He’s been called a ‘lethal force’ who’s not afraid to take on medical authorities. And it all started with pain week
|Toronto Star 06 Dec 2018 at 05:35|
Back in 2010, a handful of University of Toronto professors gave in to an “impertinent” first-year medical resident and consented to a meeting with him.
In a boardroom of the medical sciences building on King’s College Circle, Nav Persaud warned the group he had discovered some big problems with a course they ran on pain management.
The then-29-year-old doctor-in-training charged there were serious errors in the curriculum for “pain week,” which was taught annually, over the span of a week, to hundreds of students from health science programs, including medicine, dentistry, nursing and pharmacy.
But the unsolicited advice — coming from a trainee no less — was most unwelcome, according to some in attendance.
“Who do you think you are? How dare you question these materials.”
That was the gist of the response, recalls Dr. Rick Glazier, a professor from the faculty of medicine and research director in the department of family medicine at St. Michael’s Hospital, where Persaud was doing his residency.
Even though Persaud was polite and respectful in asking tough questions, “he was treated as being out of his place, as being highly impertinent,” says Glazier.
The academics who organized the program shut Persaud down, denying his assertions, the senior doctor recounts.
But the harsh reception did not dissuade the young man from endeavouring to set right what he saw as a significant and potentially dangerous problem.
The pain-week battle would mark the first time in Persaud’s career he would take on authorities in the health world. He has since gone on to make a name for himself as a crusader for improved care, often with Big Pharma in his crosshairs.
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At only 38, he has also distinguished himself as an advocate for patient safety, social justice, transparency and pharmacare — not to mention a brilliant researcher and practitioner. With a reputation for being principled and persistent, he has not been afraid to rock the boat if that’s what it has taken to effect change.
In just under a decade, Persaud has helped expose and eventually get banned a Big Pharma marketing scheme that saw brand-name drug companies digitally insert vouchers into electronic patient records with the intent of boosting sales. He helped create the Health Justice Program , a partnership between St. Mike’s and legal clinics, which provides legal assistance to patients encountering difficulties that affect their well-being, for example, mould problems in rental housing. And spearheaded an effort at his family practice clinic to stop pharmaceutical reps from providing freebie drug samples, a marketing scheme aimed at boosting drug sales.
But it all started with the pain-week course and the problems that came to his attention in 2009 in the emergency department of St. Mike’s. A medical student had written an order for Percocet for a patient who had overdosed on Tylenol. It was an odd — and dangerous — choice, given that Percocet contains acetaminophen — the generic name for drugs such as Tylenol, which the patient had just OD’d on. It also contains oxycodone, an opioid.
Persaud caught the mistake in time. He then had a conversation with the student, who had already been through pain week, and learned she was unaware of what was actually in the drug.
“I started wondering how it was that medical students were being taught information that was misleading and potentially dangerous for patients, especially in the context of what by then had become the opioid crisis,” Persaud says.
So he started doing some digging.
He had taken the same course years earlier, but the problems didn’t jump out to him then. But to a more experienced and knowledgeable Persaud, they were glaring.
For starters, he discovered that a reference book provided to students free of charge was paid for by Purdue Pharma. That was the same drug manufacturer that three years earlier, in 2007, pleaded guilty in a U.S. court to misleading regulators, doctors and patients about the highly addictive nature of its drug OxyContin. It paid $600 million (U.S.) in penalties.
Persaud also learned that a course lecturer had previously received money from Purdue, as a member of its speakers’ bureau.
Course material wrongly described oxycodone as a weak opioid, less powerful than morphine. In fact, it’s at least 1.5 times stronger than morphine.
Also included in the material was a quote attributed to a 2006 Canadian Medical Association Journal article, stating that placebo-controlled trials showed “strong” and “consistent” evidence that opioids relieve pain and improve function for patients with chronic, non-cancer pain.
Persaud looked up the original article, but the quote was nowhere to be found.
After getting nowhere in addressing his concerns with the course organizers, Persaud took them up the ladder, to associate deans, vice-deans, deans and anyone else who would listen.
In navigating the daunting world of academic politics, he sought advice from two superiors at St. Mike’s — Glazier and Dr. Philip Berger, then chief of family medicine.
Dr. Nav Persaud was just a doctor in training when he noticed some big problems with a course the University of Toronto ran on pain management. He pushed to get the curriculum fixed -- and succeeded.
Glazier’s research expertise is in the area of evidence-based medicine. He also has a personal interest in the opioid crisis. A year earlier, his 18-year-old son Daniel died from an accidental opioid overdose.
The highly respected researcher — a senior scientist at the Institute for Clinical Evaluative Sciences who was appointed in October as scientific director of the CIHR Institute of Health Services and Policy Research — was stunned by the dismissive response to Persaud: “It was such a flagrant denial of fact. (Persaud) was objecting to things that were clear and objective errors.”
