Change The Topic

By July 2018 Canada will have legalized marijuana. Will this result in  northern reefer madness? I think not.  I do hope the discussion shifts to more pressing issues than that of marijuana.  However the next topic – that of medicalizing drugs of abuse  – is likely to be even more polarizing for the psychiatric community.

The opiate crisis needs to be addressed.  A New York Times article reports NYT OpiateDeathsthere were an estimated 59,000 drug overdose deaths in 2016 in the U.S.  Drug overdose is now the leading cause of death for Americans under 50.

At least half of ACT clients will struggle with co-occurring substance use problems at some point.  This, in combination with psychotic illnesses, poverty and the multiple other challenges ACT clients face, may make them even more at risk than the general population.  (I haven’t found any publications on how the opiate crisis is affecting ACT clients. If you  know of any please let me know.)

I blogged about this issue previously – if you have time read Relativity Risk (click to view).  Note where cannabis falls on the graphs!Drug Harm Graph

Dr. Nutt, an expert in the field wrote how:

“We saw no clear distinction between socially acceptable and illicit substances. The fact that the two most widely used legal drugs lie in the upper half of the ranking of harm is surely important information that should be taken into account in public debate on illegal drug use. Discussions based on a formal assessment of harm rather than on prejudice and assumptions might help society to engage in a more rational debate about the relative risks and harms of drugs.”

Some European countries have moved to medicalizing drugs of abuse.  In a 2014 legal journal article titled Uses and Abuses of Drug Decriminalization in Portugal (click to view pdf) the author says  that “The dire predictions of critics—“from rampant increases in drug usage among the young to the transformation of Lisbon into a haven for ‘drug tourists’ ”—did not come to pass.” She points out that “Portugal’s 2001 decriminalization law did not legalize drugs as is often loosely suggested. The law did not alter the criminal penalty prohibiting the production, distribution, and sale of drugs, nor did it permit and regulate use. Rather, Portugal decriminalized drug use…”

So what has been the effect? While still debated, the author concludes that “The removal of criminal penalties for drug use was intended to de-stigmatize addicted users and encourage treatment. According to Portuguese drug policy officials, the new system has effectively done just that.”

The fentanyl-related deaths that have hit communities such as Vancouver  – but also smaller centers, including my home of Winnipeg – have prompted the Canadian government to take steps, even ordering prescription-grade heroin.HealthCanadaHeroin

I know some will shudder at the thought of physicians ‘prescribing’  heroin.  I do!  However the issue isn’t whether we, as physicians and mental health professionals, ‘support’ drug abuse.  I think using drugs is BAD!  However the choice is not between good and bad options – it’s between bad and worse. Nearly 60,000 Americans and 2,500 Canadians died of opiates in 2016!

ACT clinicians, like other front-line staff may be equipped with naloxone kits, but naloxone is a fleeting intervention for what is almost always a long-term problem.  ACT clinicians should always be listening for opportunities to help clients work towards abstinence but the reality of the work is going to remain focused on harm-reduction.  There are not enough treatment options out there to begin with. For ACT clients who, for multiple reasons, can’t tap into or benefit from conventional treatment settings, there are even fewer.

BTW if your team doesn’t have a copy of Muesser et al’s Integrated ITDD CoverTreatment of Dual Disorders, buy one now! (click to view my previous post on this)  

I don’t  presume to have the answers but I do think we need to have discussions.

Thank you for listening.

Shalom Coodin


Train ’em and Pay ’em

Can mental health consumers act as teachers for mental health professionals? Should they? If so do they have the pedagogical skills to be educators?

In a 2014 paper titled Consumer involvement in the tertiary-level education of mental health professionals: A systematic review the authors look at the research on this. Interestingly the first citation is of a Judy Chamberlain paper – (see my recent post).

While it’s important to research how to best involve consumers in teaching perhaps it’s time to, as a certain footwear company recommends, just do it!

First we have to recognise the value of lived experiences. On the issue of what we call patients (yes, I am a physician and I still use this term to remind me of my role) I’m increasingly comfortable with the title of Expert By Experience (see my blog I Got A Name on this)   Consumer, client and patient all have validity.  But when a patient asks what I think they should do – whether it’s to use or not use a medication for example, or to try returning to work – usually, before me answering, I’ll point out that my patient is truly the expert. They’ve lived with depression, PTSD, anxiety, psychosis, addiction or all of the above.

