“We have to rethink the way we deliver healthcare in order to achieve equity”

Why a Sunnybrook plastic surgeon runs a clinic for underserved communities in the Far North

Dr. Jeffery Fialkov is Head of the Division of Plastic Surgery at Sunnybrook Health Sciences Centre and Associate Professor in the Division of Plastic Surgery at the University of Toronto.

And since 2019, Dr. Fialkov has also worn another hat as head of an outreach clinic that offers plastic surgery treatment to underserved communities in Nunavut.

Together with fellow Sunnybrook plastic surgeon Dr. Paul Binhammer and plastic surgery resident Syena Moltaji, Dr. Fialkov makes two trips a year to Rankin Inlet to offer consultations and surgical care to hundreds of residents from communities across Nunavut’s central Kivalliq region.

Generally, people living in the region’s remote Arctic communities must fly south to cities like Winnipeg if they require specialist care, at great financial and social cost. Dr. Fialkov set out to disrupt that model by bringing care closer to the people who need it.

The initiative is funded by Nunavut’s Department of Health. A major research project to assess its impact is now underway thanks to donor support through Sunnybrook Foundation and the University of Toronto’s Department of Surgery.

Here, Dr. Fialkov discusses why he started the program, how it works -- and his hopes for where it might fit in the future of healthcare.

What made you decide to start this clinic?

I first thought of starting this clinic after I learned that accessing specialized medical care not locally available in Nunavut requires extensive travel by patients to major urban centres outside of the territory.

The remote hamlets in the Kivalliq region are not accessible by road. The only way to travel to and from these communities is by boat, plane, or across land by sled in winter. If someone living in Kivalliq has a simple hand condition like trigger finger -- which can usually be treated with minor surgery in a local facility rather than a hospital – they would have to fly to Winnipeg to get care. First, they would have to travel for a consultation with a plastic surgeon, which often involves a one- or two-night stay given wait times and flight delays. Then they might have to wait years for the surgery date. And then they would have to travel back to Winnipeg and stay overnight again for the procedure.

Many people from Inuit communities across Kivalliq live traditional lifestyles, with several people in each household who are interdependent. It can be hard for patients to leave hunting, fishing, or caregiving duties, even for a few days at a time. This means some patients simply live with these significant quality of life impairments rather than travel to receive care.

It struck me that of all the surgical specialties, plastic surgery is perhaps the most transportable because we do so much with local anesthetic, and many of the procedures do not require a lot of infrastructure. Our goal for this initiative was simple: to provide expert care in the field of plastic and reconstructive surgery to the largely Inuk local and regional population, utilizing available resources in an effort to reduce wait times and costs and improve accessibility.

The biggest community in Kivalliq is Rankin Inlet, located about 300 km north of Churchill, Manitoba, with a population of about 3,000. It is home to the Kivalliq Health Centre, a healthcare facility that has some in-patient beds. This is where we set up our clinic. We purchased a whole bunch of instruments and equipment, such as lighting and a cauterizing machine, and we converted one of the acute care rooms into a makeshift operating room.

What are some of the most common procedures you perform?

About fifty percent of what we do is hand surgery. Many of the people in the communities we serve live off the land and use their hands for hunting and fishing. Some of the common conditions we treat are trigger finger or carpel tunnel syndrome. We also treat a range of other conditions, from congenital ear deformities in kids to eyelid surgery or facial paralysis.

What have you learned along the way?

We recently returned from our seventh trip to Rankin Inlet. Over the years, we have learned to be less paternalistic. We learned to listen more closely to our patients and their needs. For example, when we first started the program, we only ran the clinic for a few days once a year during hunting and fishing season. But many patients did not want to undergo surgery at that time of year because it could impair their livelihood. So, we decided to start running the clinic two times a year – once in the fall and once in the spring. This way, we could offer patients consultations on one trip and perform their surgery on the following trip. This has worked out well.

How does this impact your clinical duties at Sunnybrook?

One of the special things about Sunnybrook is that the Plastic Surgery Department has two of every type of subspecialist – for instance there are two hand surgeons on staff. This means that we can make these trips to Nunavut without compromising the service we provide in the hospital. It’s a great model and very sustainable.

What do you enjoy most about providing plastic surgery care to patients in Nunavut?

There are so many ways the work is fulfilling. What I have really come to love over the years is learning about the Indigenous communities in the region and what amazing people they are. And I like delivering care there because in some ways you are like a country doctor: the surgery is simple, but with a unique skill set that we have and can provide. The doctor-patient interaction is also nice, we know each other by name and we feel welcomed. People seem to appreciate our being there. I love going. I can’t wait to go back every time.

In the future, we hope to expand the program so that we can take our services directly to smaller communities. Currently, patients still have to fly to Rankin Inlet to get care. We would like to fly out to various hamlets across the Kivalliq region to do the initial consults so that patients would only need to travel once for their surgery.

We also try to support the development of long-term local capacity to provide health services. We invite Rankin Inlet high school students interested in healthcare to shadow us at the clinic. And with financial assistance from the Fuller Family Foundation and support from the charity Indspire, we offer a bursary to Indigenous students in Rankin Inlet who want to pursue post-secondary education in a medical field.

Is this a model you think could be replicated elsewhere?

Yes. We would also like to bring this model to Northern Ontario, where there are remote Indigenous communities around Hudson Bay and James Bay that face similar barriers to receiving specialist care because they are land and water locked. We are talking to regional health authorities to see if we can replicate the model that we are using in Rankin Inlet. We are still in the early stages but ultimately my dream is to make this model a permanent part of the University of Toronto’s and potentially Sunnybrook’s programming.

There are practical hurdles to providing these services to some communities, including remoteness. Many remote communities in the Far North do not have Internet access or healthcare infrastructure. Finding a way to provide the resources and services onsite is a better solution than flying people south to receive care. What we need is innovative lateral thinking to change the model of how we provide healthcare services to underserved populations.

In my mind, we have to rethink the way we deliver healthcare in order to achieve equity. We talk a lot about reconciliation but at the end of the day, we have to rethink and change the model of how we provide healthcare services to Indigenous populations to rectify the huge disparity that exists.