But in time, Persaud’s tenacity paid off. The university launched an inquiry. The course was subsequently overhauled; the book dropped, the lecturer dropped, and the medical school’s conflict-of-interest guidelines strengthened.
Berger was mightily impressed by this trainee he had just come to know. He would later offer Persaud a full-time job as a family doctor at St. Mike’s.
The hospital — which has an international reputation for working with disadvantaged and marginalized communities — turned out to be a good fit for the forward-thinking doctor.
As a boss, Berger also turned out to be a good fit. The pair are much alike, with reputations for pushing the envelope on issues they care about and for being unafraid to speak truth to power.
Berger, who eventually became Persaud’s mentor, describes his protégé this way: “He is fearless, very smart and singularly stubborn, all of which makes him a lethal force when he takes on institutions, governments or anybody in power.”
Berger adds: “He’s probably the smartest person I’ve ever met.”
Persaud was born in 1980 in Toronto shortly after his parents emigrated from Guyana. He and his older brother were raised in the Keele and Wilson area, in a neighbourhood with many newcomer families.
His father, an engineer back in Guyana, found employment as a labourer in an insulation factory and eventually worked his way up to management in a medical testing company. His mother got a job as an X-ray technician.
In his last year at William Lyon Mackenzie high school Persaud decided he wanted to become a scientist. The inspiration came one evening when he took the TTC down to U of T to hear the renowned, late physicist Stephen Hawking speak.
Persaud obtained an undergraduate degree in physiology from U of T where he later studied medicine.
Before graduating, he took three years off to study at Oxford University — two years on a Rhodes Scholarship and another year on a scholarship from Oxford.
There, he met a fellow student who would become his wife. Today, he and Shateel are parents to two boys, ages 9 months and 2 years.
Early in his career, Persaud was recognized for his strong research abilities. Adalsteinn “Steini” Brown, dean of the Dalla Lana School of Public Health at U of T, took notice of him when he had just finished his residency and received his first academic appointment as a lecturer in the Department of Family and Community Medicine. Today Persaud is an assistant professor.
Back in 2011, Persaud also received a financial award from the department and a national fellowship to support his research.
“He stood out from the start,” Brown says. “He was identified early on by the (department) as an outstanding scientist with high potential.”
Today, Persaud spends more than 75 per cent of his time doing research as a scientist at the Centre for Urban Health Solutions at St. Mike’s and the remainder working as a family physician at the hospital.
He has so far been published in academic journals about 75 times, most recently in November. A study he is leading was among 19 included in a on patient engagement in health research. Getting patients more involved in all aspects of health care is part of a major cultural shift now underway around the world.
It was a highly competitive process just to get a research project accepted for this initiative, which requires that patients be part of the research teams.
Persaud’s project was one of two selected for presentation at the launch of the supplement in Ottawa in mid-November. Titled CLEAN Meds , it explores the feasibility of providing free medication to patients who otherwise would go without because they cannot afford them.
If it proves feasible, a good case could be made to create such a program. It would also give a big boost to the campaign for a national pharmacare program, which Persaud supports.
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While many academics are happy just to be published, Persaud aims higher, observes Brown, board chair of the Ontario SPOR (Strategy for Patient-Oriented Research) SUPPORT Unit, which co-funded the initiative with the federal government.
“He’s a perfect representation of a new generation of leaders in research who are really, really committed to rigorous work, but who also are just as passionate about seeing it get into practice,” remarks Brown.
One such example of Persaud’s research effecting change is a 2016 study he led, which found that 1 in 10 people who died of an overdose had been released from a provincial prison within the previous 12 months. It led to the creation of a program to distribute the opioid antidote Naloxone to inmates returning to the community.
Persaud achieved success on another transparency battle earlier this year with the publication of a study , which revealed the morning sickness drug Diclectin fell short of its manufacturer’s own threshold for effectiveness. He reanalyzed data — more than 9,000 pages of it — from an earlier clinical trial, funded by the manufacturer, and poked many holes in the findings.
He fought for years to get access to the data, filing numerous access-to-information requests to both the U.S. Food and Drug Administration and Health Canada, but with little success. The data was deemed confidential business information.
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It wasn’t until the 2014 passage of Vanessa’s Law (Protecting Canadians from Unsafe Drugs Act) that Health Canada agreed to show him the manufacturer’s original trial data. But he first had to sign a confidentiality agreement promising to destroy the documents.
Health Canada has proposed updating regulations that would make publicly available reams of previously confidential clinical trial documents about prescription drugs and medical devices.
Brown says Persaud’s growing list of achievements shows that taking calculated risks can have high-impact results.
“He is very good at using traditional tactics, but also guerrilla tactics. The guy has got a conviction of his principles,” the dean remarks.
As for what to expect next in the young scientist’s career, Brown says: “I think it will be more and more of the same in larger and larger leadership roles.”
The Star is profiling 12 Canadians who are making our lives better. Next week we talk to immigrant network creator Robyn Webb.