It’s well past time for psychiatry residency programs to have included consumers as instructors.  I suggest a plan on how to do this.  Step 1 – Pay Them!  I don’t work pro bono, why would we ask consumers to do so? Step 2 – Train Them!  One of the fallacies in Medicine is that by virtue of going through medical school and then a residency that you automatically acquire teaching skills along the way.  That ain’t necessarily so.  I don’t really know if I’m any good as a teacher – I certainly would have valued learning more about how to be a better teacher.  Medical schools have increasingly recognized this, offering teaching faculty training in how to be better educators.Apple

Just being a mental health consumer or expert by experience doesn’t necessarily make one a good teacher. There are individuals who are better able to articulate and communicate than others.   We need to invite, entice and did I mention PAY those consumers and involve them in ongoing training, not one-off seminars.

I have no doubt that there are such individuals out there because I’ve met them.  We psychiatrists may not like all of what they have to say but that can make for more interesting conversations.

Can those with the most severe, disabling illnesses – ACT clients – be part of this? Yes, I think there are some.  And ACT clinicians, who know their clients so well, would be a great resource for identifying individuals who might take on the role of becoming educators.

It’s way past time.  As I near the end of my career I’m saddened to see so little having been achieved in my community on this.  Maybe the next generation.

Shalom Coodin MD FRCPC

Lobotomy Retro

In the April 16, 2017  New York Times online (free access) is an 11 minute video and article titled The Quest for a Psychiatric Cure, looking at the use of lobotomy.  Lobotomy FreemanWhile many of us know of the history its always jarring; what psychiatrists thought of as an effective treatment in retrospect turns out to be unthinkable!Lobotomy 1

It’s easy to focus on Walter Freeman and his freewheeling lobotomy road tours.  But in order to understand the history one needs to remember the context of the times.

Dr. Heinz Lehman, a Canadian psychiatrist, is remembered for having brought chlorpromazine (Thorazine in the US, Largactil in Canada) to clinical use.  In 1985 he gave a talk on The Introduction of Chlorpromazine to North America (which is well worth reading and maybe using for an ACT education session)

A somewhat long excerpt:

“I should perhaps give some sort of a feel of what things were like in the 1950s, just immediately preceding and immediately following the discovery and introduction of the psychotropic drugs. I was working at the Douglas Hospital in Montreal. It was a small hospital – not small in the number of patients, we had some 1500 or 1600 – but we had very few physicians and very few nurses, one registered nurse for 600 or 700 male patients; the others were all untrained personnel.

It was pretty horrible to work under those conditions: I felt the only way to keep morale up in the 1940s with the few doctors we had then – most had gone to war – was to do some sort of research. So I did all kinds of things, always convinced that psychotic conditions and the major affective disorders differed in principle from neurotic and personality disorders, and they, I was convinced had some sort of a biological substrate. So I kept experimenting with all kinds of drugs, for instance, large doses, very large doses of caffeine, I remember, in one or two stuporous catatonic schizophrenics – of course, with no results…  We experimented with an extract of the pituitary gland, which we thought might have some effect on psychiatric conditions. So I gave it to some of my schizophrenic patients. We kept good records of our patients then – actually daily progress notes – and there was suddenly, on October 16, you see a very long note, describing a miraculous, very dramatic improvement, almost overnight, from one day to the next: the patient was lucid, cooperative, rational, he had a different posture – it was dramatic…  So we had great hopes for this “extract 47,” until we found out, within a week or so, what had really happened: this extract had a high alcohol content! It just shows you that even with the best efforts and looking at all kinds of different criteria, whether they are rating scales or other criteria, one has to be very skeptical, before one accepts even dramatic results as being promising or novel treatments.

We did all kinds of other things. I injected sulphur in oil which was painful and caused a fever; I injected typhoid antitoxin intravenously which produced pyrexia in schizophrenic patients. Nothing helped; I even injected turpentine into the abdominal muscles which produced – and was supposed to produce – a huge sterile abscess and marked leucocytosis. Of course, that abscess had to be opened in the operating room under sterile conditions. None of this had any effects, but all of this had been proposed in, mostly, European work as being of help in schizophrenia. The best results I could obtain were with prolonged sleep, which Klaesi had introduced in the 1920s, but that was quite a dangerous procedure, because it often led to pneumonia and we did not have penicillin in those days. All this led to a lot of frustration but no discouragement. I kept on looking for something.”

