and how absolutely critical that is to helping them. That trust really is the engine in these relationships. It really drives home this idea that it’s really about building a relationship with them and making sure that they feel they can get the support from you that they need when they need it.
In terms of the work that you guys have done, you’re doing this, of course, the last two and a half years in the wake of the pandemic. And we know that the pandemic was an extraordinarily difficult time for physicians and patients alike. And it had a devastating effect on the health and lives of unhoused populations in many regions, especially here in Ontario. What are some things that you noticed in your work? And how did working so intimately with people and caring for them affect your own health and your own wellness during the pandemic, during this time?
JW: So, big question. I still remember when I think we were all pretty fearful. I think we think that we weren’t as fearful, but I think we were fearful. But also what did it mean for our patients as well and, as I mentioned, to us. I remember leaving home. I work at a shelter in North York. It is the site of the largest shelter outbreak, probably in all of Canada. There’s 250 residents there and it was 73 percent positivity in wave one. And as I’m leaving home, I’m like, I don’t know if I’m going to be coming back. It’s wanting to isolate from the family kind of thing. And my partner/wife is like, “Don’t die.” But she’s kind of tearing up there too and so it’s kind of terrifying. But I definitely wanted to be a part of the solution and respond.
Yeah, it was a crazy time, right? Even here in Toronto, we were thinking about opening up this big field hospital-style thing, similar to China, I guess, this big open space with glass windows. If you talked to anyone about having glass windows to monitor people these days, what in the world were you thinking? But speaking to the fear piece, we had no vaccine, no treatment, no idea what we were doing. I eventually worked at the installation site for people experiencing homelessness. They have nowhere else to isolate, obviously. And this referral form that we developed for people to send in when they wanted to send someone over for isolation was based on obviously their vital signs at the time and any sort of past medical history and risk factors. And to the point of not knowing what we’re doing in our own work, someone, an emerg doc, had referred someone over. The person was perfectly fine, but maybe had some risk factors, including obesity, and we refused to take the person. And the emerg doc calls and was like, “What the heck is going on over there? You can’t take this guy because he’s obese? He’s just sitting here.” So, it was a crazy time, right?
To the point of what happened to folks experiencing homelessness, obviously, the pandemic had limited shelter capacity. And so, the lack of affordable housing led to this mass migration to very public encampments. Usually, encampments were more invisible and off the beaten path. But in Toronto, they took up some of the more major parks. And so, what I noticed in the work, in terms of SCOUT work and street medicine, folks are always under this constant threat of eviction and small scale eviction tactics, including receiving eviction notices like trespass notices, having their possessions remove, and basically being pressured to take indoor spaces without really a whole lot of information to go on, like, what’s the place like? Are they going to be able to accommodate another person? My dogs? But also giving people very short turnaround times to accept the offer. For people who are living outside specifically, everything shut down.
So drop-ins, which is really the fabric of social services, I would say, for people who are particularly unsheltered. They had to change their operation as places of gathering and community building or like Seeds of Hope was affected. They basically became places of dishing out survival gear, food and clothes, things they would already do, but without that community building and the reciprocity. And so, I think, to some extent, it did sort of hurt the relationship building in some ways, and the community building. I also think about when everything was shut down, access to basic needs, like sanitation, a warm place to go shower, those were pretty hard to come by.
There was a large encampment at Lamport stadium and it took a while for the city to open up to basically use the arena as a space where folks could use the washroom and shower. But they were open at these obscene hours from 7 a.m. to 3 p.m. And so where are you gonna go after 3 p.m.? As someone who’s working there, we’re out on the streets seeing people, it’s a little bit of an occupational hazard for us, not being able to go anywhere to go to the washroom. So even for us, if we were there, we got to make sure we ourselves use the washroom before 3 p.m. But this is what people experience every single day. When I get home, I’m gonna be able to take a shower, use the washroom, no problem. But just like basic needs were not being met. Like who knew McDonald’s, Tim Hortons are actually maybe the fabric of society. (Laughter)
Like drop-ins, when they all closed and shut down, there’s no place to access a washroom, no place to just sit and chill, have a coffee and warm up. So, I think houselessness or people experiencing homelessness, it was much more visible and palpable during the early going, especially when everything was shut down. And also, my biggest fear in the first winter was we had this mass migration, but when you talk with folks, it’s like, “Well, have you like camped out before?” And by and large, no, these are first time encampment dwellers choosing, making the best choice given the circumstances in their lives to live outside. But I’m fearful that you may not have the skills to do so. I’m worried about your itty bitty toes, and feet and hands. And we did see quite a bit of frostbite, unfortunately. I would say one of the positives was you may have heard of Khaleel Seivwright. He builds all these tiny homes for folks who were camping out. What he did was totally digit- and limb-saving, and life-saving for a lot of folks. But, of course, the city shut him down. So, there were a lot of things going on for sure.
To answer your question, I would say, I worked in a number of different capacities over the course of the pandemic, including the isolation center, as I mentioned. But working there, in particular, in conjunction with all of my other work at drop-in shelters and also the street medicine, you just see people cycling through the shelter system. I wouldn’t necessarily see someone physically at the isolation site if there’s nothing really going on with them. But just seeing names go in and out, in and out, in and out, the same names. People are moved everywhere and anywhere. And that sucks, because how are you supposed to maintain any semblance of stability if you’re moving so much, and basically being forced to move.
MS: I know that in different areas of the health system, we’ve heard physicians and system leaders say that as bad as the pandemic has been, it has helped us to do different aspects of our jobs better. We’ve learned certain things thanks to the pandemic and we’re able to help our patients, the public that we serve, in a different way thanks to the pandemic. But it sounds like from your perspective, it’s still very much an uphill battle, maybe an even harder battle than it was before. Do you feel that way? Are there elements of optimism or hope that you see for treating these patients?
JW: That’s a great question. I wouldn’t say I’m all doom and gloom. There are some positives that came out of this. We, at least as an organization, Inner City Health Associates, my organization that I work for, we’ve never collaborated as much as we have up until this point between the city, our organization and other social service agencies, tertiary care. Coordinating in the way that we have — yes, it could be better, but it wasn’t really happening before. So, I think that’s definitely a positive. I think we’re moving in the right direction. I would say it’s not like people are totally numb or dismissive of the issues, and great work is being done across the board. It is, admittedly, very complex and I don’t necessarily have all the answers, but I think the collaboration piece… we cannot begin to address the problem, we’re just doctors, we don’t know anything, but it does definitely take all hands on deck, people in different roles and perspectives that will really bring forth the durable and meaningful solution.
I think another benefit has been, I would say broadly, at least within the downtown Toronto core, greater knowledge on how to provide addictions medicine and addiction support. Personally, I’ve never prescribed safe opioid supply for people who are using fentanyl, but over the course of the pandemic, because we had to do everything in our power to keep people comfortable while they’re in isolation and also when people were going to hotel shelters. It’s great that you have your own private room and a dignified space to live, but also, there was a legit risk of fatally overdosing in the privacy of your own room since no one would be able to see or respond. So, there was a lot of effort put into training physicians to be able to provide more meaningful harm-reduction-based addiction support.
And I would say in Toronto, yes, we had a lot of things go on during the pandemic, including encampment evictions, which were terrible. But there’s a lot of organizing going on, like grassroots advocacy groups, like Encampment Support Network and ALAB, they did some really, really wonderful work over the course of the pandemic and they really stepped up to support people living outside, in particular, and helping people keep alive.
MS: Hope you enjoyed part one of our conversation with Dr. Johnny. Stay tuned for part two in 2023.
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