I’ve read this article a number of times over the years and always end up humbled.  How, as a committed, caring mental health professional do you go to work every day in a hospital where there’s “one registered nurse for 600 or 700 male patients”.  How unimaginable to be one of the 700 patients suffering in such a place. Many ACT clients would have been in such settings.

Psychiatrists want to help and we are all too often faced with problems for which we do not have effective treatments.  This leaves us vulnerable to forgetting that critically important insight made by historian Leland Bell and which I blogged about 3 years ago in Cycling History.  Bell wrote how

” … institutional psychiatry has supported a bewildering array of therapeutics that have followed a roller-coaster pattern of fashionability.  A new therapy is introduced with great excitement and enthusiasm.  Sophisticated, detailed reports verify its effectiveness and show remarkable cure and improvement ratios.  This excitement and interest soon fade.  Follow-up studies and additional research challenge the initial reports and reveal that the therapy has limited applications, that it should be given only a modest place in psychiatry’s armamentarium.   Even the most dramatic therapeutics have followed this cycle of hope and disillusionment.”

These days there seems to be a lot of buzz around ketamine, an anesthetic used in veterinary medicine which may have benefit in treating refractory depression.  Authors of a recent JAMA review note that “Even these data are limited by the fact that most of those studies evaluated efficacy only during the first week following a single infusion of ketamine,” the authors caution.

It’s not that I doubt that ketamine, or deep brain stimulation or other ‘cutting edge’ treatments are of benefit.  I just think we should approach new treatments with a certain mindfulness (mindfulness is big these days), always keeping Bell’s words in the back of our minds.

Thanks for taking the time to read my musings.

Shalom Coodin


Remembering Judi

A week before the tragedy of 9/11 I attended the First International Congress on Reducing Stigma and Discrimination because of Schizophrenia held in Leipzig Germany.  At that conference I met Judi Chamberlin (click to read Wikipedia entry), an outspoken advocate of patients’ judi-chamberlinrights and a fierce critic of psychiatric labeling, of forced hospitalization and compulsory treatment.  I got to spend a bit of time with Judi and enjoyed hearing her thoughts.

Judi Chamberlin died in 2010 but her book On Our Own is still available. She didn’t pull her punches. In the introduction she writes:

George Orwell would find the language of the psychiatric system an instructive example of his profound understanding of how words can be used to transform and distort. Just as Big Brother uses benign words to mask totalitarianism, so does psychiatry use words like “help” and “treatment” to disguise coercion. “Help,” in the common sense meaning of the word, must flow from an individual perception of what is needed. There are many things that can be done to a person against his or her will; helping is simply not one of them.

I do not see psychiatry as a tool of social control; I see it as the area of medicine that deals with the most complex part of the body – 100 billion neurons with 100 trillion connections.  I also think it’s worth going back to the ideas Judi Chamberlin articulated; the need for persons with mental health issues to advocate for change, the importance of protecting the rights of individuals who may find themselves disempowered, the need for those granted power – especially psychiatrists – to always be aware of how they exercise iton-our-own. I still remain an advocate for forcing medication treatment(click to view previous blogs on this) in certain situations.

Listening to critics and critiques of what we do is of indisputable value.  Without reminders as to the dangers of labeling people (please consider reading my blog on APA -Best/Worst) , of the inherent trauma in what we must do at times, such as involuntary hospitalization, we lose a valuable perspective.

Mental health clinicians should come back to these periodically.  How about ACT teams have one education session per year to look at Judi Chamberlin’s criticisms of the mental health system?

Shalom Coodin MD FRCPC


SG’s Landmark Report

In November the Surgeon General came out with a comprehensive report titled facing-addiction-in-americaFacing Addiction in America.  Much of the content won’t come as a surprise to ACT clinicians.  For example in the executive summary it notes that:

“Our health care system has not given the same level of attention to substance use disorders as it has to other health concerns that affect similar numbers of people. Substance use disorder treatment in the United States remains largely segregated from the rest of health care and serves only a fraction of those in need of treatment. Only about 10 percent of people with a substance use disorder receive any type of specialty treatment. Further, over 40 percent of people with a substance use disorder also have a mental health condition, yet fewer than half (48.0 percent) receive treatment for either disorder.”

It’s a definite step forward when the Surgeon General, Dr. Vivek Murthy is making the rounds of various media outlets  trying to get the message out on the need for change.  Watch his interview on PBS Newshour (click to view)


When I was a young psychiatrist I had a simple solution for patients who had substance use problems – “you have to go to AA (or CA or NA or GA or …)”.  I did my patients no good.

Two years ago I wrote a blog titled RUCCIS (click to view) pointing out how Ken Minkoff has, for years, been calling on mental health programs to provide Comprehensive, Continuous, Integrated System of Care (CCISC). He writes how

In a CCISC processevery program and every person delivering clinical care engages … to become welcoming, recovery- or resiliency-oriented, and co-occurring capable.  Further, every aspect of clinical service delivery is organized on the assumption that the next person or family entering service will have multiple co-occurring conditions, and will need to be welcomed for care, inspired with hope, and engaged in a partnership to address each and every one of those conditions in order to achieve the vision and hope of recovery.”

In that blog I commented how “on Minkoff’s webpage, the word ‘chronic’ appears only once! That word has a pernicious, disempowering effect on clients and care providers. It should be expunged from our vocabularies. Long lasting, long term, long-standing – I’m okay with all of these, but chronic – NO!”.  The Surgeon General’s report does use the ‘C’ word and I appreciate that the authors have their reasons for this.  I do think we need to see these problems realistically but we also have to leave room for that mysterious element of recovery.  Tony Bennett just celebrated his 90th birthday and I just recently learned that he went through years of addiction and nearly died of a cocaine overdose.  Meeting him at that time in his life could anyone have seen where he would be 35 years later, what with having a ‘chronic’ condition?

There are no simple answers.  ACT teams should, as always, focus on delivering the best services possible.

With the holiday season upon us, Roman, Kevin and I want to wish you and yours all the best of the season and a happy and healthy New Year!

Shalom Coodin


When do you “draw the line” in working with a client?  Is there a time when ACT clinicians have to put out a “you must – or else!” statement?

I think there are rare occasions where an ultimatum is understandable.  Mostly in my experience it’s been related to concerns of violence towards the team or others.

In a 1990 paper  titled The Use of Ultimatums in Psychiatric Care (Click to view) Dr Schwartz looks at this thorny issue.  While not directly addressing ACT I think the issues are very pertinent.

I believe in the use of contingencies but as Schwartz points out:

“The threat to end treatment is not just another contingency in the context of ongoing treatment.  When we make that threat, we invoke the final contingency available when all the usual contingencies we employ have failed.  At that moment we issue an ultimatum: “Either you do as I say [enter an alcohol treatment program, take this medicine, come to sessions regularly] or I will not work with you”.  Only the language of ultimatums captures the unique power of this moment…”

He goes on:

“An ultimatum can be very powerful indeed, but the particular nature of its power must be appreciated.  Often it represents an abuse of power or a disregard of responsibility.  Yet it may be the only way out of meaningless or harmful treatment.”

Schwartz then lays out 7 principles for consideration.  The first is, beyond ethical issues a reminder as to practicality.

“An ultimatum controls the psychiatrist’s future behavior and limits the range of responses to the patient”. ultimatum-cartoon

Ain’t that the truth – the ultimatum restricts the one putting it out there leaving them little choice as to what path to take next.  And using an ultimatum doesn’t exactly invite a collective problem solving approach now does it?

Another point:

“Do not neglect the potential gain in therapeutic alliance that comes from trusting the patient unless the trust is proven to be misplaced.”

I especially admire Schwartz’s sixth point:

“Be wary of institutional pressures to trust conventional wisdom over the patient’s understanding of his own needs”. 

Read the whole article.  Even better – present it to the team to read it together as part of an educational session.  Open it up for discussion. And let me know what you think.

Thanks again for stopping by.

Shalom Coodin

Powdered dog lice and crab eyes

“A typical physician attending the insane in 17th century America administered an assortment of concoctions made from such ingredients as human saliva and perspiration, earthworms, powdered dog lice, or crab eyes. Special importance was attributed to an herb called St. John’s wort which was blessed, wrapped in paper, and inhaled to ward off attacks from the devil. LiceAstrological lore found expression in prescriptions: one physician instructed that bloodletting and blistering be timed with phases of the moon; another called for boiling live toads in March and then pulverizing them into powder, a delicacy credited with preventing and curing all kinds of diseases. From his medical treatises the doctor might prescribe ancient and medieval remedies. Hellebore, an herb used by the ancient Greeks to cure mental disorders, was specified as being “good for mad and furious men.”  A preparation known as “spirit of skull” involved mixing wine with moss taken from the skull of an unburied man who had met a violent death. Hot human blood, as well as pulverized human hearts or brains, presumably helped control “fits.” While these prescriptions represented the best-known “cures,” the nauseating quality of the mixtures suggests that the remedy rather than the illness was the more formidable obstacle to recovery.Crab eyes Vomiting may actually have been helpful, and certainly had powerful psychological effects. In any event, the “cures” reflect the state of medical knowledge in colonial America, a time when physicians and laymen read and use the same medical recipe books. Most doctors remained preoccupied with commonalities and epidemics.”

This excerpt is from Treating the Mentally Ill: From Colonial Times to the Present, a great book with a boring cover that I suspect you’d have a difficult time finding (if you indeed wanted to hunt down a copy).

In a hundred years what treatments that we use now to treat major mental illness might end up in such a list?  Will clozapine, with all its side effects, be seen as having been a misguided remedy? (and I think clozapine is the best! click to read more).

I teach a bit of history next month to psych residents.  I’ll get the residents to read another quote from this same book by Leland V. Bell where he writes of how “psychiatry has supported a bewildering array of therapeutics that have followed a roller-coaster pattern of fashionability” (Read and watch more at Cycling History)

My goal is not to make trainees cynical about psychiatric treatment but to make them humble. Physicians should always be a bit skeptical.  One needs to find the balance point between therapeutic optimism  and humility.  We understand so much more about the brain than a century ago; and yet there’s still a huge amount to learn.  I think we’re doing better than powdered dog lice, or crab eyes but let’s wait a hundred years just to make sure.

Shalom Coodin

Tough Gig

The toughest role on an ACT team is that of team leader.  Dealing with supervision, Jugglingtraining, scheduling, troubleshooting and a multitude of other tasks gives the team leader the longest, most complex job description.  The team leader undoubtedly has a tougher task than the ACT psychiatrist and as a result of course gets paid commensurately more – NOT!

Perhaps the most important role of the team leader is to set the underlying direction for the team.  Is our team focused on long term recovery or are we more focused on medication treatment and stabilization?

Years ago I attended a session at an ACTA conference (yes, I have an unresolved grief thing over losing ACTA) where the presenter was talking about the most important quality an ACT team leader needs.  She spoke of how openness to innovation was the most needed quality.

This is fascinating to me.  ACT is a very prescriptive model, after all there’s a manual for how to set up a team and tools to measure fidelity to the model. PACT Manual Cover Yet openness to innovation was a critical quality.  I agree with this. I’ll write more on this need to be open to innovation in a coming blog.

I have an observation about a team leaders’ background prior to taking the role (which I know may spark some criticism).  I think there may be a difference for someone coming from a nursing background versus a social work /psychology or related field.

It’s tough to undo the effects of years of training.  I think psychiatrists are generally conservative – not politically but in terms of not questioning the constructs that underlie what we do. I don’t remember a big emphasis on innovation during my training (maybe I missed that lecture).

I wonder if nurses get their views shaped by training in systems like hospitals, that emphasize hierarchy – doctors write ‘orders’ and nurses carry these out.  I don’t think social work students are ever taught – nor should they be – the importance of taking orders from physicians.

Does this matter?  I think nurses who move into the role of team leader may have more of a challenge to not go the ‘medical model’ route rather than maintaining a recovery orientation.  I think it’s harder for docs and nurses to maintain an openness to innovation – to finding what works for clients and for staff – after their years of training.

I suspect my bias is obvious. While I strongly support using medication  (see blog Recovery, Meds and When) and support the use of forced treatment (see my blog Forcing Treatment)these should be tools used to help individuals in their recovery, never goals in themselves. The big picture should always be on recovery.

And I know there is one role that is tougher than that of team leader, that of being a person with severe and persistent mental illness, the individuals for whom ACT exists to serve.

Let me know what you think.

Shalom Coodin MD

Choosing Death

Should an individual get to choose to end their life, with a physician’s assistance, when suffering becomes too great?

Until a year ago, as The Supreme Court of Canada noted “It is a crime in Canada to assist another person in ending her own life.The Court goes on to write that ” As a result, people who are grievously and irremediably ill cannot seek a physician’s assistance in dying and may be condemned to a life of severe and intolerable suffering. A person … has two options: she can take her own life prematurely, often by violent or dangerous means, or she can suffer until she dies from natural causes. The choice is cruel.”

The Court mandated that physician assisted suicide be legalized across Canada within a year. Now provincial medical governing bodies are trying to formulate guidelines around how this should be done.Death

What about individuals with mental illness? The Court didn’t explicitly exclude mental illness.

I know a woman who developed schizophrenia in early adulthood.  She and her family went through years of torment.  She was hospitalized for years.  She hasn’t been hospitalized for more than 20 years,  lives independently, has friends and looks after her dog.  She is sweet and warm and funny.  Yet when I ask her about her lived experience of recovery she commented that she would choose death over having to go through it again.

Am I to question her assessment of her life?

And yet…  I’ve met so many individuals who have suffered so much and still have built lives of meaning and worth.  Can mental illness be ‘grievous’?  Yes, without question.  Is is ‘irremediable’? I don’t think it is.

The Death TreatmentSome countries have allowed physician assisted suicide for individuals with mental illness.  (See The Death Treatment in the June 2015 New Yorker article on this issue and how’s it been dealt with in Belgium or, even more timely – just out today (and shorter) Margret Wente Right to Die and Mentally Ill on how we need to deal with it.Wente Right to Die

What do you think?


Shalom Coodin




“I Got A Name”

Like the pine trees lining the winding road


I got a name, I got a name

Like the singing bird and the croaking toad

I got a name, I got a name

And I carry it with me like my daddy did…

Jim Croce

What should we call people?  As a physician I don’t have a problem with the term ‘patient’ but recognize its limitations.  It doesn’t really empower individuals.  With my PACT team we used the term ‘participant’ which I came to like.  There are other options including ‘client’, ‘consumer’, ‘service user’  or one I’d not come across before – ‘Expert by Experience’.

In addressing the issue for social workers C. McDonald writes:

The words we use to describe those who use our services are, at one level, metaphors that indicate how we conceive them. At another level such labels operate discursively, constructing both the relationship and attendant identities of people participating in the relationships, inducing very practical and material outcomes (McDonald, 2006, p. 115).

 I think there are merits to each of the various options – for a thoughtful consideration have a look at this article in the (click to view) British Journal of Social Work: What’s in a Name: ‘Client’, ‘Patient’, ‘Customer’, ‘Consumer’, ‘Expert by Experience’, ‘Service User’—What’s Next? British Journal of Social Work: What’s in a Name: ‘Client’, ‘Patient’, ‘Customer’, ‘Consumer’, ‘Expert by Experience’, ‘Service User’—What’s Next?

I do have a preference in terms of recording – I think clinicians should write using the patient/participant/consumer’s name.  For reasons I haven’t yet figured out many clinicians feel they must write using ‘client’ rather than the individual’s name.  I end up reading many, many notes that have the word ‘client’ many, many times.

Rogers CarlIf you’ve been reading my blog for a bit you know I love Motivational Interviewing.  MI grew out of the work of Dr. Carl Rogers, who introduced the idea of using the word client.  I support the non-judgemental acceptance Rogers advocated.  However I don’t think calling people ‘client’ rather than using their name does anything in helping operationalize Roger’s ideas.

Years ago I asked the director of medical records at the large teaching hospital where I worked whether there was some medical-legal requirement to use the term ‘client’ or some prohibition on using names.  She knew of none.  I think some believe that using ‘client’ in notes somehow is indicative of good professional boundaries.  I’m all for good professional boundaries but don’t believe using someones name in my notes in any way diminishes my commitment to maintaining such boundaries.

I like narratives.  People’s lives are stories they share with us.  When we document, why not make note of it as a story?

When you’re doing your notes this week try using the person’s name rather than the ‘c’ word.  If you’re an ACT team leader consider using an educational session to raise this with your team and allow people to express their thoughts.

And thank you, Dear Reader, for your time.

Shalom Coodin, MD FRCPC